At a Crossroads: Clinicians and Law Enforcement, a Partnership to Protect Mental Health

Individuals with serious mental illness are over 10 times as likely to experience use of force in interactions with law enforcement than those without serious mental illness.¹ Furthermore, approximately 25% of all fatal police shootings in the US between 2015 and 2020 involved someone with a mental illness.² What can be done to prevent these tragedies? According to 2 experts, the best possible avenue is partnership and cooperation between mental health clinicians and law enforcement.

An Inside Look at Law Enforcement

Officer Jeff Futo (ret.) has been the Crisis Intervention Team (CIT) coordinator at Kent State University for 20 years and is credited with developing their award- winning CIT program. Futo is also former Portage County CIT Officer of the Year and Campus CIT Officer of the Year (Ohio). As the Ohio CIT coordinator and the law enforcement liaison for the Criminal Justice Coordinating Center of Excellence at Northeast Ohio Medical University in Rootstown, he provides guidance and technical assistance to CIT programs and coordinators across Ohio. Futo shared his experiences and law enforcement perspective with Psychiatric Times.

Law enforcement officers are often called to assist individuals experiencing a mental health crisis, and we would hope that capable officers respond. CIT programs play a critical role in preparing officers to do just that—and much more. One of the primary goals of CIT is to ensure the safety of everyone involved, including the individual in crisis. Within the CIT framework, other objectives include achieving positive outcomes, minimizing intrusiveness, and, when a crime is involved, diverting individuals to treatment alternatives when possible. When police officers are called to respond to a situation where no crime is involved, their role is to assist the individual through their crisis and seek the best possible outcome, which might involve hospitalization, a referral to services, or sometimes no action at all. Ongoing efforts are aimed at transforming local crisis response systems so that law enforcement is used as first responders only when there is an immediate threat to safety or a serious criminal issue.

Police officer training varies across the country and at different stages of an officer’s career. It ranges from basic entry-level training focused on understanding mental illness, recognizing a person in crisis, and the officer’s role, to advanced training, such as CIT training. CIT training for patrol officers is the most widely recognized and practiced crisis response training course. It typically consists of 40 hours of consecutive training days and is designed for officers assigned to patrol duties. The course is tailored to the specific responsibilities of patrol officers and is adapted to increase their understanding of their community’s crisis response system (Table).

Table. CIT Training Topics

However, CIT training is just 1 component of the CIT model. CIT is designed not only to train officers but also to establish a framework that fosters community collaboration, improves communication, and creates a structured relationship between the criminal justice and behavioral health systems to manage those in crisis. CIT is not simply about responding to individuals in crisis; it is a comprehensive approach aimed at helping communities address the needs of individuals with severe and persistent mental illness, preventing their involvement with the criminal justice system whenever possible. Although the focus is often on police officer training, CIT goes far beyond that. Law enforcement agencies and leadership involved in CIT are expected to engage more deeply in community efforts, not just training. The issue is much more complex than just training officers—it is about building a collaborative, community-wide approach to crisis management.

Most police officers who attend CIT training are typical patrol officers. Although larger agencies may have the resources to create units focused solely on crisis response, most departments lack the funding or call volume to support such specialized units.

CIT is intended to be a specialized assignment for patrol officers who are both ready and willing to become crisis response specialists. This role, along with the required training and designation as a CIT officer, is not meant for all officers—only those who are prepared and motivated to take on this specific responsibility.

When law enforcement agencies promote having CIT officers, they are proclaiming to their communities a commitment to a specialized crisis response approach. In doing so, they should base their selection of officers for this role on a careful evaluation of whether an officer is able to handle the increased demands of crisis response. Officers demonstrate their readiness through their motivation, interest, field experience, and a positive performance record.

Unfortunately, this approach is not always the case. Many police departments attempt to train all officers in CIT without having policies in place to use them strategically. By placing officers who are not ready in CIT training and not having suitable policies, these agencies treat CIT as just another form of general training, rather than a specialized assignment. This undermines the integrity of CIT, as it capitalizes on the program’s success and reputation without implementing it correctly, which can result in ineffective crisis response.

We hope that officers with a higher level of understanding about mental illness and individuals in crisis approach these types of incidents in a manner that is compassionate, patient, and focused on effective communication and positive outcomes. By applying the knowledge gained through specialized training, these officers are more prepared to assess situations, reduce tensions, and provide appropriate interventions, whether that involves linking people with behavioral health resources or ensuring their safety without the need to use force.

I wish mental health clinicians knew that officers must always prioritize safety first—for themselves, everyone around them, and the person in crisis. When responding to these situations, officers often enter unfamiliar environments where they must consider the presence of weapons and the unpredictable behavior that can accompany a mental health crisis. This level of uncertainty requires them to remain vigilant and cautious, even when a person appears cooperative and compliant.

Officers’ primary role in these situations is to assess dangerousness and determine whether the individual needs to be taken into custody for a mental health evaluation. Balancing this responsibility can be challenging, as officers must evaluate immediate risks while also considering the person’s civil rights and overall well-being. However, when a crime has been committed, the officer’s options may be limited, and in some cases, arrest may be the only available course of action, even if the person is experiencing a mental health crisis.

Psychiatrists and mental health clinicians can improve crisis response within their communities by learning about the CIT model and the benefits of cross-systems collaboration. It is important for clinicians to understand that CIT is not solely focused on officer training; it encompasses a broader concept of managing behavioral health crises in a community through collaboration and creating actionable solutions.

Clinicians should begin by researching whether their local law enforcement agencies participate in CIT and to what extent. Engaging with steering committees, training, and other areas of the program can help build stronger ties between mental health professionals and law enforcement. If local police agencies are not part of a CIT program, clinicians can advocate for its implementation, emphasizing the importance of a coordinated response that addresses the needs of people experiencing crises in their community.

Fostering Collaboration With the Mental Health Community

Mark R. Munetz, MD, professor and chair emeritus of psychiatry at Northeast Ohio Medical University (NEOMED), oversaw the Criminal Justice Coordinating Center of Excellence, the Ohio Program for Campus Safety and Mental Health, and the Best Practices in Schizophrenia Treatment Center, all at NEOMED. He is the codeveloper of the Sequential Intercept Model (SIM) and was a founding board member of CIT International.

Serious mental illness may first manifest itself in a crisis that comes to the attention of a law enforcement officer, and how such a crisis is handled can have enormous consequences for the individual experiencing the crisis and their families. For this reason, it is critical that law enforcement officers know how to recognize possible mental illness and have the skills necessary to safely manage the crisis. This is also the reason that every law enforcement agency should participate in its community’s CIT program so that a CIT officer is dispatched or called for backup when a call is identified as possibly involving mental illness. If the officer’s community does not have a CIT program, they should advocate for starting a program.

As medical director for the Summit County Alcohol, Drug Addiction and Mental Health Services (ADM) Board in the late 1990s, I became increasingly aware that a disproportionate number of the patients in our system with a serious mental illness (SMI) were being incarcerated in the county jail. We realized that many of these individuals would have been better served if there were diversion alternatives to offer the police. We learned about the CIT program that had started in Memphis in the late 1980s and the emergence of specialty mental health dockets (ie, mental health courts). Akron, Ohio, had the good fortune of having both a leader in the Akron Police Department open to learning about the CIT program and a municipal court judge who had been a drug court judge and was determined to start a mental health court. At the same time, the ADM board obtained a free consultation from what is now the Substance Abuse and Mental Health Services Administration Gather, Assess, Integrate, Network, and Stimulate (SAMHSA GAINS) Center to help us look at how best to address issues at the interface of the mental health and criminal justice systems. Patricia A. Griffin, PhD, was the consultant and, over time, we came to collaborate on a systematic approach to addressing the problem of the overrepresentation of individuals with SMI in the criminal justice system. Thanks to SAMHSA GAINS Center Director Hank Steadman, PhD, the SIM evolved (Figure).^3,4

Figure. The Sequential Intercept Model^3,4

The SIM is a framework communities can use to systematically address the overrepresentation of individuals with SMI at all points in the criminal justice system. It takes advantage of the fact that people move through that system in a reasonably predictable linear fashion from arrest to an initial hearing, to jail awaiting trial or adjudication of competency to stand trial, to release or reentry, and finally to community supervision and support. At each point through this flow, opportunities exist to intercept the individual and divert them from the justice system to the treatment system where they can be better served. For communities without these programs, constituents can start anywhere; any and all movement toward addressing this very complex and challenging problem is worthwhile. Psychiatrists and other clinicians should take a leadership role and they should get comfortable talking with the various players in the justice system: police officers, sheriff deputies, prosecutors and defense attorneys, judges, jail administrators and corrections officers, and parole and probation officers. The earlier in the process we can move people to the treatment system the better, which is why I so strongly support the CIT model.

The SIM has been put into practice by a process developed by Dr Griffin and her colleagues called Sequential Intercept Mapping. The facilitated process involves bringing individuals from multiple systems in a community together for a day-and-a-half workshop to review the services available in that community, as well as the gaps and challenges at each intercept. The group determines priorities and agrees on an initial action plan to begin addressing key gaps. This process has helped many communities begin to address the overrepresentation of individuals with SMI that makes sense for their community.

A key part of the SIM model, which sometimes has been overlooked, is what we called the ultimate intercept, likely the best way to address the complex problem. The ultimate intercept, which might now be called Intercept 0, is an accessible, effective trauma- and criminologically informed mental health system providing evidence-based and promising practices to individuals with SMI as early in the course of illness as possible. The intention is to prevent criminal justice system involvement altogether. Although a great deal of emphasis has been on the crisis response system, which is clearly important work, the ultimate intercept includes early identification and ongoing mental health (and substance use) treatment to avoid crises.

I recommend clinicians learn about and get involved with local CIT programs and efforts to develop co- responder or alternative to law enforcement response programs and provide support as needed. Although these programs are developed or in development in many communities, crisis responders find their biggest challenge is getting individuals linked to services once the crisis is resolved. The mental health system needs to offer treatment and support to avoid crises in the first place, as well as to engage or reengage individuals post crisis so they achieve and maintain stability.

Overall, this is an exciting time for communities that are developing partnerships between law enforcement, emergency medical services and fire departments, mental health, public health, family advocacy, and peers with lived experience of serious mental illness and substance use disorders. It will take time for communities to figure out what combination of specialized law enforcement response (eg, CIT), co-response, and alternative response models work best to safely resolve mental illness crises. The fact that serious mental disorders are relapsing and remitting illnesses means that some crises are inevitable. But the mental health and overall health care system must do all that it can to engage individuals as early on in the course of their illness as possible and provide ongoing treatment and support for as long as it is needed. In the meantime, our criminal justice partners have become our biggest advocates as we try to do the best we can to serve the population of individuals with SMI.

Concluding Thoughts

According to one estimate, 1997 individuals with mental illness have been killed by police officers since 2015, often as a result of calling for help.² Yet officers have a duty to protect others and should have the ability to defend themselves. The resulting crossroads represent an opportunity for law enforcement and psychiatric professionals to start and support programs like CIT and SIM in their communities.

Working models of CIT programs and SIM models can be seen everywhere from Johnson County, Kansas, to Lucas County, Ohio, where teams have developed electronic systems that allow cross-system communication about CIT encounters. Counties are able to track and analyze the prevalence, length of stay, and recidivism of individuals with mental illness in the local jail or identify overlapping clients of the different systems.⁵ According to the Associated Press, 14 of the 20 most populous US cities have created civilian, alternative, or nonpolice response teams.⁶ But the work has only just begun.

References

1. Laniyonu A, Goff PA. Measuring disparities in police use of force and injury among persons with serious mental illness. BMC Psychiatry. 2021;21(1):500.

2. 1164 people have been shot and killed by police in the past 12 months. The Washington Post. Updated October 10, 2024. Accessed September 24, 2024. https://www.washingtonpost.com/graphics/investigations/police-shootings-database/

3. The Sequential Intercept Model (SIM). SAMHSA. Updated May 24, 2024. Accessed October 11, 2024. https://www.samhsa.gov/criminal-juvenile-justice/sim-overview

4. Munetz MR, Griffin PA. Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness. Psychiatr Serv. 2006;57(4):544-549.

5. Data collection across the Sequential Intercept Model: essential measures. SAMHSA. Accessed October 11, 2024. https://store.samhsa.gov/sites/default/files/pep19-sim-data.pdf

6. Peltz J, Bedayn J. Many big US cities now answer mental health crisis calls with civilian teams—not police. AP News. Updated August 28, 2023. Accessed October 11, 2024. https://apnews.com/article/mental-health-crisis-911-police-alternative-civilian-responders-ca97971200c485e36aa456c04d217547