People with serious and untreated mental health and substance use conditions often encounter barriers that prevent receiving the right services. The absence of appropriate services causes many harms including mental health and substance use crises. Unfortunately, we do not have appropriate systems in place to respond to mental health and substance use crises. Among the wide-spread problems are:
As a result, persons experiencing mental health or substance use crisis may:
Mental Health America (MHA) supports coordinated efforts to:
For a full review of alternatives,, including cost-benefit analyses, see SAMHSA’s 2014 report: Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies.1
People with serious and untreated mental health and substance use conditions often encounter barriers that prevent receiving the right services. Police officers, behavioral health providers, and community stakeholders face challenges in determining and implementing the proper ways to intervene during behavioral health crisis. Unfortunately as a result, interactions with people with mental illness in crisis often result in actions that significantly hurt recovery. For example, in 2016, a quarter of all fatal police shooting nationwide involved people with behavioral health or substance use conditions.[1]
In addition to these tragic outcomes, services and funding are frequently misused. For example, police officers and emergency room personnel are caught up in a cycle of inappropriate, ineffective, and untimely referrals to render care that often results in increased fear and mistrust among individuals with mental health needs. Too often, individuals are also inadequately treated in emergency departments or inappropriately sent to jails due to the lack of more suitable options.
Mental Health America (MHA) supports coordinated efforts: (1) to identify and provide those services necessary to reduce the prevalence of mental health and substance use crises; and (2) to ensure that crises are responded to in a manner that is least damaging and most apt to result in a peaceful and therapeutic outcome. This includes providing mobile crisis response teams made up of mental health professionals and peers and linking to peer-run crisis respite or psychiatric urgent care centers. For a full review, including cost-benefit analyses, see SAMHSA’s 2014 report: Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies.[2]
Increasing Police Contacts
In the twentieth and twenty-first centuries, police contact with people in behavioral health crises has increased. Prior to 1960, people with behavioral health conditions were removed from the community and confined in inpatient facilities, or people were arrested intermittently for being drunk and disorderly or disturbing the peace, detoxified or de-escalated in jail, and released with little ongoing treatment. Now, the criminal justice system is one of the primary institutions called upon to deal with the persons with mental health concerns, and while people with substance use conditions may not be jailed for having an addiction, they are often arrested for acts committed while using. In the case of substances like amphetamines, crack cocaine and PCP, intervention often incites resistance and does not effectively support recovery.
Law enforcement agencies spend a significant portion of their resources engaging with people experiencing behavioral health and substance use conditions. Approximately 10% of all police contacts involve persons with serious mental illness.[3] Although intoxication is harder to quantify, the number of police contacts with people disabled by substance use is undoubtedly greater. However, few attempts to quantify the resources spent on these interventions have been made to date.[4] Mental health issues are more commonly addressed, but similar strategies need to be developed and used in dealing with substance use disorders.
Police arrest a substantial number of people with behavioral health conditions. The percentage of those in pre-trial detention with serious mental illnesses in the United States is 14.5% for males and 31% for females.[5] However law enforcement officers often express reservations regarding the lack of training and resources devoted to the engagement and treatment of people with mental illness and addictive disorders. As of 1999, a majority of U.S. police departments in cities with populations over 100,000 did not have any specialized strategies to deal with behavioral health crises.
Alternative Response Models
Many of the problems associated with police involvement in behavioral health crises can be avoided by creating alternatives. Non-behavioral medical emergencies, such as heart attacks, strokes and non-vehicular accidents are often handled by the 911 system. But rather than dispatching a police officer, an ambulance is sent. A law enforcement response to a mental health crisis is almost always stigmatizing for people with mental illnesses and should be avoided when possible. Whenever possible, mental health crises should be treated using medical personnel or, even better, specialized mental health personnel. Substance use disorders need to be handled in a way that promotes recovery, not victimization.
While SAMHSA’s 2014 report, Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, offers a comprehensive list, some models that MHA would highlight include:[6]
Mobile Crisis Response Teams
Mobile Crisis Response Teams should be the first point of contact in calls regarding mental health crises. Made up of mental health professionals, community health workers, and/or peers, these teams have the knowledge and skills to respond and refer individuals in crisis to the appropriate resources. They work closely with police, crisis services, and communities to support individuals and their families in navigating systems and supports. With specialized knowledge and the ability to engage people who may be at risk for “wellness checks,” access to Mobile Crisis Response Teams can help prevent crises and avoid unnecessary hospitalization, police interactions, and arrests. The best of these models contain peers who can most effectively empathize with and engage the individual in crisis.
Peer-Run Crisis Respite
When responding to mental health crises, emergency responders often take people in crisis to emergency rooms that are ill-prepared to support them. To promote the best outcomes for recovery, crisis respite should be made available to all. In contrast to the unnecessary hospitalization and missed opportunities for connecting to services that occur in emergency rooms, crisis respite services are tailored specifically to the need of consumers experiencing crises. Peer-run crisis programs are places where people can to connect with peers with lived experience of mental health conditions, in an environment that promotes autonomy and empathy and provides people with the hope and resources to move in their recovery. This includes linking people in recovery to ongoing community-based services.
Psychiatric Urgent Care Clinics
Psychiatric urgent care clinics are the same as other urgent care clinics, but are specially trained to attend to mental health and substance use needs. It offers a place for individuals to go and receive immediate attention, avoiding a potential crisis. By making pre-crisis services available like any other health care services it makes mental health crisis avoidance accessible and normative.
Police Specialized Response
Crisis Intervention Teams
While Crisis Intervention Teams, or CIT, focus on law enforcement training and procedures, the program is also designed to coordinate the efforts of law enforcement personnel, mental health providers and community stakeholders in order to increase the safety of encounters and, when possible, divert people suffering from mental illness away from the criminal justice system and into mental health treatment. The fundamental element of the CIT model is 40 hours of specialized training provided by mental health clinicians, consumer and family advocates, and police trainers.[7] The curriculum includes training on recognizing the signs and symptoms of mental illnesses in addition to training on mental health treatment, co-occurring disorders, legal issues, and de-escalation techniques.
CIT identifies eight elements that serve as core components of the program:
Co-Responder Model
In the co-responder model, trained police officers work together with behavioral health workers to respond to crisis calls and ensure that appropriate services and resources are provided. The goals of the co-responder model are deescalate the crisis, prevent injuries, provide appropriate services, and reduce the number of arrest.[9] The initial assessment is conducted with a trained behavioral health worker at the scene which can prevent unnecessary arrest or hospitalization.
The Benefits of Alternative Response Models
Alternative crisis response models offer an opportunity for law enforcement agencies, behavioral health providers, and community stakeholders to work together to provide the most appropriate intervention to those in crisis. Communities and law enforcement agencies that have implemented alternative crisis response models have seen positive results. Some promising initiatives include:
Training Dispatchers
Responding appropriately to behavioral health crises requires that those who answer “911" calls and coordinate and dispatch responders also be trained to recognized such crises and be knowledgeable about all of the alternatives available for responding to various kinds of crises.[17]
Avoiding the Use of Handcuffs and Restraints
Being taken away from one’s home, a community treatment setting or other location in handcuffs is a particularly traumatizing and a sometimes dangerous event. People in crisis may pose such a danger to themselves or others that restraints may seem necessary, but more often than not, restraints are overused by default. Children with mental health concerns should not be restrained mechanically and certainly not handcuffed when being transported in the community – especially out of school. Before restraints are utilized, respondents to a mental health crisis should use de-escalation techniques, work with support systems available to promote compliance and voluntary treatment, and if a person voluntarily agrees to be transported to another location, use no restraints at all. Compliance protects both the person and others and is less traumatizing and physically harmful to the person.
Attending to the Mental Health Needs of Law Enforcement Personnel
Law enforcement jobs are often quite stressful, particularly in the high-crime neighborhoods in which too many persons with mental illness must live. Job stress often leads to Post-Traumatic Stress Disorder (PTSD) and other serious mental illnesses.[18] One of the common symptoms of untreated PTSD is hyper-vigilance, which causes an exaggerated perception of danger and makes it difficult to respond with care and restraint to an encounter with a person in mental health crisis. The high rate of mental health conditions among police is demonstrated by the high rate of suicide, divorce and substance use problems.[19] Unless the police are healthy, it is unrealistic to expect them to demonstrate consistent and appropriate responses to difficult and sometimes life-threatening situations. Insuring that police officers are appropriately screened, diagnosed and treated is made more difficult by a police culture which often views mental illness as a weakness which cannot be acknowledged to peers or supervisors. Police departments must recognize the mental health needs of officers, must carefully screen officers and must develop strategies to engage them in treatment.
Effective Period
The MHA Board of Directors adopted this policy on March 3, 2017. It will remain in effect for a period of five (5) years and is reviewed as required by the MHA Public Policy Committee.
Expiration: December 31, 2022
[1] Tate, J., Jenkins, J., & Rich, S. (2016). Fatal force 963 people have been shot and killed by police in 2016. Washington Post. https://www.washingtonpost.com/graphics/national/police-shootings-2016/ and https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4848.pdf
[3] Deane, M.W., Steadman, H.J., Borum, R., Veysey, B. & Morrissey, J. “Emerging Partnerships Between Mental Health and Law Enforcement,” Psychiatric Services 50(1):99–101 (1999).
[4] Short, T.B.R., MacDonald, C., Luebbers, S., Ogloff, J.R.P. & Thomas, S.D.M., “The Nature of Police Involvement in Mental Health Transfers,” Police Practice and Research 2012:1–13 (2012).
[5] Watson, A.C. & Fulambarker, A.J.. “The Crisis Intervention Team Model of Police Response to Mental Health Crises: A Primer for Mental Health Practitioners,” Best Pract Ment Health 8(2):71 (2012).
[8] Ellis, H.A., “Effects of a Crisis Intervention Team (CIT) Training Program upon Police Officers Before and After Crisis Intervention Team Training,” Archives of Psychiatric Nursing 28:10–16 (2014). See also Watson, A.C. & Fulambarker, A.J. supra.
[9] Shapiro, G. K., Cusi, A., Kirst, M., O’Campo, P., Nakhost, A., & Stergiopoulos, V., “Co-responding Police-Mental Health Programs: A Review”, Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 606–620, (2015).
[10] Croft, B. & ?svan, N., “Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services,” Psychiatric Services 66(6):632-637 (2015).
[11] Greenfield, T., Stoneking, B., Humphreys, K., Sundby, E. & Bond, J., “A Randomized Trial of a Mental Health Consumer-Managed Alternative to Civil Commitment for Acute Psychiatric Crisis,” American Journal of Community Psychology 42(1):135-144 (2008).
[12] Dumont, J. & Jones, K., “Findings from a Consumer/Survivor Defined Alternative to Psychiatric Hospitalization,” Outlook (Vol. Spring 2002, pp. 4-6). Cambridge, MA: Evaluation Center @ HSRI and National Association of State Mental Health Program Directors (NASMHPD) Research Institute (2002) (Not listed on PubMed).
[15] George Washington University News - Crisis Intervention Unit