The Changing Landscape of Mental Health Crisis Response in the United States

CIT

The CIT model is a specialized police-based prebooking diversion response program. It was developed in 1988 in a joint collaborative effort between the University of Tennessee in Memphis and the Memphis Police Department.¹² In its original conception it included three components: a forty-hour training of self-selected officers by community mental health workers, persons with mental illness and their families, and officers; training and special coding for dispatch officers; and a centralized drop off mental health facility with an automatic acceptance policy to minimize police officer transit time.

Since its inception, CIT has expanded rapidly. At one time it was touted as the most promising partnership between law enforcement and mental health professionals.¹² Today, CIT programs exist in over 2700 communities nationwide.¹³ In its original form it called for only self-selected officers to undergo the training, though several departments across the country (including in our home state, Minnesota) decided to have all officers undergo the requisite training. It is, however, unclear how many jurisdictions have effectively implemented all three components of CIT. This is because sizes of police departments vary, and small or remote departments do not always have the resources available for full implementation. In fact, research indicates that only a minority of programs have the third component (i.e., a drop off or receiving facility).^7,14 Several others have not been able to engage local emergency psychiatric services to foster collaboration between police and treatment services.¹⁵

CIT outcomes were initially reviewed by Compton and colleagues in 2008.¹² They discovered 12 reports describing empirical research on CIT in three broad categories: those reporting on officer outcomes; those involving disposition of calls eliciting a CIT response; and those describing CIT as an example of prebooking jail diversion. The authors found that evidence was most compelling for officer-level outcomes and concluded that the training component of the CIT model may have a positive effect on officers' attitudes, beliefs, and knowledge relevant to interactions with such individuals. CIT-trained officers have reported feeling better prepared in handling calls involving individuals with mental illnesses. In addition, their review indicated that CIT, in comparison to other pre- and postdiversion programs, may have a lower arrest rate and lower associated criminal justice costs. They underscored a need for demonstrating the connection between officer-level outcomes and patient-level outcomes. The authors noted that for localities focusing almost solely on the officer-training aspect of CIT, patient- and systems-level benefits may be difficult to demonstrate unless training is complemented by other reforms such as dispatcher involvement, the availability of a single point of drop off, and adequacy of treatment services in the community.

In a 2008 critique of CIT programs, Geller¹⁶ noted that research on CIT outcomes assumed that the training accounts for any differences without consideration of numerous other factors that could be involved. Geller questioned whether systemic factors, such as laws, policy, available resources, and insurance factors, may all better account for outcomes and whether CIT may have had minor effects. Geller noted that CIT imposes a cost to police departments and burdens mental health systems. He pointed out that in various localities, differences in the community-based service system, the insurance and entitlement system, the public hospital system, and emergency detention statutes are so vast that any police training related variables are negligible.

In 2019, the Journal published a comprehensive review of research related to CIT by Rogers et al.⁷ that included 198 studies. They found that most studies involved measures of planning, logistics, and training operations related to CIT, and that outcome-based studies were few and largely based on self-reports of CIT-trained officers. The authors found that CIT has been shown to have some measurable positive outcomes, mainly in the area of officer-level outcomes. These include increased officer satisfaction and self-perception of a reduction in the use of force. In addition, they noted that studies of specific CIT programs have found some positive but mixed outcomes or trends toward statistical significance in terms of increased diversion to psychiatric services overall. This may lead to cost reduction mainly through a reduction of hospitalization days and inpatient referrals from jail.

Rogers et al.⁷ also reported that studies lack evidence for a reduction in injuries associated with CIT involvement. They concluded that existing literature on CIT outcomes has not shown consistent reduction in the risk of mortality or death during emergency police interactions with CIT involved officers. In addition, since use of deadly force by the police itself is relatively rare, this low base rate coupled with relatively underpowered studies creates an elevated risk of Type II error (i.e., false negative error). The authors noted that several other variables could affect the outcome of incidents that lead to high-risk encounters with the police, including race of the person, officer characteristics, officer perception of threat and intoxication, militarization of police, and gun ownership patterns. They echoed Geller's concerns about the efficacy of CIT and questioned if the decision to use deadly or injurious force during an encounter may be insensitive to preencounter training such as CIT.^7,16

CRT

The second crisis response model, CRT, is a police-based, specialized mental health response. It takes an additional step in the direction of mental health specialization by pairing a mental health worker with a police officer during a crisis response. These mental health workers may be social workers, paramedics, nurses, or psychiatrists.¹⁷ This model has similar goals to CIT of diverting individuals from the criminal justice system, increasing access to mental health treatment, and introducing more mental health expertise into these encounters.

CRT implementation varies widely in the integration of police and mental health workers. A 2018 review from the United Kingdom identified 19 variations of CRT across the United States, Canada, Australia, and the United Kingdom.¹⁸ This study found that some teams had a ride-along model where a police officer and mental health worker responded to crises in the same vehicle, which may or may not be a police car. Other teams had only control room support where a mental health worker assisted police remotely by phone or radio. Some teams included both ride-along and control room support.

There is also variation in dispatch models for CRT. Teams may be dispatched by 911 centers or may self-dispatch in response to 911 calls heard over police radio.¹⁷ Some teams only dispatch when called directly by police in the field. Others take calls from a direct line used by emergency services and the public. Teams also differ in the hours of their availability.¹⁸

Some CRT include both a paired initial team and a subsequent mental health worker evaluation.^17,19,–,23 For example, the CRT in Indianapolis, Indiana, discussed in Bailey et al.¹⁷ contacted individuals 48 hours after the mental health crisis incident by phone or in-person to provide limited case management, connect with treatment and services, provide appointment transportation, and maintain medication regimens.

There is conflicting evidence about whether the CRT model reduces psychiatric hospitalizations or costs.^18,22,24,25 Puntis et al.¹⁸ found four related studies that demonstrated a decrease in mental health holds (see below) when comparing co-response to police-only responses. Jenkins and colleagues²⁶ found that mental health hold rates were reduced but hospital admission rates were increased when CRT responded in-person but not when they provided consultation to police over the phone. Notably, the mental health holds cited in Puntis¹⁸ and Jenkins²⁶ are a type of police detention in the United Kingdom that, while not considered an arrest, can include relocation of a person having a mental health crisis to a police station.

Bailey and colleagues¹⁷ found that people served by CRT had a lower likelihood of arrest at the crisis incident compared with people served by a police-only response, and this was particularly true for Black individuals. Lopez²⁷ showed that for mental health crisis calls, 1.4 percent of individuals served by a CRT were arrested, compared with 13.3 percent of individuals served by a police-only response.

Puntis et al.¹⁸ cited studies that have shown that after a CRT was introduced, citizens' perceptions of procedural justice improved, encounters were felt to be less traumatic or criminalizing, and responders were perceived as more skilled at de-escalation. Providers have reported in studies that co-response interventions are valuable and improve collaboration among police and medical professionals. Surveys of police officers, however, reported no perceived difference in effectiveness, ability to respond to those in crisis, stigmatization, or level of mental health training between models.

MCU

A third model of crisis response is the mental-health-only response, in which mobile mental health teams (Mobile Crisis Units) respond separately from police. This response still requires coordination with emergency services and police for both dispatch and backup because most people in the United States currently call 911 when experiencing a mental health crisis and these teams depend on police backup for situations that are beyond their capacity.²⁸

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends this mental-health-only response as the preferred crisis response modality in its 2020 National Guidelines for Behavioral Health Crisis Care.²⁸ These guidelines recommend that a crisis response team, also known as a mobile crisis team, should, at minimum, pair a clinician with a peer in two-person teams, should not restrict services to particular locations or times, and should provide warm hand-offs in care, including transportation when needed. SAMHSA also recommends using law enforcement only in special circumstances, using real-time GPS technology to support connection to resources, and the ability to schedule outpatient follow-up appointments. Notably, the mental health only response is one piece of the recommended crisis response system which also includes a regional crisis call center and crisis receiving and stabilizing facilities.

The CAHOOTS (Crisis Assistance Helping Out On The Streets) program in Eugene, Oregon, began over 30 years ago and includes many of the SAMHSA recommended practices.^28,29 This team pairs a medic and a crisis worker trained in mental health who respond to crises in program vans. Training includes class time, field time, and mentorship. It is administered by a local nonprofit organization which has a human services partnership with the city and is funded by the city government, a coordinated care organization, and donors. The teams are integrated into the police department with an official communication protocol whereby 911 calls are diverted to CAHOOTS via radio. The radios also allow for police backup, though out of 24,000 calls in 2019, police backup was only required for 150.²⁹

Several communities have developed crisis systems based on the CAHOOTS model with variations based on local needs and municipal organization. One common refrain is the need to partner with law enforcement and other stakeholders to foster understanding and trust. An evaluation of the similarly situated Denver STAR (Support Team Assisted Response) program found collaboration helpful for assignment of calls.³⁰ A report from Olympia, Washington, cites the value of ongoing stakeholder meetings to discuss difficult cases.³¹

The mental-health only response is consistent with a person-centered approach. It relies on trust over force. On an individual level, crisis workers can “meet people where they are”³² rather than with a law enforcement or public safety agenda. On a broader level, a mental-health-only response system may be safer for people of color because they tend to experience violence at the hands of police at a higher rate.^4,32

Regarding outcomes, SAMSHA's 2014 Crisis Services report³³ found research to support that mobile crisis teams “are effective at diverting people in crisis from psychiatric hospitalization, effective at linking suicidal individuals discharged from the emergency department to services, and better than hospitalization at linking people in crisis to outpatient services” (Ref. 33, pp 10–11).

988 Suicide and Crisis Lifeline

The 988 Suicide and Crisis Lifeline was launched in July 2022 and is a new development in how mental health crisis response teams can be mobilized. It evolved from the National Suicide Prevention Lifeline (NSPL), which has existed since 2005. The number of calls to the NSPL grew from about 50,000 calls in 2005 to about 2.6 million calls in 2021.³⁴ With this increased usage, there was a growing recognition of the need for an easier to remember number to replace the NSPL and improve access.

The 988 Lifeline was also created out of concern about the patchwork system for accessing mental health crisis services across the county. In some states, each county may have a different mental health crisis response number, and 911 call centers often lack the resources to handle mental health crisis calls.^8,35 By unifying crisis response numbers with 988, the hope is that there can be more training, standardization, and dissemination of best practices to call center counselors.

Congress passed the National Suicide Hotline Designation Act of 2020¹¹ in October 2020 to establish 988 as the new national mental health crisis number. This law permitted states to levy taxes to respond to 988 calls and mandated specialized services for populations at high-risk for suicide, including LGBTQ youth, minorities, and people living in rural areas.¹¹ Under this law, states are considered largely responsible for implementing and building the necessary infrastructure for the 988 Lifeline with the help of some federal grants.³⁶

Prior to the launch of the 988 Lifeline, the National Alliance on Mental Illness (NAMI) and the National Association of State Mental Health Program Directors (NASMHPD) drafted a Model 988 bill,³⁷ which included the creation of 24/7 988 crisis hotline centers and 24/7 mobile crisis teams. It also recommended follow-up for people who access 988 services, creation of annual reports on 988 usage, and payment of crisis services by Medicaid.

As of September 30, 2022, 19 states had passed or had pending 988 implementation legislation. For example, Washington state passed some of the most comprehensive legislation, which includes a 988 fee added to phone bills, funding appropriations, a crisis response funding account, a strategy committee, reporting requirements, and a health insurance coverage mandate for behavioral health emergency services. In contrast, Minnesota, our home state, has existing funding for NSPL call centers but did not pass additional 988 implementation legislation that was introduced in Spring 2022.^38,39

At its launch, the 988 Lifeline was described as a national network of more than 200 crisis centers that provide 24/7 support to people experiencing a mental health crisis. Beginning July 16, 2022, all phone companies and text messaging providers were required to route all calls and text messages to “988” to the 988 Suicide and Crisis Lifeline. A call is routed to a local crisis center based on the caller's area code.³⁴

In the week that the 988 lifeline was launched, it received over 96,000 calls, texts, and chats, a 45 percent increase from the week before and a 66 percent increase compared with the NSPL during the same week in 2021.⁴⁰ Analysts project that 988 will receive 24 million contacts annually by 2027, though this could reach 41 million depending on calls routed from local emergency numbers.⁴¹