C.I.T. or M.H. Co-Response: Which model is safer for everyone?


Dr M. Sefton (left) Officers Ernest Stevens and Joe Smarro of SAPD Mental Health Unit


WESTBOROUGH, MA May 5, 2018 When people are in crisis law enforcement officers respond to the call for help. Because of a spate of police officer involved shootings there is a call for less police violence.  Yet in fact, it is the primary action of the citizen the evokes the lethal response by police. Those who call for “more police training in mental health counseling and less training in the use of firearms” have never been faced with the life or death conundrum – kill or be killed. Meanwhile, police officers are being called upon to de-escalate hazardous encounters daily using skills taught to them in the academy or in-service training. A detective in an urban department recently told me that the majority of their calls for service are for people exhibiting signs of mental illness.
The Department of Justice published a BJA Spotlight on Safety article entitled Defusing Difficult Encounters that essentially teaches officers to slow down the scene by projecting calmness and establish rapport. This is done by asking open-ended questions, e.g. “tell me what happened today”? Constantly assess the dynamic, changing threat by using communication strategies, defusing strategies, and mindfullness. Finally, take action using the minimum about of force needed to bring about a peaceful outcome.  Taking action does not necessarily mean the subject is arrested or goes to hospital.  In my experience if family members are actively engaged in the person’s life they may assist with aftermath intervention such as detox, rehabilitation, or hospitalization, if needed.  Ultimately, the use of force continuum follows the principle of causation by guiding police decision making based on the level of threat in any police encounter.
There are two dominant approaches to encounters of police and persons with mental illness. The first involves having mental health clinicians either ride along with patrol officers (or detectives) and roll on calls that involve someone exhibiting signs of mental illness. In some cases clinicians are housed at police facilities and interview subjects once they are brought in for determination of needs – rather than simply sending the person to the local emergency department.  The second method of police-mentally ill interaction teaches LEO’s to directly engage the person using skills they are taught such as empathic listening, establishing rapport, defusing emotional crises, and initiating treatment options e.g. hospitalization, medication management, return to psychotherapy, detoxification, 12-step AA or NA meetings.  Family members are encouraged to facilitate some treatments and I believe play a large role in keeping family members sober.  The drug or alcohol abuse often makes the mental illness more unpredictable and unstable.  Significant threats to public safety and direct risk to police officers can be mitigated if the abuse of drugs and alcohol can be managed by members of the immediate family.
Crisis Intervention Training (CIT) for police officers is an expensive and ambitious program that teaches first responders how to recognize and engage citizens exhibiting signs of mental illness.  I have seen this for myself work smoothly in San Antonio, Texas in 2017.  The SAPD is using a program developed by police and mental health professionals in Memphis, TN in the early 2000’s and adopted by SAPD in 2003.  I was fortunate enough to ride with two of the department trainers Officer Ernest Stevens and Officer Joseph Smarro.  I was shown the MH intake facility and met Roberto Jimenez, M.D, the program medical director who began his career at Boston City Hospital as I did. I visited the entire continuum of services including Bexar County sponsored housing and career development programs.  It was quite an experience and I remain in contact with the unit to this day.  Some believe that this “sensitivity training” will reduce the number of officer involved shootings with those who are known to be mentally ill. CIT training offers plenty of practice role-playing scenarios that come directly off of the call sheets affording a reality-based training opportunity.
In something of a contrast many department utilize the service of a mental health expert – usually a clinical social worker or licensed mental health counselor, to provide the de-escalation intervention, dialogue and liaison with mental health services to reduce the need for jail and the risk to everyone involved from escalating behavior and missed understanding. I have spoken to police officers accustomed to this method who believe it works well.  They develop a rapport and trust in the mental health clinician who comes on the scene only when it is safe to do so to begin their assessment. This too is designed to reduce the risk of unintended consequences and divert individuals away from jail and into treatment programs. Given the speed at which violent encounters take place I believe there are risks to everyone involved using this model of de-escalation. When an officer has one instant of hesitation he or someone else may be victimized in the time it takes to make contact, size up the call, and gain compliance.
The NYPD uses a clinician model that tracks hospital discharges and uses a preemptive strategy meeting with mentally ill persons prior to any growing crisis.  Their belief is that by keeping them off the police radar they reduce the likelihood of an acute crisis and divert potentially lethal encounters.
“Steve Coe, the CEO of Community Access, an organization that advocates for the mentally ill and works with the NYPD training officers on how to treat that community, said he hopes the task force focuses on creating a system that also would dispatch social workers to emergencies involving the mentally ill.” according to a report in the Wall Street Journal – April 21, 2018
Crisis Intervention Team training (CIT), is a progressive first-responder collaborative effort that works closely with community stakeholders, health care organizations , and various advocacy groups. The CIT model was first developed in Memphis and has spread throughout the country. The San Antonio Police Department adopted this model in 2003 and it has continued to grow immensely year after year. 40-hour CIT training allows law enforcement officers to respond with a new skill set which has a myriad of benefits both data specific and anecdotally. Additionally, CIT in San Antonio directly benefits individuals with a mental illness, while improving the safety of patrol officers, mental health consumers, family members, and citizens within the community. Because CIT is a collaborative program, it provides the foundation necessary to promote community and statewide solutions to assist individuals with a mental illness.
The 40-hour CIT model aims to reduce both stigma, and the need for further involvement with the criminal justice system through jail diversion programs. CIT provides an opportunity for effective problem solving regarding the interaction between the criminal justice and mental health care system. San Antonio Police Chief William McManus has mandated the 40-hour CIT training to all cadets and peace officers on the department. The San Antonio Police Department has fully embraced CIT by allowing a full-time Mental Health Detail to grow from two-officers to 10-officers, according to a SAPD spokesperson with knowledge of the SAPD program.
Dual Diagnosis – Mental Illness and Substance Abuse/Dependence
Arguably, when the police are called to keep the peace or investigate a violent person call they are required to meet the threat with heightened awareness for their personal and the safety of the immediate family and others.  If the violent person is actively aggressive or menacing with threat of lethal injury to the police or others than there is unlikely going to be any de-escalation until the threat of lethal force is eliminated. More often than not the person of interest is intoxicated or under the influence of drugs as well as suffering from some form of mental illness like depression or paranoia.  In the time it takes to find just the right words to engage a threatening subject who is waving a firearm or machete or baseball bat people may die – including members of the police who are trained and responsible for calls like this. When people attend psychotherapy sessions and 12-step recovery programs the proclivity for violence is greatly reduced.
No single model is best and all are still in the growing stages of establishing protocols for bringing those most disturbed individuals in from the margins. More and more officers are receiving CIT training every year according to Sefton in 2017.  Inevitably, drug abuse is a co-morbid factor that alters perception and fuels underlying anger and violent tendencies. On the other hand, if the violent person responds to officer directives to cease and desist all violent action and submit to being taken into protective custody or arrest – only then can mental health assessment be initiated.

San Antonio Mental Health Unit (2018) Personal correspondence on Crisis Intervention Team – Mental Health Unit.
Sefton, M. (2017). Police are building bridges and throwing life savers.  Blog post https://msefton.wordpress.com/2017/03/30/police-are-building-bridges-and-throwing-life-savers/ Taken April 21, 2018