Recommendations for Implementation

Because calls involving people with mental illness can be influenced by a wide array of variables, a clearly articulated flowchart is a good way to enhance officer response to people with mental illness. A flowchart such as the one in Figure 1 helps officers decide what options are best suited to each situation they encounter. In order to develop such a tool, people involved in each point of the system should identify the different response options available for each type of scenario typically encountered by responding officers.

Figure 1 shows a sample flowchart that might be used by a Crisis Intervention Team combined with a Mobile Crisis Team, an admittedly rare but effective response approach.  The chart depicts multiple situations and next steps recommended for each.

A flowchart helps clarify when diversion from the criminal justice system is appropriate and when it is not.  For example, in the rare event that the threat of violence exists, a flowchart developed by the individual department can reinforce the decision as to when treatment providers and police can address the problem or when other special response teams should be called in. This reference can assist in determining appropriate levels of response (which do not include SWAT teams unless absolutely necessary) that are based on the likely success of de-escalation techniques and accurate assessments of threat.

It is critical for a successful diversion program to have a place where responders can take people with mental illness who require emergency evaluations.  The most common difficulty encountered by police is the lack of available facility space or long waiting times for intake procedures. Consumers with co-occurring disorders or additional special needs may not seem to fit any access requirements. Agreements between law enforcement and mental health facilities can result in designated centers for drop off, procedures at the center that shorten the wait for police referrals, and coordinated efforts to identify available beds and hard-to-access services (such as for co-occurring disorders) from a wide range of options.  Given the difficulties in sorting out whether a person's symptoms are due only to mental illness or to substance abuse, these facilities must have the capacity to work with both disorders.

Example:  Memphis (TN) Police Department

A key element to success for the Memphis Police Department has been the relationships developed with the mental health community. For example, the local psychiatric emergency room agreed to provide emergency evaluations to all people with mental illness brought in by the police.  The hospital also assumes immediate responsibility for assessment and referral - to either community-based or inpatient treatment at the local state hospital - while officers return to police service in as little as 15 minutes.

Example:  Florence (AL) Police Department

The Florence Police department liaison, with the help and support of the chief, negotiated an agreement with the director of the local emergency room to "fast track" medical assessments conducted on people with mental illnesses who were brought in by police.  These assessments now take less than 30 minutes.

Example:  Anne Arundel County (MD) Mental Health Facility

In Anne Arundel County, Maryland, the county mental health facility maintains a countywide bed registry to assist law enforcement in easily locating an available bed.

Example:  Seattle (WA) Crisis Intervention Team

Crisis Intervention Team officers from the Seattle Police Department may transport individuals who appear to have a mental illness to a Crisis Triage Unit at a Seattle-area hospital. King County health care providers developed the unit, which is open 24 hours a day, 7 days a week to respond to people in crisis.

Long drives to mental health facilities may remain the rule in rural areas, but it is possible for officers to be assured that the effort will be worthwhile. For instance, telemedicine gives officers and psychiatrists or other mental health professionals an opportunity to ensure that preliminary assessments are performed in a timely manner. These preliminary assessments help to guard against transportation that is ultimately unnecessary, and they ensure that proper arrangements are made to receive the individual.

In most communities today, there are a limited number of clearly designated emergency intake centers - perhaps just one. Each intake center should have staff on hand or on call that can respond quickly and make an assessment of the needs of each person who comes to them.  It is less important where the intake center is - in a hospital or in a community mental health center, for example - than that the staff at the center be informed of what resources are currently available and have the authority to place the individual in the appropriate services. Investing staff with these "gatekeeper" functions is very important both for ensuring a smooth and rapid "hand-off," and for coordinated follow-up - whatever form it may take. Most important for police, of course, is that mental health staff be able to rapidly assume responsibility for an individual brought to them so that the officer can resume his or her duties.

Additionally, the community mental health center in some communities may operate an on-site emergency intake service only during business hours. Police and others would use the center at those times. After hours, the emergency intake service may shift to a local hospital, providing mental health workers with medical backup and laboratory services. In many settings, the mental health workers at the hospital also answer the overnight emergency telephone calls coming into the mental health center and thus have a sense of the demand for services.  If services are lacking, mental health, police, and other criminal justice system professionals should lobby with consumer advocates for proper appropriations for such facilities.          

In any setting, it is important that mental health workers be dedicated to emergency services, instead of being called away to treat accident victims or others coming to the emergency room for nonpsychiatric reasons. In many settings, it should be noted, the staff on hand may not include a psychiatrist. In all cases, however, a psychiatrist must be on call and available on short notice.

Example:  The Providence Center (RI)

In Providence, Rhode Island, the Providence Center, a community-based, non-profit mental health provider, maintains an emergency services center at its main treatment site that operates during extended business hours, Monday through Friday. During other hours, emergency services are provided at a nearby hospital, where a Providence Center employee answers the emergency telephone line and makes on-site assessments of individuals who come to the hospital or are transported by police or others.

Erratic behavior can be caused by drugs or alcohol and other medical conditions as well as by a mental illness. While police may suspect the cause of erratic behavior, the actual factors may not be known for days or weeks. It is therefore important for the receiving mental health staff to be knowledgeable about the distinctions between mental illness, other medical conditions, and drug or alcohol involvement.  The intake staff must have access to laboratory services and other diagnostic technology to accurately assess detainees' needs for treatment. Easy access to emergency medical care is similarly important.  Staff must also be able to connect with needed drug and alcohol services and/or professionals with the ability to treat substance abuse and mental illness simultaneously if such services are called for (see Policy Statement 1: Involvement With Mental Health System).

Staff at the intake center must also be able to determine whether the individual meets criteria for involuntary commitment and, more important, be authorized to take appropriate steps in the event that commitment is warranted.

When the person with mental illness does not meet the criteria for involuntary commitment, it is especially important that law enforcement and staff at the intake center identify some short-term housing options for those who are homeless.  Without a linkage to some type of housing, the police are likely to encounter the person on the streets not long after dropping him off at the intake center.  Programs that make short-term housing available for individuals who do not meet the criteria for involuntary commitment should also work to connect clients with long-term housing opportunities.  

Example:  Baltimore Crisis Response, Inc. (BCRI), Baltimore City (MD)

Baltimore Crisis Response, Inc. (BCRI) manages mental health crisis beds within Baltimore City that are available on a voluntary basis to individuals who do not meet criteria for involuntary admission to a hospital and have not been charged with a crime that requires detainment.  BCRI staff work closely with emergency rooms, the Baltimore Police Department, and mental health agencies to afford access to these beds as a form of pre-booking diversion.  BCRI case managers work with individuals admitted to the mental health crisis facility to connect them to long-term housing and other services.  

The type of insurance coverage an individual has can affect efforts to gain access to emergency psychiatric services. Private insurance, especially, may be governed by "medical necessity" criteria that can be interpreted to exclude someone with mental illness from emergency admission to some hospitals. Publicly funded mental health centers may be excluded from preferred provider lists developed by private insurers, which in some instances can complicate or even eliminate the possibility of admission. If an individual is an active Medicaid or Medicare patient, admission is still likely to be governed by some level of managed care admission criteria. While many hospitals and mental health centers receive funds allowing them to accept uninsured individuals, the absence of any coverage complicates admission and, at a minimum, can cause further delays. None of these insurance issues are unique to mental health service delivery, but when they arise in instances involving someone who is psychotic or deeply suspicious they can stand between that person and the services he or she needs.

Chapter VI: Improving Collaboration, discusses the importance of formal agreements between the criminal justice system and mental health system components on the roles and responsibilities of each partner.  The following checklist outlines particular areas of such agreements that are specific to the concerns of law enforcement and mental health professionals when developing agreements. (See Policy Statement 26: Institutionalizing the Partnership, for more on elements of successful agreements.)

• What emergency detention authority do officers have and how will custodial transfer occur? It must include protections for taking the person into custody and provide liability protection as long as they are in custody.  Partners will need to know what existing authority (local laws, indemnity clauses, and state statutes) may impact rights and obligations.
• What information can be shared under what circumstances? Confidentiality provisions for verbal or document exchange should address what will happen when information is included in either police or mental health reports that relates to an ongoing criminal investigation or to a mental health treatment plan. (See Policy Statement 25: Sharing Information.)
• How do law enforcement officers make the determination whether or not to place a person with mental illnesses in custody for transport to a mental health facility?  It is important to specify rules based on how the person gets to the facility - in custody or voluntarily. 
• When does responsibility actually shift from the on-scene responder to a mental health professional? (This could be at the scene, by phone, in a waiting room, etc.) There must be clarification of the point at which the responsibility to provide services transfers from one entity to the other.
• What intervention (such as an advocacy service) is available when a person suspected of having a mental illness is being held in a holding cell and is in need of services but who does not qualify for emergency evaluation?
• What liability protection is in place? Liability suits are related to practice, custom, policy, or accepted standards of care. The premise under liability law is that an officer cannot be sued for general duty to protect someone from being victimized, injured, or killed.  However, if through a partnership a law enforcement agency creates a new special duty that it is later unable to fulfill, departments and/or officers can be held liable. Law enforcement counsel should consider whether any agreement creates a new special duty to the individual that would create liability if breached. Each party should be held liable for its own agents' actions. If the memorandum of understanding (MOU) is carefully structured, a breach resulting in litigation would not focus on it being a joint venture with shared liability.
• What are the budgetary considerations?  Cost or funding responsibilities must be addressed.

Ideally, any person brought to a mental health provider by police officers will be someone already known to the system or will be able to easily fit into existing services. Unfortunately, such cases appear to be more the exception than the rule. Perhaps because people who are not already engaged in the system come into contact with the police more frequently than others who are successfully engaged in treatment, they face a number of obstacles in entering the system. Because contact with police may, in fact, turn out to be a person's introduction to the mental health system, it is important that the system's door be open at this critical juncture and engagement not be made more difficult by bureaucratic concerns. Establishing protocols that allow a case to be opened or reopened smoothly can help with this process.

An important test of the partnership between police and mental health providers is the ability of officers and providers to agree on who needs mental health services. If police officers bring an individual they perceive to be in need to a provider, they expect the provider to offer appropriate services to that individual. Mental health providers must respect the observations and judgments of police officers charged with making quick decisions in the field. By the same token, police officers must respect the assessment of mental health providers about which cases they are able to address and which cases are beyond their capacities. If the law enforcement and provider agencies have not worked together before, it may take a period of trial and error for a balance to be struck. The important thing is for police and providers to ensure that they will learn as they go along and that every effort will be made to meet each individual's needs in the process. There must also be an understanding that if an individual's needs cannot be met, there is a shared plan for getting those resources established.

Even with appropriate training, police officers will occasionally seek services for someone who cannot be helped by the local mental health provider. It is important in such instances, however, that providers not simply turn the individual away or leave him or her under the responsibility of the police. Protocols should be developed that delineate how police and providers should work together to find some assistance for the individual, even if it is not in the mental health system.

One source of assistance for people with mental illness is peer support programs.  Several types of peer groups exist to help consumers, including Drop-In Centers, Warmlines, and Clubhouses.  "Drop-in centers" are informal social and recreational programs that serve as information clearinghouses and meeting locations for other peer support groups, including 12-step groups. Traditionally, people with mental illness fill staff positions.  "Warmlines" are telephone support systems staffed by consumers trained to listen empathetically, provide information about appropriate resources, and act as a link to needed or desired supports and services.  Warmline staff does not provide suicide intervention or crisis intervention, but they are trained to recognize the need to engage the more critical support offered by a suicide hotline.  The staff also makes outgoing calls, contacting consumers who have asked to be called regularly to stay connected to a support system.  "Clubhouses" are collaborative efforts between professionally trained staff and consumers who provide vocational support and prepare consumers to enter into or return to the workforce.

In many instances, law enforcement officers may deliver a person with a mental illness to a mental health provider only to discover that any of a number of complicating factors may make it difficult to connect that person with appropriate services. For example, the provider will want to determine whether the person has insurance or qualifies for Medicaid or other benefits or entitlements. Similarly, the person may have more than one diagnosis or display no interest in receiving services. In these instances, too, protocols must be in place to ensure the delivery of appropriate services or responses.

In some communities, ACT programs have been put in place or adapted to provide or arrange for comprehensive treatment and supports for people with mental illness whose behavior has brought them to the attention of law enforcement. The concentrated individual attention that characterizes the ACT model can provide assurance that a person in need will receive appropriate services. In other instances, it may be that clinical services aren't needed, and the most effective connection can be made with peer services, either at a drop-in center or through individual contact with a peer counselor who is trusted because of the shared experience of mental illness.   

Regardless of the model used, mental health providers should take steps to ensure thorough follow-up for any individual who is brought to them under mutually agreed conditions by law enforcement authorities. Follow up may help stop the cycle of repeated involvement with the criminal justice system, while offering mental health providers a ready barometer of conditions and situations that receive police attention. "Follow-up" in this case means, at a minimum, a thorough examination, which may result in a referral to a more appropriate provider. The protocols developed to ensure services must also include a component that allows providers and police to regularly assess the appropriateness of referrals.  In addition, each participating agency should designate a liaison to work with counterparts to resolve problems.

Example:  Anne Arundel County (MD) Mobile Crisis Team

The Mobile Crisis Team (MCT) approach is successful in Anne Arundel County because the MCT is connected to a local clinic, emergency shelter beds, and an In-Home Intervention Team. The MCT has the resources to ensure that people with mental illnesses get the intervention necessary. The Broken Arrow, Oklahoma, Police Department is among other agencies using a similar approach. 

To respond as appropriately as possible in the incidences of barricaded subjects or violent situations, effective communication must exist between police, special responders and department negotiators.  While agencies are often under pressure to resolve situations quickly, it is often the best approach to allow time for communication to work in these crisis situations. Hostage negotiators will likely be called to a scene when initial efforts by responding officers to resolve a critical incident have failed.

The effective resolution of these encounters is also dependent on the involvement of specially selected and trained mental health professionals who have expertise in crisis negotiation and familiarity with police operations.  State-level mental health agencies will likely know of individuals suited to this role.  These mental health professionals will be able to assist law enforcement in understanding the motivation for the incident, which is critical to defusing the situation.

Research has shown that people with mental illness, like many people with disabilities, are at a greater risk for victimization.[1] People with mental illnesses have been shown to be vulnerable to sexual assault as well as other violent crimes.[2]   These crimes are also disproportionately unreported, probably because these victims fear reprisals or retribution from their abusers for coming forward or fear the police won't believe them. 

People with mental illness who have been victimized repeatedly may confuse events in their reports to law enforcement.  This confusion does not negate their victimization and the importance of investigating the crime.  In fact, people with mental illness may experience the trauma of victimization more acutely than other victims, partly because it triggers memories of past abuse.  This history of abuse is relevant to case investigation and should be explored. 

Unfortunately, when victims with mental illness do report their crimes, they are frequently viewed as unreliable witnesses and their cases are often dropped. Law enforcement must become more aware of the complexities of working with victims who have mental illness and should collaborate with their mental health partners to increase the reliability of evidence.  These professionals can help law enforcement sort out these complex issues and improve case outcomes.  Resources for responding to crime victims who have disabilities can be obtained through the Department of Justice's Office for Victims of Crime.[3]

Law enforcement agencies should provide information to these victims about available services that can help reduce their vulnerability and promote positive contacts with the criminal justice system agents who can inform them of case progress.  Law enforcement can also work with consumers and their advocates to conduct crime prevention outreach.

Affected third parties can include victims, family members, employers, or others who share a home or part of their lives with people with mental illness.  As in other similar situations, these individuals need a variety of supports and may look to law enforcement for help in accessing resources.  In particular, victims (who may also be family members) should be apprised of the course of action to be taken by law enforcement and mental health agencies, and what they can expect the outcomes of the actions to be.  They should also be made aware of national resources for victim assistance, including the National Organization for Victim Assistance, the National Center for Victims of Crime, and the Office for Victims of Crime.

In many instances, families try to maintain normalcy when dealing with one of their own who has a mental illness. It may be that the incident resulting in police involvement is the first public acknowledgment of mental illness in the home. Or it may be that the incident is the first manifestation that has clarified mental illness as a problem. In any case, the incident may represent the first time the family has reached out for help and thus the first opportunity for necessary supports to be made available to them. It is important, therefore, for police officers and mental health workers to be knowledgeable about the full range of resources that are available for families and others close to the affected person.

For example, police departments and their mental health partners can provide information on peer supports, such as consumer-managed neighborhood projects, drop-in centers, and warmlines, which offer nonemergency support to consumers by telephone.  Regional NAMI affiliate organizations, community chapters of the Depressive and Manic Depressive Association, and local United Way organizations are all good resources for peer support and services. Families may also contact statewide consumer-managed organizations, an example of which is the Tennessee Mental Health Consumer Network.

If police have been called to a home as a result of a threat or threatening action, they should be able to inform family members in the home on ways to protect themselves. Even in instances where the individual is placed in treatment, voluntarily or involuntarily, it can usually be expected that he or she will be at liberty in the community within perhaps a matter of days. Families should be made aware of the process for obtaining a protective order, the associated risks and benefits, as well as what to expect should the order be obtained and violated by the ill family member.

In many instances, of course, members of the family may represent classes given special status or protection under the law. Children of a person with mental illness, for example, may be subject to actions taken by the child protection authorities intended to remove them from the risk of harm. If elderly individuals or spouses have been threatened or harmed, police may be required by law to arrest the individual family member or to notify other authorities. (It should be noted that mental health workers who uncover evidence of elderly, spousal, or child abuse may also be obligated under the law to notify certain authorities.)

Families that report and deal with incidents have great need for support. They may feel isolated and not know where they can turn for information that will help them provide the best care for their relative and for themselves. It is helpful for police to be aware of the resources available to assist families in these situations, such as NAMI. However, it is essential that mental health providers be prepared to provide complete information on support and education resources to families.

In some places, mental health agencies provide classes or resource centers stocked with information for families. More generally, community mental health providers rely on separate nonprofit organizations to provide information and support. Most commonly, these local organizations are affiliated with such previously cited national organizations as NAMI, the National Mental Health Association, or the National Depressive and Manic Depressive Association and are able to offer information and programs developed by these organizations. By meeting and communicating with others who have been through similar situations, families are able to learn skills that will help them to be effective advocates for themselves and for their relatives.

Law enforcement agencies should work with their mental health partners to prepare packets of information on available community-based resources for people with mental illnesses and substance abuse disorders and for their families.  These packets should accommodate the full range of cultures and languages present in the community.

Example:  Community Mental Health Centers

Community mental health centers in many communities have prepared packets of information for families of clients receiving emergency services. These packets include information about the services the center provides, the rights of patients, payment options, and materials from the local NAMI affiliate and the statewide Mental Health Association. In addition, counselors who meet the families in these initial encounters encourage the families to make contact with one of the organizations, taking time to allay their concerns about privacy, shame, and cost. The organizations, in turn, provide useful information, including Web addresses, book lists, schedules of classes or events, local contact information, as well as descriptions and contact information for area provider agencies.

Depending on the nature of the response chosen, officers will either leave the person at the scene, transport the person to a mental health facility, transport the person to their home or to the home of a friend or family member, or transport the person to a detention facility.

If police are requested to transport the person to the mental health facility for a voluntary admission, this is service, not a custodial transport.  In general, police can take a person with mental illness into custody, only (1) when the individual has committed a crime; (2) the individual is at significant risk of causing harm to self or others and meets the state's criteria for involuntary emergency evaluation; or (3) in response to a court order or directive of a mental health or medical practitioner who has legal authority to commit a person to a mental health facility.

Before agencies revise policies on custodial and noncustodial transfer of people with mental illness, pertinent laws and liability issues should be explored. However, it is possible to decrease stigma and enhance the dignity of people with mental illness during the transport process.

Example:  Washington, D.C., Police Department

A Washington, D.C., policy states that if the responding officer is asked to transport someone for voluntary admission and the officer deems the person to be nonviolent, the officer can provide transport to the facility without handcuffs.

If a person's behavior poses an imminent risk of serious harm to self or others, officers may need to take reasonable steps to physically restrain the person.  If time permits, guidance from a mental health professional should be sought about the best restraint methods for the person and situation. Unless there is immediate danger to the individual, others, or officers, responding officers should move slowly and allow the person time to calm down in an effort to gain voluntary cooperation before resorting to physical restraints.

In some communities, police are able to call mental health staff to handle transport. Often known as mobile crisis teams, these mental health units are able to assume responsibility for the individual in question on the scene, allowing officers to return to patrol.

Example:  Montgomery County (MD) Police Department

In Montgomery County, Maryland, the Police Department's Crisis Intervention Team works closely with the county mental health agency's Crisis Response Team. In many instances, the Crisis Response Team is called to the scene by the CIT, allowing police officers to transfer responsibility for an individual without accompanying that person to a mental health intake center or hospital emergency room.

Depending upon the jurisdiction, a person taken into custody for a criminal offense is brought either to a police holding facility or to the local jail pending the initial appearance in court.  While this stay in custody awaiting the court appearance is usually brief - in most instances less than 24 hours - it can be a vital time for a person with mental illness.  Research has shown that most suicides that occur in custody take place within the first 24 hours.[4]   In addition, the behavior that led to the arrest may be the manifestation of an individual experiencing a mental health crisis.

As a result, intake procedures into these facilities should screen for a risk of suicide and assess the need for emergency psychiatric evaluation.  Staff should also be trained in suicide prevention and crisis management procedures.  These screening procedures are for the purpose of providing appropriate treatment, not for gathering evidence for a criminal proceeding. Agency staff should also note that people with mental illness may need access to their medication.  Officers must follow departmental rules for verifying that any pills or capsules the person is carrying are prescribed, or to obtain the needed medication, so that they may authorize the individual to continue the prescribed treatment should they be detained.

As mentioned earlier, police officers should be aware that some medications that treat mental illness have side effects that may require attention.  For example, medications may cause tremors, nausea, extreme lethargy, confusion, dry mouth, constipation, or diarrhea.  Police officers should attend to needs for water, food, and access to toilet facilities.  It is important not to mistake these side effects as evidence of alcohol or drug abuse. (See Policy Statement 13:  Intake at County / Municipal Detention Facility, for more information on intake procedures.)