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?Law Enforcement Personnel Need More Training In Order To Adequately Interact with the Mentally Ill
Introduction
The deinstitutionalization of patients from mental health facilities or asylums began over five centuries ago and has had far-reaching consequences. The foundations of the decentralization movement according to Lamb and Bachrach are 1) persons residing in psychiatric hospitals would be released to families and alternative living facilities in the community, 2) potential new admissions would be diverted to alternative community facilities, and 3) special services for the care of non-institutionalized mentally ill persons would be developed (2001). It was believed that individuals would receive necessary and appropriate care at the community level. Unfortunately, the lack of consistent care that a person with a mental illness requires often results in homelessness or reliance on police intervention to receive treatment. Law enforcement professionals have increasingly become the initial contact for individuals who are experiencing a mental health crisis and do not possess the necessary skills and knowledge to safely and effectively bring resolution to the situation. Law enforcement agencies, as well as individuals with mental illness, would benefit from law enforcement personnel receiving additional specialized training in mental illness, and the creation, implementation, and utilization of collaborative response approach or teams.

Statement of Problem
It has been well documented that many of the individuals who were released from state mental hospitals had difficulties acclimating back into society and their communities (Hartford, Heslop, Stitt, & Hoch, 2005). Lacking sufficient social skills and support as a result of being institutionalized, many are in need of coordinated multidisciplinary resources which may include medical, psychiatric and case management, and in part is a contributing factor to the large number of untreated and homeless mentally ill (Lamb & Bachram, 2001). Between 1959 and 2016 the number of state psychiatric beds available in the United States declined from 339 per 100,000 to a mere 11.7 per 100,000 (Fuller et al 2016).
Unfortunately, an adequate level of care for deinstitutionalized individuals has never established. When deinstitutionalization began, a sufficient housing plan was not created for people being released (Wachholz & Mullaly, 1993). As a result, it is suggested that 15% to 24% of the population of people with mental illness are in jail and 28% are homeless (Davis, Fulginiti, Kriegel & Brekke, 2012). The lack of consistent care that a person with a mental illness requires often results in homelessness or reliance on police intervention to receive treatment.

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One unintended consequence of decentralization is the steady increase of interactions between law enforcement personnel and the mentally ill (Hartford, Heslop, Stitt, & Hoch, 2005). In urban centers with populations of 100,000 or more, approximately 7% of all police interactions with the public involve people with mental illnesses (Deane, Steadman, Borum, Veysey, & Morrissey, 1999). These interactions can be time-consuming, potentially dangerous, and in most cases an individual’s first contact with social or criminal justice systems (Reuland 2010).

Another contributing factor for increased interaction with law enforcement is the decrease in funding for mental health services. This is a key reason for the rising numbers of arrests of people with mental illness and jail becoming a default place of treatment (Teplin, 2000). Financial responsibility shifted from the mental health arena to law enforcement with respect to treating people who are incarcerated and law enforcement has had to take other measures such as the creation of specialized response teams in order deal with the mentally ill (Lamb ; Weinberger, 2005; Teplin, 2000).
Numerous studies have been conducted that have documented the disproportionate number of people with a mental illness who have entered the criminal justice system instead of psychiatric treatment facilities (Ellis 2014). According to Hails ; Broum, approximately 685,000 people with mental illness are incarcerated every year; and that between 6% and 15% of all inmates have a severe mental illness (2003).

Law enforcement personnel frequently respond to crisis calls involving individuals with mental illness such as schizophrenia and bipolar disorders, or substance issues such as alcohol or opiate, and often serve as the primary source for referral to mental health services. For this reason, it is necessary for law enforcement personnel to be knowledgeable about the various mental illnesses/disorders signs and symptoms, and have familiarity with available community resources in order to redirect individuals to these resources and not to the judicial system (Compton et al 2008).

Law enforcement Training and creation of CIT teams
Half of law enforcement professionals feel that they have inadequate training in mental health and do not know what to do when encountering cases dealing with a person with a mental illness (Wells ; Schafer, 2006). Sadly, excessive force has been used in some jurisdictions by law enforcement professionals resulting in the death of a person experiencing a mental health crisis (Hails ; Borum, 2003).

According to one study that surveyed 84 law enforcement agencies across the United States that had more than 300 officers, new personnel receives between zero and 41 hours of training devoted to responding to calls involving people with mental illness (Hails ; Borum, 2003). Law enforcement agencies that responded to the questionnaire commented that training time also covered other areas including substance abuse, developmental disabilities, and supervision of unmanageable suspects (Hails ; Borum, 2003).

Hails ; Borum indicate that of 70 agencies surveyed, a minimum number reported that their training curriculum was based on collaboration between the mental health services and law enforcement (2003). Less than half of the agencies surveyed indicated the use of specialized response programs when interacting with individuals who are either known to have or are suspected of having a mental illness (Tucker, Van Hasselt, Vecchi, ; Browning, 2011).
Law enforcement personnel have taken notice of the inadequate training. According to a study conducted in Indiana, it was identified that 80% of law enforcement personnel from five different agencies recognized that mental health training needed to be improved and 75% were willing to participate in additional training (Wells ; Schafer, 2006). These law enforcement professionals advised that the major problems they encountered included identifying mental illness, knowing how to interact with these individuals, and a lack of awareness of the options and resources available (Wells ; Schafer, 2006). Financial constraints also hinder the ability of law enforcement agencies to implement specialized response teams (Tucker, Van Hasselt, ; Russell, 2008).

Attitudes and Perception
Criminal justice policies elicit a variety of responses, emotional and behavioral from both law enforcement personnel and people with mental health concerns (Jennings, Gover, ; Piquero, 2011). It has been identified that if law enforcement personnel have a negative attitude towards a person experiencing a mental health crisis the likelihood of using appropriate de-escalations techniques, avoiding excessive force and referral to mental health services decreases (Ellis 2014). Conversely, it can be assumed that if law enforcement personnel views mental illness as just that an illness that needs treatment, they are more willing to de-escalate the situation or make a referral to a mental service.

Factors specific to law enforcement personnel themselves also influence dispositional decisions. Training and attitudes surrounding mental health problems affect how they approach people with mental illnesses and how they are likely to handle these situations.

Calls involving people with mental illnesses are often viewed as not “real police work” (Wachholz ; Mullaly, 1993). Watson, Corrigan, and Ottati (2004) conducted several studies regarding the attitudes of law enforcement officers towards people with mental illnesses. Watson et al. (2004) suggest that law enforcement officers tend to question the credibility of a person with mental illness, which leads to the possibility of the individual not being helped. The law enforcement officer may not believe what the person with a mental illness states and important evidence may be ignored. The authors also suggest the perception of the level of dangerousness of a person with mental illness is greater among law enforcement officers. The assumption by law enforcement officers that a person with mental illness is dangerous can lead to violent outcomes.

Another Watson et al. (2004) study focuses on police knowledge on labeling a person with a mental illness. The authors suggest that an officer’s ability to label a mental illness along with their perception and attributions to the situations will affect the kind of assistance the person will receive. If the law enforcement officer believes that the person with a mental illness is responsible for their actions and feels anger towards the individual, officers are less likely to offer help and more likely to be more punitive.
Dispositions
Law enforcement personnel have a great amount of discretion in their decisions when interacting with a person with a mental illness (Godfredson, Ogloff, Thomas, & Luebbers, 2010). Training to be able to differentiate between symptoms of substance use and mental or emotional symptoms plays a vital role in the outcome for the individual exhibiting the symptoms. Legal policies empower law enforcement personnel to intervene but lacks specificity in what the intervention should be (Tucker, Van Hasselt, Vecchi, & Browning, 2011). The disposition chosen is based not only on the situation but also on the severity of symptoms expressed by the individual (Godfredson, Ogloff, Thomas, & Luebbers, 2010). These dispositions may include leaving the person with mental illness with a friend or family member, referral to mental health services, emergency medical care or arrest (Cooper, Mclearen, & Zapf, 2004). In some situations, law enforcement personnel recognize that a person should be evaluated by a mental health professional before any action is taken, but due to lack of community resources and effort needed to obtain an evaluation arrest become the easy option (Wells & Schafer, 2006).

Arrest.

Research shows that officers typically resort to arresting a person with a mental illness in three types of situations: when the individual is thought to be inappropriate for hospitalization, when their behavior has exceeded community acceptance and it is thought that the individual would require further police intervention if nothing is done (Teplin, 2000; Tucker, Van Hasselt, & Russell, 2008). Based on these situations, officers are making arrests when they feel they have no other options. Law enforcement officers often resort to arrest because they feel that they have to act when handling a call with a person with mental illnesses (Patch & Arggio, 1999).
Another plausible reason that law enforcement personnel prefer arrest over hospitalization is their frustration with the mental health system and lack of available beds. Hospitalization stays may be too short to be effective and thus lead to repeated interaction with the same people with mental illnesses. There may also be a perception among law enforcement officers that there is a lack of effective community mental health treatment (Fisher, Normand, Dickey, Packer, Grudzinskas & Azeni, H., 2004).

Hospitalization.

Hospitalization as a treatment for people who have mental illnesses is used the least of all formal police disposition options (Teplin, 2000). Utilization is inhibited by the limited number of psychiatric beds available in communities as well as officers’ unwillingness or inability to wait long amounts of time for a physicians’ evaluation (Green, 1997; Teplin, 2000). There are less state hospital beds per capita than at any time since before the nation stopped criminalizing mental illness in the 1850s (Fuller et al 2016).
According to a study conducted in 2012, law enforcement officers did not make a mental health referral in 58% of the cases involving people who were not receiving mental health services. This suggests that hospitalization is the least likely disposition taken by law enforcement personnel (Van den rink, Broer, Tholen, Winthorst, Viser & Wiersma, 2012).

Resolve informally.

According to numerous studies, officers choose to handle many mental health calls by resolving the situation informally (Lamb, Weinberger, & DeCuir, 2002; Teplin, 2000; Tucker, Van Hasselt, & Russell, 2008). Many communities have people with mental illnesses who are well known in the neighborhood by the residents and law enforcement alike. Officers may feel that they can diffuse situations with these better-known people by methods such as talking them through a crisis or soothing them (Teplin, 2000). Some of these people have been labeled “troublemakers” and officers feel that intervention in these cases is not worth the trouble; and as a result, they have stopped trying to hospitalize or arrest them (Teplin, 2000). One study concluded that officers are somewhat more lenient when they know that someone has a mental illness (Watson et al., 2009). In one study where researchers observed officers’ interactions, about 20% of officers took no action with a person when they could have been justified in arresting the person (Green, 1997).

Officers who have more years of experience are more likely to resolve situations with people with mental illnesses informally and avoid arrests by relying on collaborations with mental health workers to find appropriate dispositions (Godfredson, Ogloff, Thomas, ; Luebbers, 2010). In fact, most officers’ first choice is an informal resolution (Teplin, 2000). According to one set of data, 72% of cases are resolved informally (Teplin, 2000).

In addition to a lack of community resources and support during these interactions, situational factors influence officers’ dispositional decisions. Factors including whether the officer or agency answering knows the individual and suspicion of substance use aid officers in making their decisions (Cooper, McLearen, ; Zapf, 2004; California Commission, 2002). If the individual is known to the officer or agency as a person with a mental illness, law enforcement officers are more likely to take an informal approach. It is difficult for law enforcement officers to make decisions when they are unable to differentiate whether the person is mentally ill or under the influence of a substance because it affects the decision on how they will handle the case.

Crisis Intervention
The Crisis Intervention Team (CIT) is the newest and the most innovative approach to bridge these disparity gaps. This unique and creative program was established for the purpose of developing a more intelligent, understandable, and safe approach to mental health crisis events (Eleventh Judicial Circuit Criminal Mental Health Project, 2010). There is a wealth of interdisciplinary literature including criminal justice, criminology, and sociology with evidence supporting CIT as an effective law enforcement/police tool when intervening with persons with mental illness. A search of the literature indicated that very little on CIT has been addressed from the discipline of nursing. Nurses could potentially contribute significantly to CIT from their clinical expertise in community health, theoretical models, and research findings. Psychiatric Mental Health nursing expertise can serve as an important component of CIT in the future from the standpoint of ongoing community program development and evaluation, and evidence-based practice that results in quality health outcomes. The Crisis Intervention Team (CIT) model is a specialized police-based program intended to enhance police officers’ interactions with individuals with mental illness and improve the safety of all parties involved in mental health crises (Compton, Bahora, Watson & Oliva, 2008). The standard CIT training is a 40-hour course consisting of classroom didactics on the disease process and signs and symptoms of mental illness and substance use disorders. There are video and live experiential role-play scenarios depicting the de-escalation of a person in a mental health crisis. During the training, officers are taken on field trips where they visit local acute care psychiatric facilities, community mental health centers, and correctional facilities.

The establishment of CIT was in response to a local high profile incident in which an armed man with a history of a mental illness was killed by a police officer (Bahora, Hanafi, & Chien, 2008). The Memphis model of CIT was established as the prototype of collaboration between law enforcement and mental health professionals and adopted in a number of large municipalities across the country (Compton, Bahora, Watson & Oliva, 2008). CIT is a revolutionary approach to transforming mental health treatment to a segment of society with a long history of social stigma and mental health disparity. The Psychiatric-Mental Health Nursing model has the potential to radically improve care of the severe and persistently mentally ill in the community by partnering with law enforcement.

The CIT Program Model The first Crisis Intervention Team (CIT) training was developed and implemented in Memphis Tennessee in 1988 in conjunction with mental health professionals, local advocates, the National Alliance on Mental Illness (NAMI) and has evolved into a specialized program supported by the evidence from multiple studies (Bahora, Hanafi, & Chien, 2008). The leaders of CIT have identified several core elements. These include, but are not limited to: (1) partnerships, (2) community ownership, (3) law enforcement policies and procedures, (4) recognition and honors, (5) availability of mental health receiving facilities, (6) training and advance in-services of officers and dispatchers, (7) evaluation and research, and (8) outreach to other communities (Compton, et al., 2011, and Hanafi, Bahora, Nemir, & Compton, 2008). CIT is intended to enhance police officers’ interactions working with individuals having mental illness or substance abuse problems. By applying crisis intervention skills, negotiators can help the person in crisis defuse their emotions, lowering the potential for a violent incident and increasing the likelihood of better decision making (Compton, Bahora, Watson ; Oliva, 2008). The goal of using CIT techniques is to de-escalate and safely get the person in crisis to the most appropriate mental health facility where the most effective treatment is available.

The roles of contemporary mental health professionals are multifaceted and interface across disciplines, including law enforcement and criminal justice. Police officers often serve as de facto psychiatric triage specialists assuming many of the roles usually assume by Nurses, Social Workers and Case Managers (Compton, et al., 2009). Law enforcement professionals often are the community’s first-line responders to mental health crisis usually through the 911 emergency dispatch systems. These calls to EMS may come from the patients themselves, family members, neighbors, or other professionals throughout the community. The responding law enforcement officer must quickly assess the nature of the emergency and determine if the individual is experiencing a psychiatric emergency. Without the proper tools, such as those taught in CIT, police officers have to rely on high-intensity police units such as Special Weapons and Tactics (SWAT) to intervene with someone in a mental health crisis (Watson, 2010). The SWAT team would usually be called out if the person in crisis possessed a weapon, barricaded themselves in a building, or is threatening to jump off a high structure. For individuals experiencing a psychiatric crisis, this approach could prove counterproductive sometimes with tragic consequences (Compton, et al., 2009).

Despite the fact that police officers frequently respond to calls and crisis situations involving persons with serious mental illness, they receive very little training about mental illness. This results in a schism between expectations placed on officers and the minimal training they typically received for dealing with someone they encountered who are experiencing a psychiatric crisis (Demir, et al., 2009). These are complicated issues that demand an innovative intervention such as the CIT model. CIT is an.

an interdisciplinary and collaborative model consisting of four primary outcomes measures. These are: (1) increasing police officers’ knowledge of mental illness, (2) increasing their awareness of community services options and alliances (3) decreasing criminalization of the mentally ill, and (4) improving the safety of both the officer and the person with mental illness.

The wealth of empirical research and scholarly articles supports the benefit of CIT as an effective evidence-based, community-based healthcare intervention that benefits persons who are experiencing a psychiatric crisis. For example, studies by Bahora, et al., (2008), Broussard, et al., (2010), and Compton, et al., (2009) supported CIT as a means to increased and retained knowledge about mental illness, positive perceptions and attitudes toward persons with mental illness, officers choosing less force, and choosing to deliver persons with mental illness into treatment rather than jails.
Compton, et al., (2006), Compton, et al., (2009), and Demir, et al., (2009) reported effectiveness of CIT on improving police officers’ understanding of mental and substance abuse illnesses, as well as enhancing their perceptions and attitudes in a more favorable manner. Inquiries by Godschalx, (1984), Hartford, Heslop, Stitt, & Hoch, (2005) also concluded that CIT has meaningful benefits as a health and safety program for officers, persons served, and the community at large. Likewise, Ritter, et al., (2010), Vermette, Pinals, & Applebaum, (2005), and Aydin, Yigit, Inandi, & Kirpinar, (2003) reported effectiveness in CIT as an educational intervention across several healthcare disciplines. In contrast, while they offered important preliminary findings, studies by Compton, et al., (2011), Compton, & Chien, (2008), Godschalx, (1984), Hanafi, et al., (2008), and Teller, Munetz, Gil & Ritter (2006) had some methodological limitations. The authors could not determine the most effective curriculum content for CIT or the most effective methods for conducting the training for officers.

Conclusion
The complexities of mental health crisis events require special expertise in planning and implementing specialized skills-training on how to care for persons who are experiencing these forms of emotional and behavioral disturbances. This often results in adverse effects that include the use of unnecessary force, taking mentally ill persons to jail instead of psychiatric hospitals, and a growing number of ligations being sanctioned against police departments.

References
Compton, M., Bahora, M., Watson, A. & Oliva, J., (2008) A comprehensive review of extant research on crisis intervention team (CIT) programs, The Journal of the American Academy of Psychiatry and the Law, 36(1), 47–55.

Cooper, V., McLearen, A., & Zapf, P. (2004). Dispositional decisions with the mentally ill: Police perceptions and characteristics. Police Quarterly, 7(3), 295-310.
Deane, M.W., Steadman, H.J., Borum, R., Veysey, B.M., & Morrissey, J.P., (1999) Emerging partnerships between mental health and law enforcement. Psychiatric Services 50(1); 99-101.

Ellis, H. A. (2011). The crisis intervention team: a revolutionary tool for law enforcement: the psychiatric-mental health nursing perspective. Journal of Psychosocial Nursing and Mental Health Services, 49, (11), 37-43.
Fuller, D.A., Sinclair, E., Geller, J., Quanbeck, C., & Snook, J. (2016) Going, going, gone: trends and consequences of eliminating state psychiatric beds, Treatment Advocacy Center.

Hartford, K., Heslop, L., Stitt, L., & Hoch, J. S. (2005). Design an algorithm to identify persons with mental illness in a police administrative database. Internal Journal of Law and Psychiatry, 28, 1-11.
Lamb, H. R., & Bachrach, L. L. (2001).Some perspectives on deinstitutionalization. Psychiatric Services, 52, (8), 1039-1045
Reuland, M. (2010). Tailoring the police response to people with mental illness to community characteristics in the USA. Police Practice & Research, 11(4), 315-329.
Reuland, M., Schwarzfeld, M., Draper, L., (2009) Law enforcement responses to people with mental illnesses: A guide to research-informed policy and practice. Council of State Governments Justice Council.

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