Open Forum
An Agenda for Advancing Research on Crisis Intervention Teams for Mental Health Emergencies Amanda Brown Cross, Ph.D. Edward P. Mulvey, Ph.D. Carol A. Schubert, M.P.H. Patricia A. Griffin, Ph.D. Sarah Filone, M.A. Katy Winckworth-Prejsnar David DeMatteo, J.D., Ph.D. Kirk Heilbrun, Ph.D.
The popularity of crisis intervention teams (CITs) for law enforcement agencies has grown dramatically over the past decade. Law enforcement agencies and advocates for individuals with mental illness view the model as a clear improvement in the way the criminal justice system handles individuals with mental illness. There is, however, only limited empirical support for the perceived effectiveness of CITs. This Open Forum analyzes research needs in this area and offers recommendations. Two major gaps in CIT research are identified: verifying that changes in officers’ attitudes and skills translate into behavioral change and determining how criminal justice–mental health partnerships affect officers’ behavior. Research addressing these gaps could help set benchmarks of success and identify evidenceThe authors are with the Pennsylvania Mental Health and Justice Center of Excellence. Dr. Cross, Dr. Mulvey, and Ms. Schubert are also with the Law and Psychiatry Program, Department of Psychiatry, University of Pittsburgh School of Medicine (e-mail: [email protected]). Ms. Filone, Ms. Winckworth-Prejsnar, Dr. DeMatteo, and Dr. Heilbrun are also with the Department of Psychology, Drexel University, Philadelphia. 530
based practices for CIT, substantially increasing the empirical base of support for CIT. (Psychiatric Services 65:530–536, 2014; doi: 10.1176/appi.ps.201200566)
T
he crisis intervention team (CIT) model for law enforcement officers was developed in Memphis after the 1988 police shooting of 27-yearold Joseph Dewayne Robinson. Robinson was in the midst of a mental health crisis, threatening suicide and cutting himself with a knife. Officers repeatedly ordered him to drop the knife, and he became agitated and moved toward the officers while brandishing the knife. He was shot eight times. A public outcry following his death led police to develop the CIT model to intervene more effectively and humanely in situations involving a mental health crisis. The CIT model brings together the criminal justice and mental health systems with the goals of reducing the risk of injury to both police officers and persons with mental illness and diverting persons to mental health treatment instead of jail when appropriate. The need for police officers to develop skills in handling mental health crises is pressing because the criminal justice system is a central component of the current system for managing PSYCHIATRIC SERVICES
and serving people with mental illness (1). Every day, the criminal justice system amasses large numbers of individuals with mental illness at each point of processing. The CIT model is a promising method to divert the flow of persons with mental illness from standard criminal justice processing at the front end and toward treatment services. Although it is not clear exactly how many CIT programs are in operation, the Memphis CIT Center (cit.memphis. edu), which maintains a directory of CIT programs nationwide, lists nearly 3,000 member programs. CIT models across the United States differ substantially, with varying degrees of fidelity to the original Memphis model (2,3). In fact, CIT implementation varies so much across localities that it is difficult to discuss the CIT model as a uniform intervention process. In its original form, the CIT approach was an ambitious intervention to improve the way municipalities managed mental health emergencies by increasing criminal justice–mental health partnerships and conducting police officer training (4). As jurisdictions replicated the Memphis program and organizations (for example, the National Alliance on Mental Illness [NAMI]) promoted the CIT model, officer training has received more emphasis under CIT auspices than have partnerships with mental health agencies (2).
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As this intervention grows, it presents an opportunity to learn more about how individuals with mental illness can be diverted effectively from the criminal justice system. This is an opportunity for the field to improve operations strategically, rather than simply assuming that training will have a marked positive effect. This Open Forum examines the CIT intervention, presents a conceptual model of the program’s intended mechanisms, and summarizes empirical evidence about CITs. We then propose a research agenda to generate the information needed to identify which aspects of this innovation are associated with positive outcomes and might thus form a nucleus of a more uniform practice.
Figure 1
Conceptual framework of the crisis intervention team model Essential elements
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Behavioral outcomes
Officer attitudes • Decreased social distance from persons with mental illness • Confidence responding to mental health crises • Responsiveness of mental illness to appropriate treatment
Officer training
What is the CIT approach? Although definitions of the CIT model’s essential elements lack consensus (3), descriptions of the CIT model typically include two principal components: officer training and criminal justice–mental health partnerships. These components are seen as working together to produce change in officers’ attitudes, skills, and knowledge (learning outcomes) and subsequent changes in officers’ behavior during encounters involving individuals with mental illness (behavioral outcomes). Figure 1 shows a conceptual model of CIT operations. This proposed conceptual model is one of several possibilities. (For example, Watson and others [5] proposed an alternative model in 2008.) It is presented here as a heuristic for building an empirical base for CIT effectiveness. A multitude of other elements, outcomes, and pathways could reasonably be integrated into this model, but we limited the model to the most basic, quantifiable set of causes and effects underpinning the intended functioning of the CIT program. Once research establishes how these elementary components of the CIT model operate, a broader range of inputs and outputs can be introduced and examined. Currently, though, it seems most important for the field to simply describe the effectiveness of the intervention in achieving its core, articulated goals as a foundation for more refined testing of additional components and processes.
Learning outcomes
Police–mental health partnerships
Skills • Verbal crisis deescalation Knowledge • Origins and effects of mental illness • Mental health services
Reduced injuries during police encounters Increased diversion to mental health treatment
Services • Access to custodial mental health center • Community treatment options
As shown in Figure 1, training and partnerships of criminal justice agencies and mental health service providers ideally work simultaneously and synergistically to promote learning outcomes (change in police officers’ attitudes, skills, and knowledge), which in turn are thought to affect officers’ behaviors during encounters with individuals with mental illness. The salient goals of the CIT model are to reduce injuries to officers and subjects during encounters and to prevent the unnecessary arrest of persons whose only clear “crime,” in some cases, is displaying symptoms of mental illness. Many who are interested in the CIT program consider increased referrals to mental health treatment a third relevant outcome, although we do not include it as an outcome in Figure 1 distinct from diversion to treatment. The term diversion, as used here, re-
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fers to preventing arrest through alternative case disposition. Treatment referrals or transports of persons with mental illness who are not at risk of arrest are certainly desirable but are not a core goal of the CIT model as designed (6). The first core element of the CIT model is a 40-hour, officer-level training. According to the University of Memphis’ manual (6), the training should consist of “didactics/lectures, onsite visitation and exposure to several mental health facilities, intensive interaction with individuals with a mental illness, and scenario-based de-escalation skill training.” Trained officers should become more confident in their ability to respond effectively to a mental health emergency, more knowledgeable about the origins and effects of mental illness and treatment, more aware of community treatment options, and better prepared to verbally deescalate crises. 531
The second essential element is a systems-level partnership, linking criminal justice and mental health agencies. Collaboration between these systems is intended to distribute the responsibility of taking action in mental health emergencies among criminal justice and mental health professionals, allowing police to access mental health services efficiently. The objectives are to increase officers’ options by removing barriers that interfere with immediate access to mental health care (for example, lack of beds and insurance processing delays). This is addressed by creating custodial mental health dropoff centers or mobile units with norefusal policies for law enforcement referrals and by expanding options for treating persons with mental illness in the community to prevent emergency situations (2,7). Municipalities wishing to implement the most robust form of the CIT model must be flexible at high administrative levels (for example, police department leaders and the mental health services director) to support the organizational investments in police training and system partnerships. Without such support and options, the ability of CIT programs to reduce injury and increase diversion will be limited (8). A robust CIT intervention promotes a comprehensive approach to solving problems associated with undertreated or untreated individuals with mental illness in the community.
Empirical evidence of the effects of CIT programs Surprisingly little research has been conducted to gauge the effectiveness of CITs for reducing injuries to officers or subjects or increasing diversion from jail. Moreover, some studies are methodologically weak, primarily because of small samples (9,10), lack of a comparison group (11,12), or research design features that are less rigorous than desired (particularly regarding uncontrolled selection effects). Comprehensive reviews of CIT research are available (13,14). Learning outcomes: attitudes, skills, and knowledge Evidence suggests that CIT training is effective in improving officers’ knowledge about mental illness and its 532
treatment, attitudes toward persons with mental illness and interactions with them, and officers’ confidence about their ability to respond appropriately to mental health crises (10,13,15). Although results are not consistent across studies (16), some research has also found that CIT-trained officers are less likely to endorse the use of force against persons with mental illness (17). Behavioral outcomes: injury reduction and jail diversion Two studies that tested whether CITtrained officers used less force against subjects who display psychiatric symptoms reached different conclusions. One study found that against highly resistant subjects, CIT officers selfreported less use of force than non-CIT officers (16). Another found no differences in use of force by CIT training status (18). No study has tested whether CIT training is associated with reduced injuries to officers or subjects during encounters by using documentation methods other than officer self-report. Several studies indicate that CIT training is associated with increased referrals or transports to psychiatric services (12,18–20), but only one of these studies found an impact of CIT training on arrest rates (18). In one study, persons diverted to mental health services through a CIT later reported statistically significant and clinically meaningful reductions in psychiatric symptoms, compared with arrested persons (21). However, diversion did not reduce the likelihood of reoffending. This study also found that CIT diversion cost $8,110 (in 2013 dollars) more per offender over the 12-month study period than traditional criminal justice processing. These increased costs were related to providing mental health treatment outside the criminal justice system. These findings should be considered cautiously in assessing the overall effect of this intervention. Selection bias is a serious problem in nearly all existing studies of CIT interventions; most CIT-trained officers are volunteers. In addition, subjects chosen for jail diversion programs were selected on the basis of their level of risk or needs. It is unknown, therefore, which of the observed effects of CIT programming are attributable to the PSYCHIATRIC SERVICES
programming itself and which are attributable to preexisting differences between groups. Research on differences between officers with and without CIT training found that CIT officers were more likely to know someone who works in the mental health field or to have personal or vicarious experience with mental health treatment (15,22); they were also less experienced as officers (10,22) and perceived a greater need for training on mental health calls (10). Analyses of differences in attitudes about mental illness among officers with CIT training and those without such training have reached conflicting conclusions. One study found no statistical differences between the groups on empathy and “psychological mindedness” (22) while others found that officers with CIT training reported lower desired social distance from people with schizophrenia (10,15), greater empathy (15), and lower beliefs that mental illness is caused by bad parenting (10). More work is needed on this topic.
Perceptions of the CIT model among practitioners CIT programs are expanding rapidly, as prominent voices in the criminal justice and mental health fields call for greater application of the model. NAMI provides a CIT Advocacy Toolkit (nami.org), and the Bureau of Justice Assistance and countless law enforcement agencies, such as CIT International (citinternational.org), advocate for the adoption of CIT programs (22–25). The officer training element of the CIT model has become the focus of many of these dissemination efforts. This is logical, because CIT officer training has many of the characteristics of rapidly spreading innovations. That is, it is perceived as preferable to what was previously in place, culturally appropriate for the audience (law enforcement agencies), relatively easy to adopt, and visible to others (26). The second essential element of the CIT model, criminal justice–mental health partnerships, does not possess the characteristics of rapidly spreading innovation to the extent that officer training does. Perhaps as a result it is not as widely adopted (5,27,28).
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Creating criminal justice–mental health partnerships is challenging. The process often requires the development of new professional relationships, expansion of mental health institutional capacity, resolution of issues regarding confidentiality, and possible budget increases (recall that delivering mental health treatment under the CIT approach costs more than traditional criminal justice processing). As a result, some municipalities forego these partnerships in whole or in part (2). It is questionable whether this approach will produce the full potential benefits of CIT intervention (29,30).
A proposed research agenda Despite the humane motivations and popularity of the CIT model, it (like other programs in these times of shrinking resources) will be scrutinized for its impact and the soundness of its approach. The research base regarding this innovation can be expanded to provide a better understanding of how the program works currently and how it might work better. There are two major gaps in the research on CITs: whether changing officers’ attitudes, knowledge, and skills translates into behavioral change, and how criminal justice–mental health partnerships affect officers’ behavior. If done well, research addressing these questions could help set informed benchmarks of success and identify evidence-based practices for CITs. Here we propose an agenda for future research on CIT effectiveness, focusing on these issues. Although some of the proposed research will be challenging or require substantial funding, it is nonetheless necessary to understand the impact of CITs to potentially improve practice in this area. Links between training and injury prevention and jail diversion To date, it has been assumed that CIT implementation yields changes in learning outcomes, which in turn promote behavioral change on the part of officers during encounters with individuals with mental illness in the community. Whether changes in officers’ attitudes, knowledge, and skills targeted by CIT training actually lead to behavioral changes is an important PSYCHIATRIC SERVICES
empirical question at the core of the justification for the widespread implementation of this program. Yet sufficient empirical data have not been brought to bear on this question. Typical CIT training involves interactive techniques, such as role-play. Compared with professional development education, these training approaches are linked to better practice outcomes (31). However, these approaches also show postintervention attitude changes that are much larger in magnitude than behavioral changes (32). Studying behavioral change, in addition to attitudinal change, is thus a crucial next step for CIT effectiveness research. Research should explore each of the proposed pathways between officer training, learning, and behavioral outcomes (Figure 1). This is not an easy task. In addressing this question, researchers must confront the reality that many standard approaches for program evaluation will be impossible or impractical to implement. Two issues make this type of research particularly difficult: validly measuring police behavior and accounting for selection bias. Observational data might improve the quality of measures of police behaviors; however, police encounters with individuals in a mental health crisis involve a relatively small proportion of police calls. One study in a large city observed police patrols for more than a year and found that for every 73 person-hours of observation, there was only one encounter with an individual with apparent mental illness (33). Another analysis of two large observational studies found that just 6% of police contacts involved an individual with mental illness (34). Therefore, collecting observational data on a scientifically sufficient number of encounters would be a lengthy process. Useful data could be obtained if on-call researchers selectively accompanied CIT-trained officers on mental health disturbance calls (identified by dispatchers) and if the data obtained from these calls could be compared with data from a sample of calls not related to mental health issues. The alternative of using officers’ reports of incidents poses other problems. Arresting officers may not be
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objective informants about the circumstances that prompted them to use force or arrest. In addition, some evidence suggests that police officers tend to miss signs of mental illness in subjects (33), so the accuracy of officers’ ratings of an individual’s mental condition might be questionable. Reports by officers can certainly be improved, possibly enough to be useful for circumscribed determinations. For example, authors of a report from the Criminal Justice and Mental Health Consensus Project (35) recommended that officers report only observable conduct, such as incoherence, delayed response, disorientation, mania, anxiety, and hallucinations or delusions, rather than attempting to ascribe the cause of such behaviors (for example, the person is “mentally ill” or “off his meds”). These and other official records (for example, arrest and hospitalization records) could be combined to document the behavioral changes associated with CIT training, but investigators will have to capture valid encounter-level behavioral data that may not be reflected in official records. Several other approaches might yield valid police encounter data. Follow-up interviews with both police officers and involved citizens (completed as soon as possible after the incident to maximize recall) might be used to obtain impressions of the incident (for example, how the event unfolded, level of perceived threat, use of force, and incident resolution). If time demands and caseloads allow, ratings of change in the street performance of officers obtained from their supervisors might also provide an indicator of the impact of officer training. In addition, technology has created the possibility of remote observation of policesubject interactions. Officers are increasingly wearing small cameras on their uniforms during patrol for the purposes of collecting evidence, protecting the public from police misconduct, and protecting officers from false claims (36). Video from these cameras could be a rich source of data regarding the effects of CIT training. Using a combination of these approaches could increase the validity of reports of police behavior; none are perfect alone. 533
Accounting for selection bias is a second impediment to assessing the link between changes in officers’ attitudes, knowledge, and skills and their on-duty behavior. Research has generally relied on comparisons of trained volunteers (or officers selected by their supervisors for training) and untrained officers, making it difficult to separate individual characteristics (for example, predisposing temperament) from the effects of training. However, CIT developers consider officer self-selection to be one of the most important characteristics of a successful CIT program (37). Several research strategies could address the issue of selection bias in CIT research without much disruption of departmental policies regarding selection of officers for CIT involvement. A randomized trial is not the only way to address this issue. First, officers who volunteer for CITs could serve as their own controls. Their use of force, arrest, and treatment referral rates before and after CIT training could be compared in an interrupted time-series model. Second, the implementation of mandatory training can create natural experiments. In some smaller departments, CIT training is mandatory for all officers, and in some larger departments (such as in Houston, Texas), CIT participation is voluntary for experienced officers but mandatory for new officers (38). In these situations, departments delivering mandatory CIT training could be compared with similar departments that have not instituted CIT training. Third, officers who volunteer could be randomly assigned to receive CIT training immediately or to wait for training. These groups could be compared on outcomes of interest during the period between training the first and second groups. Fourth, matching procedures, such as propensity score matching (39), could be employed to account for potential differences between the voluntarily trained group and other officers. The propensity score matching approach, however, would require a large data collection effort in order to obtain enough relevant information about officers (for example, attitudes about mental illness, history of use of force, and personal relations with individuals with mental illness) to 534
create acceptably equivalent matched groups. Effects of CIT partnerships Implementation of CITs varies between departments, particularly regarding the establishment of functional criminal justice–mental health partnerships. Often because of budget constraints, many municipalities focus most of their CIT resources on officer training rather than on mental health partnerships (5,27,28,37), producing an officer training intervention instead of the originally conceived systems change intervention. Whether and how the partnership with mental health providers affects the achievement of the goals of the CIT approach is an open question for future research. It seems unlikely that officer training alone will suffice to reduce arrest of persons with mental illness (dashed lines in Figure 1). Some districts lack a reliable system for transferring a subject into mental health custody or a facility that will admit any policereferred person who is willing to accept treatment and who does not meet criteria for involuntary hospitalization. In these districts officers are sometimes left with arrest and jail as the only option for resolving a situation (28,29). Officer training, even highquality training, may not be enough to offset such organizational factors. It has been long recognized that organizational structure and support affect officers’ behavior in the community (40). These factors are likely pivotal to the success of CIT programs. Yet they are rarely considered when measuring CIT effectiveness (the study by Watson and others [5] is an exception). Future studies of CITs could examine organizational factors as possible moderators of the success of officer training, providing valuable information about how context fuels success. Future work could include a qualitative assessment of political, economic, social, and personnel issues that facilitate or impede implementation efforts (from both the criminal justice and mental health sectors). At a more basic level, studies should carefully report exactly what was implemented under the CIT program, including the training elements delivered, characterPSYCHIATRIC SERVICES
istics of trained versus untrained officers, and contextual information regarding criminal justice–mental health relationships. Across multiple studies, this level of detail would build a knowledge base about implementation characteristics associated with success. Comparative community studies would be useful if they could test clearly formulated hypotheses about how CIT-trained officers apply their training differently in method or quantity in locales with strong or weak mental health partnerships (the determination of which would require attitudinal surveys across both the mental health and criminal justice sectors). The application of attitudes, skills, and knowledge might be affected by perceptions about available alternatives or likely personal risk from taking certain actions. In pursuing this agenda of basic descriptive, quasi-experimental research, investigators could identify aspects of an organization’s culture or practices that promote the successful translation of training principles into desired behaviors of officers. There is much room for productive research across jurisdictions. For example, research could examine arrest rates of persons with mental illness in localities where strong criminal justice–mental health partnerships are facilitated by a program other than the CIT model (Los Angeles, for example). Such research could illustrate how CIT training and organizational practices might make independent or synergistic contributions to achieving fewer arrests and more frequent appropriate jail diversion for individuals with mental illness. It might also be possible to capitalize on recent advances in geographic information systems mapping to examine how the built environment of mental health crisis services that is available to law enforcement within a jurisdiction affects practice (41). Combining data regarding officers’ perceptions of the number and location of jail alternatives and these objective indicators could clarify some of the processes related to service referral patterns. For instance, difference scores (objective options minus perceived options) may be an important component for understanding encounter disposition and could highlight an area for officer
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training. The effects of organizational and community context on achieving the goals of the CIT model are greatly underexplored, even though they are assumed to be a central component of success for these efforts.
Conclusions CITs are currently in place in many locales across the country, and the program continues to spread. The attractiveness of the CIT model to law enforcement and mental health professionals rests on its potential to improve safety for officers and consumers and reduce the number of individuals with mental illness entering the criminal justice system unnecessarily. The time is right to consider how this innovative practice might be working so it can be improved and routinized. The question is not whether the CIT approach “works.” Like most new approaches, it probably works effectively in some places and less effectively in others. The pressing task for the research community is to identify aspects of the model that contribute to success, so that these aspects can be emphasized and strengthened. Without identifying what matters in this innovative intervention, we risk seeing CITs become a temporary trend in police training. We have proposed addressing two central research questions to move this agenda ahead. Neither is straightforward. Both will require innovative approaches to field research, as well as careful design and measurement, to yield convincing and useful information. However, answers to the questions of whether demonstrated changes in officers’ attitude, knowledge, and skills translate into changes in their field behavior and how certain organizational arrangements or practices alter police encounters with individuals with mental illness would produce great payoffs. Research on these two questions could identify the most potent components of the CIT intervention, which may allow a more focused and refined approach. This agenda could also provide realistic estimates of how officer training alone might help agencies improve response to mental health crises and how influential it is to have a mental health crisis unit as part of this effort. PSYCHIATRIC SERVICES
The burgeoning adoption of CIT programs throughout the United States makes this an ideal time to rigorously study the effects of these programs. This research can answer eminently practical questions about whether the investment of time and resources into CIT programs is really paying off—and if not, how do we make the intervention worthwhile? As the CIT model spreads and matures, it will retain some flexibility so that those who implement it can modify certain components to increase its chances of success. However, if this point in the dissemination and establishment of CIT programs passes without understanding of the model’s effectiveness and processes, it is likely that programs will become so ingrained and inflexible that adaptations will be very difficult. The time for useful evaluation is now. Acknowledgments and disclosures The authors completed this report as part of their work related to the Pennsylvania Mental Health and Justice Center of Excellence. They thank the Pennsylvania Commission on Crime and Delinquency (PCCD) and the Office of Mental Health and Substance Abuse Services (OMHSAS) of the Pennsylvania Department of Public Welfare (DPW), which provide funding for the center. They also appreciate the oversight and guidance provided to the center by the Mental Health and Justice Advisory Committee (MHJAC) of the PCCD. The views expressed are those of the authors and do not represent the views of and should not be attributed to PCCD, OMHSAS, DPW, MHJAC, or any individual member of these groups. The authors report no competing interests.
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An Agenda for Advancing Research on Crisis Intervention Teams for Mental Health Emergencies Amanda Brown Cross, Ph.D. Edward P. Mulvey, Ph.D. Carol A. Schubert, M.P.H. Patricia A. Griffin, Ph.D. Sarah Filone, M.A. Katy Winckworth-Prejsnar David DeMatteo, J.D., Ph.D. Kirk Heilbrun, Ph.D.
The popularity of crisis intervention teams (CITs) for law enforcement agencies has grown dramatically over the past decade. Law enforcement agencies and advocates for individuals with mental illness view the model as a clear improvement in the way the criminal justice system handles individuals with mental illness. There is, however, only limited empirical support for the perceived effectiveness of CITs. This Open Forum analyzes research needs in this area and offers recommendations. Two major gaps in CIT research are identified: verifying that changes in officers’ attitudes and skills translate into behavioral change and determining how criminal justice–mental health partnerships affect officers’ behavior. Research addressing these gaps could help set benchmarks of success and identify evidenceThe authors are with the Pennsylvania Mental Health and Justice Center of Excellence. Dr. Cross, Dr. Mulvey, and Ms. Schubert are also with the Law and Psychiatry Program, Department of Psychiatry, University of Pittsburgh School of Medicine (e-mail: [email protected]). Ms. Filone, Ms. Winckworth-Prejsnar, Dr. DeMatteo, and Dr. Heilbrun are also with the Department of Psychology, Drexel University, Philadelphia. 530
based practices for CIT, substantially increasing the empirical base of support for CIT. (Psychiatric Services 65:530–536, 2014; doi: 10.1176/appi.ps.201200566)
T
he crisis intervention team (CIT) model for law enforcement officers was developed in Memphis after the 1988 police shooting of 27-yearold Joseph Dewayne Robinson. Robinson was in the midst of a mental health crisis, threatening suicide and cutting himself with a knife. Officers repeatedly ordered him to drop the knife, and he became agitated and moved toward the officers while brandishing the knife. He was shot eight times. A public outcry following his death led police to develop the CIT model to intervene more effectively and humanely in situations involving a mental health crisis. The CIT model brings together the criminal justice and mental health systems with the goals of reducing the risk of injury to both police officers and persons with mental illness and diverting persons to mental health treatment instead of jail when appropriate. The need for police officers to develop skills in handling mental health crises is pressing because the criminal justice system is a central component of the current system for managing PSYCHIATRIC SERVICES
and serving people with mental illness (1). Every day, the criminal justice system amasses large numbers of individuals with mental illness at each point of processing. The CIT model is a promising method to divert the flow of persons with mental illness from standard criminal justice processing at the front end and toward treatment services. Although it is not clear exactly how many CIT programs are in operation, the Memphis CIT Center (cit.memphis. edu), which maintains a directory of CIT programs nationwide, lists nearly 3,000 member programs. CIT models across the United States differ substantially, with varying degrees of fidelity to the original Memphis model (2,3). In fact, CIT implementation varies so much across localities that it is difficult to discuss the CIT model as a uniform intervention process. In its original form, the CIT approach was an ambitious intervention to improve the way municipalities managed mental health emergencies by increasing criminal justice–mental health partnerships and conducting police officer training (4). As jurisdictions replicated the Memphis program and organizations (for example, the National Alliance on Mental Illness [NAMI]) promoted the CIT model, officer training has received more emphasis under CIT auspices than have partnerships with mental health agencies (2).
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As this intervention grows, it presents an opportunity to learn more about how individuals with mental illness can be diverted effectively from the criminal justice system. This is an opportunity for the field to improve operations strategically, rather than simply assuming that training will have a marked positive effect. This Open Forum examines the CIT intervention, presents a conceptual model of the program’s intended mechanisms, and summarizes empirical evidence about CITs. We then propose a research agenda to generate the information needed to identify which aspects of this innovation are associated with positive outcomes and might thus form a nucleus of a more uniform practice.
Figure 1
Conceptual framework of the crisis intervention team model Essential elements
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Behavioral outcomes
Officer attitudes • Decreased social distance from persons with mental illness • Confidence responding to mental health crises • Responsiveness of mental illness to appropriate treatment
Officer training
What is the CIT approach? Although definitions of the CIT model’s essential elements lack consensus (3), descriptions of the CIT model typically include two principal components: officer training and criminal justice–mental health partnerships. These components are seen as working together to produce change in officers’ attitudes, skills, and knowledge (learning outcomes) and subsequent changes in officers’ behavior during encounters involving individuals with mental illness (behavioral outcomes). Figure 1 shows a conceptual model of CIT operations. This proposed conceptual model is one of several possibilities. (For example, Watson and others [5] proposed an alternative model in 2008.) It is presented here as a heuristic for building an empirical base for CIT effectiveness. A multitude of other elements, outcomes, and pathways could reasonably be integrated into this model, but we limited the model to the most basic, quantifiable set of causes and effects underpinning the intended functioning of the CIT program. Once research establishes how these elementary components of the CIT model operate, a broader range of inputs and outputs can be introduced and examined. Currently, though, it seems most important for the field to simply describe the effectiveness of the intervention in achieving its core, articulated goals as a foundation for more refined testing of additional components and processes.
Learning outcomes
Police–mental health partnerships
Skills • Verbal crisis deescalation Knowledge • Origins and effects of mental illness • Mental health services
Reduced injuries during police encounters Increased diversion to mental health treatment
Services • Access to custodial mental health center • Community treatment options
As shown in Figure 1, training and partnerships of criminal justice agencies and mental health service providers ideally work simultaneously and synergistically to promote learning outcomes (change in police officers’ attitudes, skills, and knowledge), which in turn are thought to affect officers’ behaviors during encounters with individuals with mental illness. The salient goals of the CIT model are to reduce injuries to officers and subjects during encounters and to prevent the unnecessary arrest of persons whose only clear “crime,” in some cases, is displaying symptoms of mental illness. Many who are interested in the CIT program consider increased referrals to mental health treatment a third relevant outcome, although we do not include it as an outcome in Figure 1 distinct from diversion to treatment. The term diversion, as used here, re-
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fers to preventing arrest through alternative case disposition. Treatment referrals or transports of persons with mental illness who are not at risk of arrest are certainly desirable but are not a core goal of the CIT model as designed (6). The first core element of the CIT model is a 40-hour, officer-level training. According to the University of Memphis’ manual (6), the training should consist of “didactics/lectures, onsite visitation and exposure to several mental health facilities, intensive interaction with individuals with a mental illness, and scenario-based de-escalation skill training.” Trained officers should become more confident in their ability to respond effectively to a mental health emergency, more knowledgeable about the origins and effects of mental illness and treatment, more aware of community treatment options, and better prepared to verbally deescalate crises. 531
The second essential element is a systems-level partnership, linking criminal justice and mental health agencies. Collaboration between these systems is intended to distribute the responsibility of taking action in mental health emergencies among criminal justice and mental health professionals, allowing police to access mental health services efficiently. The objectives are to increase officers’ options by removing barriers that interfere with immediate access to mental health care (for example, lack of beds and insurance processing delays). This is addressed by creating custodial mental health dropoff centers or mobile units with norefusal policies for law enforcement referrals and by expanding options for treating persons with mental illness in the community to prevent emergency situations (2,7). Municipalities wishing to implement the most robust form of the CIT model must be flexible at high administrative levels (for example, police department leaders and the mental health services director) to support the organizational investments in police training and system partnerships. Without such support and options, the ability of CIT programs to reduce injury and increase diversion will be limited (8). A robust CIT intervention promotes a comprehensive approach to solving problems associated with undertreated or untreated individuals with mental illness in the community.
Empirical evidence of the effects of CIT programs Surprisingly little research has been conducted to gauge the effectiveness of CITs for reducing injuries to officers or subjects or increasing diversion from jail. Moreover, some studies are methodologically weak, primarily because of small samples (9,10), lack of a comparison group (11,12), or research design features that are less rigorous than desired (particularly regarding uncontrolled selection effects). Comprehensive reviews of CIT research are available (13,14). Learning outcomes: attitudes, skills, and knowledge Evidence suggests that CIT training is effective in improving officers’ knowledge about mental illness and its 532
treatment, attitudes toward persons with mental illness and interactions with them, and officers’ confidence about their ability to respond appropriately to mental health crises (10,13,15). Although results are not consistent across studies (16), some research has also found that CIT-trained officers are less likely to endorse the use of force against persons with mental illness (17). Behavioral outcomes: injury reduction and jail diversion Two studies that tested whether CITtrained officers used less force against subjects who display psychiatric symptoms reached different conclusions. One study found that against highly resistant subjects, CIT officers selfreported less use of force than non-CIT officers (16). Another found no differences in use of force by CIT training status (18). No study has tested whether CIT training is associated with reduced injuries to officers or subjects during encounters by using documentation methods other than officer self-report. Several studies indicate that CIT training is associated with increased referrals or transports to psychiatric services (12,18–20), but only one of these studies found an impact of CIT training on arrest rates (18). In one study, persons diverted to mental health services through a CIT later reported statistically significant and clinically meaningful reductions in psychiatric symptoms, compared with arrested persons (21). However, diversion did not reduce the likelihood of reoffending. This study also found that CIT diversion cost $8,110 (in 2013 dollars) more per offender over the 12-month study period than traditional criminal justice processing. These increased costs were related to providing mental health treatment outside the criminal justice system. These findings should be considered cautiously in assessing the overall effect of this intervention. Selection bias is a serious problem in nearly all existing studies of CIT interventions; most CIT-trained officers are volunteers. In addition, subjects chosen for jail diversion programs were selected on the basis of their level of risk or needs. It is unknown, therefore, which of the observed effects of CIT programming are attributable to the PSYCHIATRIC SERVICES
programming itself and which are attributable to preexisting differences between groups. Research on differences between officers with and without CIT training found that CIT officers were more likely to know someone who works in the mental health field or to have personal or vicarious experience with mental health treatment (15,22); they were also less experienced as officers (10,22) and perceived a greater need for training on mental health calls (10). Analyses of differences in attitudes about mental illness among officers with CIT training and those without such training have reached conflicting conclusions. One study found no statistical differences between the groups on empathy and “psychological mindedness” (22) while others found that officers with CIT training reported lower desired social distance from people with schizophrenia (10,15), greater empathy (15), and lower beliefs that mental illness is caused by bad parenting (10). More work is needed on this topic.
Perceptions of the CIT model among practitioners CIT programs are expanding rapidly, as prominent voices in the criminal justice and mental health fields call for greater application of the model. NAMI provides a CIT Advocacy Toolkit (nami.org), and the Bureau of Justice Assistance and countless law enforcement agencies, such as CIT International (citinternational.org), advocate for the adoption of CIT programs (22–25). The officer training element of the CIT model has become the focus of many of these dissemination efforts. This is logical, because CIT officer training has many of the characteristics of rapidly spreading innovations. That is, it is perceived as preferable to what was previously in place, culturally appropriate for the audience (law enforcement agencies), relatively easy to adopt, and visible to others (26). The second essential element of the CIT model, criminal justice–mental health partnerships, does not possess the characteristics of rapidly spreading innovation to the extent that officer training does. Perhaps as a result it is not as widely adopted (5,27,28).
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Creating criminal justice–mental health partnerships is challenging. The process often requires the development of new professional relationships, expansion of mental health institutional capacity, resolution of issues regarding confidentiality, and possible budget increases (recall that delivering mental health treatment under the CIT approach costs more than traditional criminal justice processing). As a result, some municipalities forego these partnerships in whole or in part (2). It is questionable whether this approach will produce the full potential benefits of CIT intervention (29,30).
A proposed research agenda Despite the humane motivations and popularity of the CIT model, it (like other programs in these times of shrinking resources) will be scrutinized for its impact and the soundness of its approach. The research base regarding this innovation can be expanded to provide a better understanding of how the program works currently and how it might work better. There are two major gaps in the research on CITs: whether changing officers’ attitudes, knowledge, and skills translates into behavioral change, and how criminal justice–mental health partnerships affect officers’ behavior. If done well, research addressing these questions could help set informed benchmarks of success and identify evidence-based practices for CITs. Here we propose an agenda for future research on CIT effectiveness, focusing on these issues. Although some of the proposed research will be challenging or require substantial funding, it is nonetheless necessary to understand the impact of CITs to potentially improve practice in this area. Links between training and injury prevention and jail diversion To date, it has been assumed that CIT implementation yields changes in learning outcomes, which in turn promote behavioral change on the part of officers during encounters with individuals with mental illness in the community. Whether changes in officers’ attitudes, knowledge, and skills targeted by CIT training actually lead to behavioral changes is an important PSYCHIATRIC SERVICES
empirical question at the core of the justification for the widespread implementation of this program. Yet sufficient empirical data have not been brought to bear on this question. Typical CIT training involves interactive techniques, such as role-play. Compared with professional development education, these training approaches are linked to better practice outcomes (31). However, these approaches also show postintervention attitude changes that are much larger in magnitude than behavioral changes (32). Studying behavioral change, in addition to attitudinal change, is thus a crucial next step for CIT effectiveness research. Research should explore each of the proposed pathways between officer training, learning, and behavioral outcomes (Figure 1). This is not an easy task. In addressing this question, researchers must confront the reality that many standard approaches for program evaluation will be impossible or impractical to implement. Two issues make this type of research particularly difficult: validly measuring police behavior and accounting for selection bias. Observational data might improve the quality of measures of police behaviors; however, police encounters with individuals in a mental health crisis involve a relatively small proportion of police calls. One study in a large city observed police patrols for more than a year and found that for every 73 person-hours of observation, there was only one encounter with an individual with apparent mental illness (33). Another analysis of two large observational studies found that just 6% of police contacts involved an individual with mental illness (34). Therefore, collecting observational data on a scientifically sufficient number of encounters would be a lengthy process. Useful data could be obtained if on-call researchers selectively accompanied CIT-trained officers on mental health disturbance calls (identified by dispatchers) and if the data obtained from these calls could be compared with data from a sample of calls not related to mental health issues. The alternative of using officers’ reports of incidents poses other problems. Arresting officers may not be
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objective informants about the circumstances that prompted them to use force or arrest. In addition, some evidence suggests that police officers tend to miss signs of mental illness in subjects (33), so the accuracy of officers’ ratings of an individual’s mental condition might be questionable. Reports by officers can certainly be improved, possibly enough to be useful for circumscribed determinations. For example, authors of a report from the Criminal Justice and Mental Health Consensus Project (35) recommended that officers report only observable conduct, such as incoherence, delayed response, disorientation, mania, anxiety, and hallucinations or delusions, rather than attempting to ascribe the cause of such behaviors (for example, the person is “mentally ill” or “off his meds”). These and other official records (for example, arrest and hospitalization records) could be combined to document the behavioral changes associated with CIT training, but investigators will have to capture valid encounter-level behavioral data that may not be reflected in official records. Several other approaches might yield valid police encounter data. Follow-up interviews with both police officers and involved citizens (completed as soon as possible after the incident to maximize recall) might be used to obtain impressions of the incident (for example, how the event unfolded, level of perceived threat, use of force, and incident resolution). If time demands and caseloads allow, ratings of change in the street performance of officers obtained from their supervisors might also provide an indicator of the impact of officer training. In addition, technology has created the possibility of remote observation of policesubject interactions. Officers are increasingly wearing small cameras on their uniforms during patrol for the purposes of collecting evidence, protecting the public from police misconduct, and protecting officers from false claims (36). Video from these cameras could be a rich source of data regarding the effects of CIT training. Using a combination of these approaches could increase the validity of reports of police behavior; none are perfect alone. 533
Accounting for selection bias is a second impediment to assessing the link between changes in officers’ attitudes, knowledge, and skills and their on-duty behavior. Research has generally relied on comparisons of trained volunteers (or officers selected by their supervisors for training) and untrained officers, making it difficult to separate individual characteristics (for example, predisposing temperament) from the effects of training. However, CIT developers consider officer self-selection to be one of the most important characteristics of a successful CIT program (37). Several research strategies could address the issue of selection bias in CIT research without much disruption of departmental policies regarding selection of officers for CIT involvement. A randomized trial is not the only way to address this issue. First, officers who volunteer for CITs could serve as their own controls. Their use of force, arrest, and treatment referral rates before and after CIT training could be compared in an interrupted time-series model. Second, the implementation of mandatory training can create natural experiments. In some smaller departments, CIT training is mandatory for all officers, and in some larger departments (such as in Houston, Texas), CIT participation is voluntary for experienced officers but mandatory for new officers (38). In these situations, departments delivering mandatory CIT training could be compared with similar departments that have not instituted CIT training. Third, officers who volunteer could be randomly assigned to receive CIT training immediately or to wait for training. These groups could be compared on outcomes of interest during the period between training the first and second groups. Fourth, matching procedures, such as propensity score matching (39), could be employed to account for potential differences between the voluntarily trained group and other officers. The propensity score matching approach, however, would require a large data collection effort in order to obtain enough relevant information about officers (for example, attitudes about mental illness, history of use of force, and personal relations with individuals with mental illness) to 534
create acceptably equivalent matched groups. Effects of CIT partnerships Implementation of CITs varies between departments, particularly regarding the establishment of functional criminal justice–mental health partnerships. Often because of budget constraints, many municipalities focus most of their CIT resources on officer training rather than on mental health partnerships (5,27,28,37), producing an officer training intervention instead of the originally conceived systems change intervention. Whether and how the partnership with mental health providers affects the achievement of the goals of the CIT approach is an open question for future research. It seems unlikely that officer training alone will suffice to reduce arrest of persons with mental illness (dashed lines in Figure 1). Some districts lack a reliable system for transferring a subject into mental health custody or a facility that will admit any policereferred person who is willing to accept treatment and who does not meet criteria for involuntary hospitalization. In these districts officers are sometimes left with arrest and jail as the only option for resolving a situation (28,29). Officer training, even highquality training, may not be enough to offset such organizational factors. It has been long recognized that organizational structure and support affect officers’ behavior in the community (40). These factors are likely pivotal to the success of CIT programs. Yet they are rarely considered when measuring CIT effectiveness (the study by Watson and others [5] is an exception). Future studies of CITs could examine organizational factors as possible moderators of the success of officer training, providing valuable information about how context fuels success. Future work could include a qualitative assessment of political, economic, social, and personnel issues that facilitate or impede implementation efforts (from both the criminal justice and mental health sectors). At a more basic level, studies should carefully report exactly what was implemented under the CIT program, including the training elements delivered, characterPSYCHIATRIC SERVICES
istics of trained versus untrained officers, and contextual information regarding criminal justice–mental health relationships. Across multiple studies, this level of detail would build a knowledge base about implementation characteristics associated with success. Comparative community studies would be useful if they could test clearly formulated hypotheses about how CIT-trained officers apply their training differently in method or quantity in locales with strong or weak mental health partnerships (the determination of which would require attitudinal surveys across both the mental health and criminal justice sectors). The application of attitudes, skills, and knowledge might be affected by perceptions about available alternatives or likely personal risk from taking certain actions. In pursuing this agenda of basic descriptive, quasi-experimental research, investigators could identify aspects of an organization’s culture or practices that promote the successful translation of training principles into desired behaviors of officers. There is much room for productive research across jurisdictions. For example, research could examine arrest rates of persons with mental illness in localities where strong criminal justice–mental health partnerships are facilitated by a program other than the CIT model (Los Angeles, for example). Such research could illustrate how CIT training and organizational practices might make independent or synergistic contributions to achieving fewer arrests and more frequent appropriate jail diversion for individuals with mental illness. It might also be possible to capitalize on recent advances in geographic information systems mapping to examine how the built environment of mental health crisis services that is available to law enforcement within a jurisdiction affects practice (41). Combining data regarding officers’ perceptions of the number and location of jail alternatives and these objective indicators could clarify some of the processes related to service referral patterns. For instance, difference scores (objective options minus perceived options) may be an important component for understanding encounter disposition and could highlight an area for officer
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training. The effects of organizational and community context on achieving the goals of the CIT model are greatly underexplored, even though they are assumed to be a central component of success for these efforts.
Conclusions CITs are currently in place in many locales across the country, and the program continues to spread. The attractiveness of the CIT model to law enforcement and mental health professionals rests on its potential to improve safety for officers and consumers and reduce the number of individuals with mental illness entering the criminal justice system unnecessarily. The time is right to consider how this innovative practice might be working so it can be improved and routinized. The question is not whether the CIT approach “works.” Like most new approaches, it probably works effectively in some places and less effectively in others. The pressing task for the research community is to identify aspects of the model that contribute to success, so that these aspects can be emphasized and strengthened. Without identifying what matters in this innovative intervention, we risk seeing CITs become a temporary trend in police training. We have proposed addressing two central research questions to move this agenda ahead. Neither is straightforward. Both will require innovative approaches to field research, as well as careful design and measurement, to yield convincing and useful information. However, answers to the questions of whether demonstrated changes in officers’ attitude, knowledge, and skills translate into changes in their field behavior and how certain organizational arrangements or practices alter police encounters with individuals with mental illness would produce great payoffs. Research on these two questions could identify the most potent components of the CIT intervention, which may allow a more focused and refined approach. This agenda could also provide realistic estimates of how officer training alone might help agencies improve response to mental health crises and how influential it is to have a mental health crisis unit as part of this effort. PSYCHIATRIC SERVICES
The burgeoning adoption of CIT programs throughout the United States makes this an ideal time to rigorously study the effects of these programs. This research can answer eminently practical questions about whether the investment of time and resources into CIT programs is really paying off—and if not, how do we make the intervention worthwhile? As the CIT model spreads and matures, it will retain some flexibility so that those who implement it can modify certain components to increase its chances of success. However, if this point in the dissemination and establishment of CIT programs passes without understanding of the model’s effectiveness and processes, it is likely that programs will become so ingrained and inflexible that adaptations will be very difficult. The time for useful evaluation is now. Acknowledgments and disclosures The authors completed this report as part of their work related to the Pennsylvania Mental Health and Justice Center of Excellence. They thank the Pennsylvania Commission on Crime and Delinquency (PCCD) and the Office of Mental Health and Substance Abuse Services (OMHSAS) of the Pennsylvania Department of Public Welfare (DPW), which provide funding for the center. They also appreciate the oversight and guidance provided to the center by the Mental Health and Justice Advisory Committee (MHJAC) of the PCCD. The views expressed are those of the authors and do not represent the views of and should not be attributed to PCCD, OMHSAS, DPW, MHJAC, or any individual member of these groups. The authors report no competing interests.
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