Crisis Intervention Team Training vs Alternatives Without Police: Which Is Better?

 

(1-29-21) Should the police be the first responders when someone with a mental illness is in distress? Recently, Crisis Intervention Team programs have come under fire because of incidents such as the killing of Patrick Kenny who had paranoid schizophrenia. The four Springfield, Oregon police officers involved in his death all had CIT training and one was a CIT instructor. Jeff Fladen, executive director of the Tennessee state chapter of the National Alliance on Mental Illness defends CIT programs, and sees them as necessary even if communities develop alternatives to having the police respond.  You can read here about the history and effectiveness of the estimated 400 CIT programs currently in the U.S.. 

CIT is Foundational (and We Need Co-Response Too)

Guest blog by Jeff  Fladen

As a leader of my state’s effort to expand CIT (Crisis Intervention Training) for law enforcement and other first responders, I have been hearing the same story nearly every day.

Instead of CIT, what about Co-Response and Alternative Response models, where mental health professionals assist the police during a mental health crisis either in person such as a social worker ride along or remotely from a control room or crisis center.

The Cahoots (Crisis Assistance Helping Out On The Street) program, launched by the White Bird Clinic in Eugene, Oregon some 30 years ago, is often brought up as an example of a successful co-response, although this program does not include social workers “riding along” with law enforcement. Cahoots features two-person teams consisting of a medic (a nurse, paramedic, or EMT) and a crisis worker who has substantial training and experience in the mental health field.

The program developed as an alternative to law enforcement acting as the mental health crisis first responder and offers an alternative approach to non-emergent issues. Other Co-response models include the Boulder Early Diversion Get Engaged (EDGE) program in Colorado, and the Boston Police Co-Responder Program, in existence since 2011. Additional programs around the country have developed  or have been announced in the past year.

I am deeply concerned that this is sometimes framed as an either/or discussion when it comes to CIT.  It shouldn’t be.

We have been working in my state of Tennessee to expand CIT programs, particularly in rural communities. CIT began in Memphis, Tennessee over 40 years ago under the leadership of Major Sam Cochran and Dr. Randy Dupont with support of NAMI Memphis.

Some of the recent criticism and concern about CIT is the result of the tragic TV imagery that we have seen about troubling fatal police encounters with African Americans and also encounters with persons living with mental illness. Some advocates have asked “how that can happen with CIT which includes de-escalation training.” They are looking for new alternatives.

Why CIT Is Important: Community Involvement 

CIT programs are thought of as a 40 hour training for law enforcement that includes de-escalation training and information about mental illness and addiction. They have been popular within law enforcement in part because officers have been thrust into the front lines to intervene in a mental health crisis. These officers often had few options other than taking people to jail or a lengthy process leading to an involuntary hospitalization or a long stay in an ER until services became available.

We have been criminalizing mental illness.

An often overlooked component of CIT is that while it includes training, it is actually a community program. When the model is appropriately followed, a local CIT program includes a task force of community leaders including criminal justice representatives, mental health and addiction providers, EMT and crisis resources, peer support, and other community advocates such as NAMI. In addition to learning about existing systems and resources, the identification of gaps in resources other than jail or hospital for those in crisis on weekends or after hours can lead to the establishment of new community programs and services. This has happened Tennessee with additional services such as new walk in centers or intensive case management.

Should The Police Always Be First responders?

Advocates for Co-Response models correctly point out that police may not be the best to be the first response for a crisis.

Police may not have the skills or ability to invest the time needed to diffuse and resolve a crisis. Police may not even view this as a legitimate part of their job. Officers may have minimal mental health training, even with CIT. Others add that encountering a uniformed officer may be triggering to the person in crisis and escalate the situation.

The experience with Cahoots shows that sending mental health workers to be first on the scene can be done safely and effectively. Not all mental health crises represent imminent threat to responders or anyone else.

Two challenges to a Co-Response model are triage and costs. Can calls be effectively screened to determine the level of threat? Or if a response team goes into the community to assess a person in crisis, can law enforcement, if needed, be called to the scene quickly?

The bigger challenge is the cost of the Co-Response model. To have 24 hour coverage that can respond to any and all calls in a rural or large urban area may be prohibitively expensive. A team that is busy with one case can not quickly respond to another.

Why We Need Both Co-Response & CIT

Even if we have an abundance of Co-Response resources in a community, CIT for some officers and mental health and addiction training is necessary for all. All law enforcement mental health encounters do not begin with a call to 911 and dispatchers also need targeted training like CIT. Law enforcement personnel will encounter persons in a mental health crisis without knowing in advance that they are occurring such as when responding to an auto accident, a domestic violence situation, or disturbance of the peace.

We need to learn how to provide appropriate triage and expand our non-law enforcement capacity to respond to crises in the field and not just at an ER, jail, or walk in mental health center. We are already moving quickly in this direction as the nation builds out response models for the new 9-8-8 system which likely will receive a wide range of calls in addition to suicide prevention.

CIT and Co-Response models both need expanded research as well as the development of standards.

While any program can call itself “CIT,” is that enough to make it so?

Recent articles criticizing CIT may have methodological flaws that decrease support for essentials programs. According to Amy Watson, CIT Researcher:

“It is frustrating to see inaccurate representations of research on CIT in the media.  Often, these critiques misrepresent the CIT model and ignore that the growing body of research indicates CIT improves officer preparedness to respond and increases referral and linkage outcomes. This sometimes leads to presenting models like CAHOOTS instead of CIT.  In reality, we need both. Foundational CIT programs built on partnerships that ensure police are prepared to respond effectively when needed AND models to provide mental health crisis response without involving police.“

If calls are triaged and law enforcement will not always be first on a scene, programs need be able to provide effective triage and assess potential dangerousness for all involved. Procedures to minimize risk to the safety of response workers will be needed in order for any alternatives to law enforcement acting as the first responder. We should be concerned about the safety of law enforcement, first responders, the person in crisis, and their family.

It’s a tall order and likely no solution will be perfect in all situations due to the unpredictability of all involved.

We need both CIT and Co-Response models and we have a great of work to do to improve our crisis response system. There are probably issues with implicit bias, both within CIT and the mental health system as well.  We need to develop better non-lethal approaches for both first responders and law enforcement to make encounters safer and less traumatic for all involved. We should develop standards for consistent implementation as well as include the opportunity for local needs and cultural differences to be considered. And we must follow the CIT model of including stakeholders in the establishment of our crisis response systems rather than a continuation of siloing or the handing down of solutions without broad input which has been much too common.

Co-Response models will allow for new types of responders to become involved. Certified Peer Support Specialists, mental health clinicians and EMT may have a role to play. New technologies such as telemedicine from the scene may be helpful. My hope is that local, regional, and statewide coalitions will grow while avoiding an either/or approach. National coalitions may be helpful as well. Perhaps, NAMI, CIT International, the One Mind Campaign, the Stepping Up Initiative along with their partners may work together.

I truly hope that my fear that CIT will be pushed aside for the suddenly very popular Co-Response approach will not take place. We need both.

About the author: Jeff Fladen, MSW, is Executive Director of NAMI Tennessee, and a former crisis worker, ER social worker, and Co-Leader of the Tennessee CIT Project. 

He quotes Amy Watson in his blog. She is a professor at Helen Bader School of Social Welfare at University of Wisconsin-Milwaukee. She also holds a courtesy appointment in the Department of Crime Law & Justice. Professor Watson has worked extensively on issues involving the relationship between the criminal justice system and mental health systems. Her current research focuses on police encounters with persons with mental illnesses and the Crisis Intervention Team (CIT) model.