Emergency departments have always served as a resource for the police in crisis situations for persons with mental illness. Nonetheless, there are substantial barriers to use of emergency services as a point of effective police referral to the mental health system (1,2,3). Police are often frustrated by long periods spent in the emergency room away from their regular patrol duties and by refusals to admit patients because of inconsistent or unmet criteria for emergency treatment.
In addition, emergency department medical and mental health staff have sometimes argued that many persons referred by police do not meet requirements in the mental health codes for involuntary treatment (2). This issue is a serious one because many individuals referred by the police refuse voluntary services (4). Thus transporting an individual in psychiatric crisis to an emergency department is often frustrating for both law enforcement and mental health professionals.
In response to the need to improve interactions between police and emergency mental health systems, a number of new crisis models have emerged that acknowledge the needs of both mental health and law enforcement professionals. One common but unstudied feature of these new models is what we call a "specialized crisis response site."
Specialized crisis response sites have been especially important in the development and implementation of many prebooking jail diversion programs for persons with mental illness and substance use disorders. These police-based diversion programs identify detainees with mental disorders and work with diversion staff, community-based providers, and the courts to produce a mental health disposition in lieu of jail (5,6).
Three of the jail diversion programs participating in the current Substance Abuse and Mental Health Services Administration (SAMHSA) jail diversion knowledge development application initiative (7) demonstrate the importance of specialized crisis response sites as core elements in their prebooking diversion programs. The three programs are in Memphis, Tennessee; Montgomery County, Pennsylvania; and Multnomah County, which encompasses Portland, Oregon. Although these programs have certain differences, they share common approaches and basic principles that can provide a basis for the development of innovative programs in other communities.
Montgomery County Emergency Services
The Montgomery County program is a pre- and postbooking diversion program based in Montgomery County Emergency Services (MCES). MCES was opened in 1974 as a not-for-profit, freestanding psychiatric hospital that includes crisis intervention, telephone hotline assistance, mobile crisis outreach, and referral to treatment (8). This program was recognized in 1978 by the National Institute of Law Enforcement and Criminal Justice as an exemplary program (9) and by Torrey and colleagues (10) in their review of exemplary alternatives to the criminalization of mental illness.
In addition to mental health services, MCES is licensed for substance abuse treatment and operates a detoxification and dual diagnosis treatment program. MCES clients include both persons who are diverted from jail and those who may never have been arrested. Of the 2,153 MCES admissions in 1999, 1,020 (47 percent) were criminal justice referrals.
When police encounter a situation involving an individual they think has a mental illness, they may transport the individual directly to MCES, or MCES may dispatch its ambulance service, whose staff are both emergency medical technicians and psychiatric crisis specialists. MCES has a no-refusal policy for law enforcement officers, which allows them to drop off persons in crisis and return to their regular patrol duties. MCES is a secure facility that is prepared to take custody of persons in crisis, even if they are county prisoners. Police spend an average of 20 minutes dropping off an individual at MCES for crisis assessment and intervention. If MCES sends an ambulance or crisis team, police do not have to come to the facility. Instead, police are asked to give statements at the scene of the disturbance, which are used to inform decisions about involuntary inpatient commitment.
The Memphis prebooking jail diversion program, which was established in 1988, has two key features: an innovative police team—the Memphis police department's crisis intervention team—and a crisis center. The crisis triage center is part of the University of Tennessee psychiatric services and is based in the emergency department at the regional medical center. This service has a no-refusal policy and a 15- to 30-minute turnaround time for police. This system has been designated as a model program by the National Alliance for the Mentally Ill and the American Association of Suicidology. It has been replicated in a number of other jurisdictions, including Albuquerque, New Mexico; Portland, Oregon; and Seattle.
The service receives 450 to 500 referrals a month. More than 70 percent of the referrals come from law enforcement agencies. The proximity to emergency medical services is helpful, given that more than 30 percent of the individuals referred have an axis III diagnosis, indicative of a nonpsychiatric medical disorder.
The Multnomah County program
The Multnomah County prebooking jail diversion program, established in 1997, has a crisis triage center and a police crisis intervention team program that is modeled after the Memphis crisis intervention team. The crisis triage center is located on the hospital campus of Providence Medical Center. The triage center is the crisis system for Multnomah County. Among the services at the triage center are a 24-hour crisis line; crisis intervention and stabilization; mobile outreach; voluntary subacute treatment, which includes chemical dependency; detoxification; mental health treatment; referral to outpatient community providers; medication management clinics; three holding rooms; and secure transport.
As in Memphis, when a person is in crisis or someone is arrested who exhibits signs of mental illness or substance abuse, crisis intervention team officers are dispatched. The triage center is a one-stop centralized crisis service for law enforcement officers. The center has a no-refusal policy for police referrals. The police may transport individuals either voluntarily or in custody. The officer provides the necessary information to the center staff, fills out one form, and returns to duty within 30 minutes. In the past two years, 2,300 individuals have visited the center, 20 percent of whom were referred by police.
No client outcome data are available to measure the impact of these specialized crisis response sites. The SAMHSA multisite study in which they are participating will provide some important data in the near future. The observations reported here have emerged from site visits and training sessions at each program by three of the authors (Steadman, Stainbrook, and Griffin), from operation of these programs by two authors (Dupont and Horey), and from involvement in the SAMHSA evaluation by one of the authors (Draine).
Identifiable, central drop-off
Each of the programs offers a centralized site, available 24 hours a day, to which police can bring an individual in psychiatric crisis who is in need of a formal assessment. A central drop-off site provides police with a single point of entry to the mental health system. Having such a site directly addresses past difficulties for police in accessing mental health services in response to a psychiatric crisis. In a national survey of 174 police departments, officers who had access to a drop-off center were significantly more likely than those who did not to describe their programs as being effective (11).
In addition, the co-location of mental health and substance abuse services at the drop-off site relieves the officer of some of the burden of discriminating between mental health, substance abuse, and other crises. It also allows a single point of access to both the mental health and substance abuse systems, which is particularly important given the high rate of co-occurring disorders in the population referred by police.
"Police-friendly" policies and procedures
Clearly, the key principle in all three programs is a mutual respect between law enforcement and mental health personnel. Mutual respect is grounded in acknowledgment of the professional interests of both behavioral health and law enforcement staff in protecting the community (12). It is operationalized in policies and procedures for response to crises.
No refusal. The no-refusal policy for law enforcement referrals means that regardless of the mental health criteria for involuntary treatment, the specialized crisis response services in all three sites uniformly accept police referrals. Strategies have been developed to facilitate legal proceedings. For example, mental health courts are on-site in Montgomery County, and the commitment law in Tennessee gives law enforcement agencies a role in this civil process.
Although not all persons referred by law enforcement officers are admitted for inpatient stays, no client is refused for financial reasons. At all three sites, the counties provide financial backup as a buffer against situations such as unfavorable utilization review decisions. Therefore, a targeted county financial commitment also facilitates the integration of police and crisis service missions. The no-refusal policy addresses one of the largest barriers in the traditional emergency room model by eliminating unnecessary arrests. Because of the policy police will not be deterred from transporting a person to the crisis center if they have concerns that the person will not meet the criteria for mental health services.
Streamlined intake. In recognition of police concerns about time spent away from their public safety responsibilities, the specialized crisis response units have streamlined the process to minimize police officers' time at the center. The regional medical center in the Memphis program has a streamlined referral process for police so that they typically spend less than 30 minutes in the crisis center to process an individual for evaluation. The Multnomah County crisis triage center and MCES have made similar special accommodations for law enforcement personnel. The triage center has an entrance separate from other admissions for police to expedite drop-offs, and it has provided the officers with a dedicated office and telephone line. The time required for a police drop-off at MCES averages 20 minutes, and MCES also provides a crisis team or ambulance service that is available 24 hours a day to assist law enforcement personnel.
Another important factor is a legal foundation in the statute, code, or policy of the specialized crisis response to enable referrals from law enforcement personnel. Each of the three programs has established legal underpinnings so that the specialized crisis response site can accept and detain an individual who may or may not have pending criminal charges. The programs in Multnomah County and Montgomery County have made use of a criminal code that allows for misdemeanor arrest diversion. The Memphis program has made use of the civil code that allows for police-based mental health crisis referral. Establishing legal foundations not only avoids the long delays brought about by the custody issue noted above but also provides some degree of protection for mental health clinicians working in what is seen as the high-risk field of "dangerousness assessment."
These legal foundations recognize the dual roles of the crisis site for public safety and individual health care. In Montgomery County, for example, a police officer may facilitate the initial involuntary hospitalization detention without the usual required review by a mental health magistrate delegate. This approach expedites the development of specialized police drop-off supports for persons in psychiatric crises.
Innovative and intensive cross-training
Training is a critical component of the specialized crisis response because it enhances collaboration and mutual understanding. Training includes both law enforcement and mental health personnel. Mental health workers often have unrealistic expectations of law enforcement's authority and respond to stereotypic images of police officers. These programs have found that cross-training with police officers enhances the collaboration and police-friendly response needed for the system to succeed. Both the Memphis and the Multnomah models encourage mental health staff to ride shifts with the officers in the diversion program and to participate in the training.
Linkages to community services
As part of the prebooking jail diversion programs, the specialized crisis response sites go beyond assessment and evaluation. They link individuals to both mental health and substance abuse services in the community. The programs have all reported the importance of maintaining strong relationships with community services. These relationships require the talents of a "boundary spanner" (13) and appear to be personal in nature in order to most easily bypass the institutional barriers often encountered in the disposition process. Often these programs have recognized the need to further link individuals to services by providing case management. Ensuring that all referrals are linked to services is associated with lower crisis recidivism (14) and possibly with lower criminal recidivism (7).
The availability of a specialized crisis response site in prebooking jail diversion programs in Montgomery County, Memphis, and Multnomah County has been a critical factor in surmounting many of the problems previously experienced in law enforcement- mental health interactions. An analysis of outcomes of specialized police responses to mental health emergencies (15) found that the arrest rate in mental health crisis situations in cities with specialized police responses was only 6.7 percent. This rate is a third of that reported by Sheridan and Teplin (16) for nonspecialized police responses. A strong message that emerges from our examination of program operations at the three study sites is that 24-hour, police-friendly specialized response sites are a key element in these programs.
Although specialized response sites for police appear to facilitate police use of psychiatric crisis services, the effectiveness of the overall crisis service is also important in supporting police. Effective crisis services provide both treatment on-site and appropriate referrals for individuals when they are stabilized. Police frustration with individuals whom they encounter repeatedly may increase when these individuals are not adequately engaged with community-based services. It appears that 24-hour specialized crisis response sites with no-refusal policies, appropriate legal foundations, and real linkages to community-based services are a key element in successful prebooking jail diversion programs for individuals with serious mental illness and substance abuse problems.
Dr. Steadman is affiliated with Policy Research Associates, Inc., 262 Delaware Avenue, Delmar, New York 12054 (e-mail, firstname.lastname@example.org). Ms. Stainbrook is with Advocates for Human Potential in Delmar, New York. Dr. Griffin is with the National GAINS Center in Delmar, New York. Dr. Draine is affiliated with the Center for Mental Health Policy in Philadelphia. Dr. Dupont is with the department of psychiatry at the University of Tennessee in Memphis. Ms. Horey resides in Portland, Oregon.