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Co-responding police-mental health programs are increasingly used to respond to 'Emotionally Disturbed Persons' in the community; however, there is limited understanding of program effectiveness and the mechanisms that promote program success. The academic and gray literature on co-responding police-mental health programs was reviewed. This review synthesized evidence of outcomes along seven dimensions, and the available evidence was further reviewed to identify potential mechanisms of program success. Co-responding police-mental health programs were found to have strong linkages with community services and reduce pressure on the justice system, but there is limited evidence on other impacts. The relevance of these findings for practitioners and the major challenges of this program model are discussed, and future research directions are identified.
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Co-responding Police-Mental Health Programs: A Review
G. K. Shapiro A. Cusi M. Kirst
P. O’Campo A. Nakhost V. Stergiopoulos
Springer Science+Business Media New York 2014
Abstract Co-responding police-mental health programs
are increasingly used to respond to ‘Emotionally Disturbed
Persons’ in the community; however, there is limited
understanding of program effectiveness and the mecha-
nisms that promote program success. The academic and
gray literature on co-responding police-mental health pro-
grams was reviewed. This review synthesized evidence of
outcomes along seven dimensions, and the available evi-
dence was further reviewed to identify potential mecha-
nisms of program success. Co-responding police-mental
health programs were found to have strong linkages with
community services and reduce pressure on the justice
system, but there is limited evidence on other impacts. The
relevance of these findings for practitioners and the major
challenges of this program model are discussed, and future
research directions are identified.
Keywords Co-responding police-mental health
programs Community outreach Mobile crisis response
Psychiatric service organization and delivery
The interaction between police officers and individuals who
experience a mental health crisis is high and increasing in North
America (Coleman and Cotton 2010).Between7and31 %of
police calls involve a person with mental illness (Abbot 2011;
Baess 2005; Wilson-Bates 2008). Not surprisingly, police have
been described as the ‘‘de facto mental health providers’
(Cotton & Coleman 2006, p. 2), ‘‘key front-line responders in
mental health emergencies’’ (Steadman et al. 2000, p. 645),
‘streetcorner psychiatrists’’ (Teplin and Pruett 1992, p. 139),
and‘societysdefacto24/7mental health workers’’ (Thomp-
son 2010, p. 3). The increase in police involvement with mental
illness is reported to be due to a number of factors including
deinstitutionalization (i.e. more individuals with psychiatric
issues residing within the community), fewer psychiatric hos-
pitals and hospital beds, decreased hospitalization, and changes
Preliminary findings were presented at the Provincial Human Services
& Justice Coordinating Committee: 2013 Educational & Training
Provincial Conference. November 25–27, 2013, Toronto, Canada.
G. K. Shapiro A. Cusi M. Kirst P. O’Campo
V. Stergiopoulos
Centre for Research on Inner City Health, Keenan Research
Centre in the Li Ka Shing Knowledge Institute, St. Michael’s
Hospital, 209 Victoria Street, Toronto M5B 1T8, Canada
G. K. Shapiro (&)
Department of Psychology, McGill University, 1205 Dr. Penfield
Avenue, Montreal H3A 1B1, Canada
G. K. Shapiro
Institute of Community and Family Psychiatry (ICFP), Lady
Davis Institute, Jewish General Hospital, 4333 Co
ˆte St-Catherine
Road, Montreal H3T 1E4, Canada
M. Kirst P. O’Campo
Dalla Lana School of Public Health, University of Toronto, 6th
floor, 155 College St, Toronto M5T 3M7, Canada
A. Nakhost V. Stergiopoulos
Department of Psychiatry, University of Toronto, 250 College
Street, 8th floor, Toronto M5T 1R8, Canada
A. Nakhost
Mental Health Services, St. Michael’s Hospital, 30 Bond Street,
Toronto M5B 1W8, Canada
Adm Policy Ment Health
DOI 10.1007/s10488-014-0594-9
in mental health laws (Cotton and Coleman 2006;Fisheretal.
Increased police interaction with, what some police units
call, ‘Emotionally Disturbed Persons’ (EDP) in crisis situa-
tions can be costly in both human and economic terms. EDPs
consume a significant amount of policing resources (Mental
Health Commission 2009; Thompson 2010). In addition,
high profile incidents of injury or deaths have longstanding
implications for persons with mental illness, their families,
and the larger community (Adelman 2003; Hails and Borum
2003). A lesser focus of the media, but equally problematic,
is the criminalization of a large number of persons with
mental illness who have committed minor crimes and are
then taken to jail rather than to hospitals or community
psychiatric facilities (Lamb et al. 1995). Individuals expe-
riencing a serious mental illness are at times arrested because
police officers cannot see any other option, or hope to avoid
the loss of time required to locate and escort an EDP to a more
appropriate facility (Finn and Sullivan 1989; Fry et al. 2002).
Furthermore, at least in the Canadian context, some officers
will occasionally charge a person with an apparent mental
illness with a minor offense because, through the justice
system, EDPs may have better access to mental health sup-
port services, a practice called ‘mercy booking’ (Wood et al.
2011). Notably, it is becoming increasingly clear that indi-
viduals with mental illnesses are often arrested not because
of symptomatic behavior or crimes related to mental health
problems (Peterson et al. 2014), but rather as a result of an
individual’s opportunities, activities, and life circumstances
(e.g. housing or employment) (Fisher et al. 2006). Never-
theless, diverting individuals with mental illness—or those
experiencing a mental health crisis—from the criminal jus-
tice system ‘‘is on numerous counts a worthy endeavor’’
(Fisher et al. 2006, p. 548), as it holds promise of connecting
these individuals to services that address the social deter-
minants of health. Improving police interactions with per-
sons with mental illness who are in crisis has not surprisingly
become a priority for police services and communities.
In order to respond appropriately to EDPs, different
configurations of police–mental health partnerships have
emerged (Laing et al. 2009; Lamb et al. 2002). These
partnerships are highly heterogeneous but generally follow
one of three strategies to assist EDPs (Adelman 2003;
Deane et al. 1999). One program model promotes mental
health expertise for police officers so that they are better
prepared to provide crisis intervention services (Watson
and Fulambarker 2013). This Crisis Intervention Team
(CIT) approach, which originated in Memphis in 1988, is a
popular model that emphasizes mental health training for
officers (for a recent overview of the CIT program see
Cross et al. 2014). In a less popular program model, mental
health consultants are hired by police departments to pro-
vide phone-based or on-site assistance to officers in the
field (Saunders and Marchik 2007; Zealberg et al. 1992). In
contrast, a third program model has established co-
responding police-mental health programs that include
both local community mental health workers and police
officers that collaboratively respond to EDPs crises.
Despite a significant amount of research on the CIT
model, there is a paucity of literature on the co-responding
police-mental health program model (Boscarato et al. 2014).
This is particularly unfortunate as ‘‘[i]n Canada, the pre-
dominant mobile response is in fact a joint mobile response,
which is exemplified by programs such as the COAST Pro-
gram in Hamilton, and the similar Car 87 program in Van-
couver’’ (Kean et al. 2012, p. 20; Kisely et al. 2010).
Similarly, co-responding police-mental health programs
have been implemented in the United States with teams that
have been evaluated in DeKalb County (Georgia), Knoxville
(Tennessee), and Los Angeles (California), among other
jurisdictions. The co-responding police-mental health pro-
gram involves a collaboration of specially trained police
officers and mental healthcare workers that provide on-site
services to EDPs in the community. The theory underlying
these programs is that a joint response is preferable as police
are specialists in handling situations that involve violence
and potential injury while mental health professionals are
specialists in providing mental health consultation to officers
and mental health care to individuals in crisis (Forchuk et al.
2010; Lamb et al. 1995). As Rosenbaum (2010) explains:
‘[t]hese teams are based on the idea that the more police and
mental health workers collaborate, the better the two systems
can serve consumers and each other effectively’’ (p. 176).
The co-responding police-mental health programs have gone
by many names including the Integrated Mobile Crisis
Response Team in Victoria (British Columbia), Mobile
Crisis Intervention Team in Toronto (Ontario), Crisis Out-
reach and Support Team in Hamilton (Ontario), Mental
Health Mobile Crisis Team in Halifax (Nova Scotia), Mobile
Mental Health Crisis Unit in Knoxville (Tennessee), Mobile
Crisis Program in DeKalb County (Georgia), the System-
wide Mental Assessment Response Team in Los Angeles
(California), and the Police, Ambulance and Clinical Early
Response in Melbourne (Victoria) (Allen Consulting Group
2012; Canadian Crisis Response Services List 2008;
Rosenbaum 2010). In this review, these programs will be
called co-responding police-mental health programs.
There are multiple objectives for the co-responding
police-mental health program, including: deescalating cri-
ses, preventing injuries to individuals in crisis and the
response team, linking individuals who are experiencing
psychiatric emergencies to appropriate services in the
community, and reducing pressure on both the justice
system (e.g. by decreasing arrests and officer’s time
involved with handling psychiatric emergency situations)
as well as the health care system (e.g. by decreasing
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unnecessary visits to the emergency department) (Borum
2000; Matheson et al. 2005; Scott 2000). Furthermore,
these programs often aim to be accountable and cost
effective. A coordinated approach is needed in order to
optimally achieve these goals (Wood et al. 2011).
Notably, co-responding police-mental health programs
differ greatly in the populations they serve, funding levels,
program guidelines, type-of response, hours of operation,
staff expertise, equipment, and training (Kean et al. 2012;
Ligon 1997). Furthermore, though the programs share a
common goal of on-scene mobile crisis intervention and
outreach, the central activities of each program may differ
(Finn and Sullivan 1989; Patterson 2010). For example,
some of the varying program activities involve program
capacity building, maintaining a presence in vulnerable
areas, staff preparedness and training, partnership building,
following-up with consumers, short-term counseling,
referral, and evaluating program outcomes.
There is a considerable need for high-quality evidence to
inform policy regarding how and when to implement co-
responding police-mental health programs (Abbott 2011;
Forchuk et al. 2010; Wood et al. 2011). As Forchuk et al.
(2010) explain, ‘‘[s]urprisingly, there is limited under-
standing of the essential components, processes, and out-
comes for crisis services to date’’ (p. 74). A review of co-
responding police-mental health programs was therefore
conducted to synthesize the published literature, identify
promising practices, and determine gaps in the literature to
guide future studies.
Search Strategy
The search included data in the English language, pub-
lished from 1970 to 2013. Scholarly peer-reviewed litera-
ture was accessed through examining the databases
Pubmed, Web of Science, JSTOR, and OVID (i.e. Medline,
PscyINFO, Cochrane databases, and Embase). The search
terms that were used included: ‘mobile crisis intervention
team’, ‘mobile crisis unit’, ‘mobile crisis program’, ‘co-
responding police-mental health team’; as well as ‘police
or law enforcement’ combined with ‘psychiatric nurses’,
‘mental health clinician’, ‘psychiatric nurse’, ‘psychiatrist’,
‘psychologist’, ‘social worker’, or ‘crisis intervention’.
Other sources, including Google Scholar, Canadian
Mental Health Association (CMHA), National Institute of
Mental Health (NIMH), National Mental Health Develop-
ment Unit (NMHDU), National Alliance on Mental Illness
(NAMI), and The Substance Abuse and Mental Health
Services Administration (SAMHSA), were accessed (using
the same search terms as above) to identify research reports
that have been published in the gray literature. Further-
more, experts were contacted and the reference lists of
relevant articles were scanned in order to locate additional
relevant literature.
Inclusion Criteria
Studies involving co-responding police-mental health pro-
gram were included in the review. Literature on interven-
tions that do not include both police and mental healthcare
workers in their response were excluded as they fall outside
the scope of our analysis.
Data Extraction
Eleven peer-reviewed papers, seven reports, and three
dissertations were identified and were reviewed in detail
(Table 1). Data were extracted that enabled the authors to
identify the components and contexts of co-responding
police-mental health program, their activities, their critical
ingredients, and their evaluated outcomes.
A number of outcomes have been used in evaluations of co-
responding police-mental health program, including: (1)
averting crisis escalation and injury, (2) linking EDPs with
community services, (3) reducing pressure on the justice
system (i.e. through reducing the number of arrests and
police officers’ handling time), (4) improving officers’ per-
ception of individuals who have a mental illness, (5)
reducing the number of hospital admissions, (6) cost effec-
tiveness, and (7) program perception. This review conducts a
narrative synthesis of the evidence along the seven afore-
mentioned outcome domains, and identifies and proposes
potential mechanisms that may underlie program success.
A Synthesis of the Evidence
Averting Crisis Escalation and Injury
The combination of professional mental health staff and
law enforcement officers attending crisis situations has
been thought to avert crisis escalation and injury (Baess
2005). Although this is an outcome that is difficult to
measure, it is believed that through police training and
‘ride-alongs’ there is an opportunity to enhance officer
understanding of mental illness and offer alternative in-the-
moment tactics for deescalating situations without resort-
ing to the use of violence (Abbott 2011). Indeed, Baess
(2005) found that clinical staff report feeling safer when
attending community crisis calls alongside police officers.
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Table 1 List of included studies
Study Publication type Methods Outcomes
Abbott (2011) Dissertation Quantitative analysis
comparing police
attitudes in four police
departments at a single
point in time
Averting crisis escalation and injury (1)
Improving officers’ perception of
individuals who have a mental illness (4)
Program perception (7)
Allen Consulting Group
Report Mixed-methods approach
that included a
quantitative comparison
of an intervention (with a
control), a qualitative
consultations with
relevant stakeholders, and
a cost analysis
Averting crisis escalation and injury (1)
Reducing pressure on the justice system
Reducing the number of hospital
admissions (5)
Cost effectiveness (6)
program perception (7)
Anderson and Taylor
Report Descriptive case report and
gap analysis
Reducing pressure on the justice system
Baess (2005) Report Mixed-methods approach
that included quantitative
analysis, and a qualitative
consultations with police
officers, professionals,
and the public
Averting crisis escalation and injury (1)
Reducing pressure on the justice system
Improving officers’ perception of
individuals who have a mental illness (4)
Reducing the number of hospital
admissions (5)
Cost effectiveness (6)
Program perception (7)
Bar-On (1995) Peer-reviewed publication Descriptive research Reducing pressure on the justice system
Borum et al. (1998) Peer-reviewed publication A quantitative analysis
surveying police in three
crisis programs, a record
review of representative
cases, and key informant
Reducing pressure on the justice system
Program perception (7)
Brown et al. (2009) Report Descriptive case report Reducing pressure on the justice system
City of Toronto Mobile
Crisis Intervention Team
Coordination Steering
Committee (2013)
Report Descriptive case report, gap
analysis, and consultation
with stakeholders and
Reducing pressure on the justice system
Cobb (1997) as cited in
Rosenbaum (2010)
Report cited in a peer-
reviewed publication
Descriptive case report Cost effectiveness (6)
Dean et al. (2000) Report Descriptive case report Reducing pressure on the justice system
Finn and Sullivan (1989) Peer-reviewed publication Descriptive analysis of
eight crisis service models
Linking of EDPs with community
services (2)
Reducing pressure on the justice system
Cost effectiveness
Forchuk et al. (2010) Peer-reviewed publication Ethnographic case-study
that compared three crisis
service models (by
consulting consumer,
family member, and
service provider focus
groups), and a naturalistic
observation of crisis
program perception (7)
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Table 1 continued
Study Publication type Methods Outcomes
Kisely et al. (2010) Peer-reviewed publication Mixed-methods approach
that included a controlled
before-after quantitative
study of an intervention
area (with a control area),
and a qualitative
assessment of the views
of service recipients,
families, police officers,
and health staff at
baseline and 2 years
Linking of EDPs with community
services (2)
Reducing pressure on the justice system
Program perception (7)
Lamb et al. (1995) Peer-reviewed publication Retrospective design that
examined the records of
consecutive referrals to a
crisis program, and the
status of subjects at a 6
month follow-up
Reducing pressure on the justice system
Reducing the number of hospital
admissions (5)
Landeen et al. (2004) Peer-reviewed publication Retrospective design that
examined data from four
time periods using a
qualitative, text-based
Reducing the number of hospital
admissions (5)
Ligon (1997) Dissertation Quantitative analysis of
consumer and family’s
surveyed satisfaction with
a crisis service
Program perception (7)
Ligon and Thyer (2000) Peer-reviewed publication Quantitative analysis of
consumer and family’s
surveyed satisfaction with
a crisis service
Program perception (7)
Ratansi (2004) Dissertation Quantitative analysis of
survey data that was
completed by the police
and the co-responding
program, and
consultations with
members of the co-
responding program
Averting crisis escalation and injury (1)
Reducing pressure on the justice system
Program perception (7)
Saunders and Marchik
Peer-reviewed publication Mixed-methods approach
that included a descriptive
case report, qualitative
interviews with key
informants, and
quantitative evaluation of
surveys completed by law
enforcement patrol
Improving officers’ perception of
individuals who have a mental illness (4)
Program perception (7)
Scott (2000) Peer-reviewed publication Retrospective evaluation of
case records of a co-
responding program (and
a control group), a
quantitative analysis of
consumer and police’s
surveyed satisfaction, and
a cost analysis
Linking of EDPs with community
services (2)
Reducing pressure on the justice system
Reducing the number of hospital
admissions (5)
Cost effectiveness (6)
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On the other hand, Ratansi (2004) examined open-ended
questions and found that ‘‘most officers believed that
working with MCT [i.e. in the co-responding police-mental
health program] had no impact or did not improve the time
spent on calls, identification, danger, or the effectiveness of
the call’’ (p. 156).
Interestingly, the Allen Consulting Group (2012)
investigated the number of times a use of force form was
completed by the co-responding police-mental health pro-
gram compared to a control ‘usual service’. They found
that less use of force forms were filled out in the co-
responding police mental health program catchment area
compared to the usual service provision catchment area.
However, the difference between the number of use of
force forms filled out in the two areas was small and this
difference narrowed during the period of investigation
(January 2010 to March 2011). Unfortunately, this analysis
does not statistically analyze this difference. Furthermore,
this report does not consider whether the type of force that
is reported differs between the two areas. Nevertheless, the
Allen Consulting Group (2012) further reports that the co-
responding police-mental health program provided de-
escalation advice on 10 % of occasions and undertook
other activities that might assist in preventing force, crisis
escalation, and injury.
Linking EDPs with Community Services
Connecting individuals in crisis with community services,
rather than the justice system or acute care services, is
thought to be the most appropriate way to support con-
sumers and prevent reoccurrence of a crisis and ‘revolving-
door’ recidivism (Finn and Sullivan 1989). As Scott (2000)
explains, ‘‘[a]n anticipated benefit of the program was
increased access for consumers to community-based
emergency services in the least restrictive environment in
order to avoid the trauma of psychiatric hospitalization
whenever possible’’ (p. 1156). Some research has evaluated
this claim. Steadman et al. (2000) examined three sites’
dispatch calls and found that in situations where a spe-
cialized response was present, the co-responding police-
mental health program in Knoxville had the largest
proportion of referrals to treatment services compared to
the other models (36 %, compared to 0 % in Memphis’s
CIT model, and 3 % in Birmingham’s program whereby
civilian officers assist police officers in mental health cri-
ses). In other words, when the co-responding police-mental
health program in Knoxville responded to a mental health
crisis, they were more likely to refer an individual to case
managers, mental health centers, or outpatient treatment,
compared to the other two specialized models. In contrast,
Memphis’s CIT model was most likely to take individuals
in crisis to a psychiatric emergency room, a general hos-
pital emergency room, a detoxification unit, or another
psychiatric facility (75 % of the time, compared to 42 % of
the time in Knoxville, and 20 % of the time in Birming-
ham); while Birmingham’s specialized team was most
likely to resolve the situation on scene (64 % of the time
compared to 23 % of the time in Memphis and 17 % of the
time in Knoxville). Seemingly, linking individuals in crisis
with community mental health services is particularly
emphasized in the co-responding police-mental health
program. This is not an isolated finding. In 2010, Kisely
et al. found that individuals who had been in contact with
the co-responding police-mental health program in Halifax
showed greater service engagement than control subjects,
as demonstrated by increased outpatient contacts.
Moreover, according to Finn and Sullivan (1989), in
Fairfax County, Virginia, 71 % of consumers followed
through with a treatment recommendation and were
actively engaged in a voluntary outpatient program within
4 weeks of the crisis intervention. Finally, although only
2 % of individuals to whom deputies gave wallet cards
listing outpatient mental health services in Washtenaw
County sought help, the number seeking community ser-
vices rose to 18 % when consumers were telephoned to
encourage aftercare within 48 h (Finn and Sullivan 1989).
Reducing Pressure on the Justice System
EDP crises create a significant pressure on the justice
system. Co-responding police-mental health programs are
believed to mitigate this pressure by reducing the number
of EDP arrests (and the related processing time) and
Table 1 continued
Study Publication type Methods Outcomes
Steadman et al. (2000) Peer-reviewed publication Comparative cross-site
design examining records
of three different police
response programs
Linking of EDPs with community
services (2)
Reducing pressure on the justice system
Program perception (7)
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decreasing police officers’ on-site handling time. A number
of studies have demonstrated low EDP arrest rates asso-
ciated with the co-responding program. For example,
Steadman et al. (2000) found the co-responding Knoxville
program had a low arrest rate of 5 % (compared to 6 % in
Memphis and 13 % in Birmingham). Similarly, Brown
et al. (2009) report that only 2 % of 445 calls resulted in
jail placement during the first nine months of the co-
responding police-mental health program in Polk County.
Unfortunately, Brown et al. (2009) did not compare the
arrest rate in Polk County to a comparable location that
does not have a co-responding police-mental health pro-
gram, or to Polk County arrest rates before implementing
the co-responding police-mental health program (in a
before-after design).
Furthermore, a study by Lamb et al. (1995) found that
only 2 of 101 consumers were arrested in Los Angeles’ co-
responding police-mental health program, despite 70 of the
101 consumers exhibiting psychiatric symptoms at referral,
20 among them being overtly violent and 29 others who
exhibited threatening behaviour. Lamb et al. (1995)
thereby concluded that ‘‘because of the use of well-trained
teams consisting of a mental health professional and a
police officer, these subjects were not criminalized, even
though they came from a population at high risk for
criminalization’’ (pp. 1269–1270). However, notably, at a
7-month follow-up, 22 % of consumers had been arrested
(12 % for crimes of violence) (Lamb et al. 1995). This
potentially indicates that despite the immediate success of
the crisis team in diverting EDPs from the criminal justice
system, consumers may not be successfully diverted in the
long-term. This finding underlines that it is especially
important that evaluative studies investigating the co-
responding police-mental health program examine both the
proximal and distal outcomes of the programs. Another
study that investigated arrest rates in DeKalb County,
Georgia, did not find a significant difference in arrest rates
between the co-responding police-mental health program
and a control group in a retrospective examination design
(Scott 2000). However, a descriptive report by Dean et al.
(2000) found that the co-responding police-mental health
program in Lumberton (North Carolina) greatly reduced
repeat calls from chronic calling problem homes.
Other research has demonstrated that co-responding
police-mental health programs decrease the on-site han-
dling time of officers, thereby reducing the burden on
police (Finn and Sullivan 1989). For example, there were
reported reductions in time spent on scene by police offi-
cers in the co-responding police-mental health program in
Halifax, Canada (136 min), compared to the control area
(165 min) (Kisely et al. 2010). Similarly, the Allen Con-
sulting Group (2012) reported that on average the police
first responder unit was released a third of the time when
the co-responding police-mental health program was
involved (52 min) compared to the control area (nearly
3 h). Baess (2005) also reported that clinician crisis
responders were able to attend to more than double the
number of high acuity calls when plain-clothed police
officers were on shift (Baess 2005). However, the meth-
odology of Baess’s (2005) study is not presented and it is
unclear what factors underlie this improvement. Further,
while patrol officers waited on average for 121 min when
they attended the emergency department on their own, they
only waited for 45 min when assisted in the co-responding
police-mental health program (Baess 2005). Anderson and
Taylor (2013) similarly argue that the co-responding
police-mental health program in Surrey, British Columbia,
reduces the overall time that police spend in hospital wait
times and diversions from hospital (Anderson 2013).
Evidently, the co-responding police-mental health pro-
gram can only decrease arrests and reduce on-site handling
time of police officers if the teams are able to reach the
scene, and do so within an acceptable amount of time.
Some research has evaluated the reach of the co-respond-
ing police-mental health program in several jurisdictions.
For example, the Allen Consulting Group (2012) found that
in 90 % of cases the co-responding police-mental health
program responded in 30 min or less from the time that
they were contacted. Furthermore, Kisely et al. (2010)
found that after implementing the co-responding police-
mental health program (that offered telephone support 24 h
a day backed by a co-responding team) in Halifax, Nova
Scotia, the number of crises to which the team was able to
respond increased. However, Steadman et al. (2000) found
that the co-responding police-mental health program only
responded to 40 % of mental disturbance calls in Knoxville
(compared to 92 % in Memphis and 28 % in Birmingham).
They argue that ‘‘one of the key concerns expressed in this
study about the Knoxville mobile crisis unit [i.e. Knox-
ville’s co-responding police-mental health program] was
that response times were excessive and impractical. The
delayed response led officers not to use the unit’s services
as often as they otherwise might have and forced them to
consider alternative dispositions’’ (Steadman et al. 2000,
pp. 648–649). The delayed response of some co-responding
police-mental health programs has been linked to trans-
portation in geographically spread out locales and a lack of
capacity (i.e. staffing concerns) (Borum et al. 1998; Ratansi
2004). As Ratansi (2004) explains, ‘‘the team [in Hamilton
County, Ohio] was not effective because manpower moti-
vation, availability, response time, and feasibility were not
adequately addressed. For example, having a collaboration
in which one of the stakeholders (MCT) is only available
9–5 during the week is a problem when the other stake-
holder is available 24/7’’ (p. 179). Indeed, availability and
access of mental healthcare workers is particularly
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problematic at night (Bar-On 1995; City of Toronto Mobile
Crisis Intervention Team Coordination Steering Committee
Improving Officers’ Perception of Individuals Who have
a Mental Illness
Some research has also examined the proposition that the
co-responding police-mental health programs improve
officers’ understanding and perception of mental illness.
Indeed, Baess (2005) found that feedback from two police
officers working on the co-responding police-mental health
program in Vancouver Island revealed that they developed
a better understanding of mental health issues (i.e. diag-
nostic criteria and behavioural interventions). Furthermore,
using a questionnaire that examines community attitudes
towards people with mental illness, Abbott (2011) found
that surveyed officers working in departments with jail
diversion programs in two Massachusetts communities (i.e.
Framingham and Quincy) reported greater tolerance for
responding to individuals with a mental illness and more
strongly endorse their role in supporting persons with
mental illness than officers working in departments without
jail diversion programs (i.e. Lynn and Peabody). However,
there was no significant difference between departments
with and without a co-responding police-mental health
program regarding levels of acceptance of individuals with
a mental illness living in community-based settings. In
another study, Saunders and Marchik (2007) demonstrated
a statistically significant increase in knowledge of mental
health problems before and after officers received training
from the co-responding police-mental health programs in
Polk County, Iowa. Interestingly however, they found that
76 % of the 210 surveyed officers reported learning about
mental health issues directly through observing the co-
responding police-mental health program staff in the field
or through discussion with the co-responding police-mental
health program staff (Saunders and Marchik 2007).
Reducing the Number of Hospital Admissions
Hospital admissions are costly and present a burden on
limited resources. There is mixed evidence that the co-
responding police-mental health programs reduce hospi-
talizations. In one study, 55 % of emergencies handled by
the co-responding police-mental health programs were
managed without psychiatric hospitalization of the person
in crisis, compared with 28 % in a control group of regular
police (Scott 2000). Scott (2000) therefore concluded that
‘mobile crisis programs can decrease hospitalization rates
for persons in crisis and can provide cost-effective psy-
chiatric emergency services that are favorably perceived by
consumers and police officers’’ (p. 1153). Similarly, Baess
(2005) reported that fewer than 15 % of 1,200 referrals
from the co-responding police-mental health program were
directed to the hospital’s emergency room (a 7.8 %
decrease compared with historical data). Furthermore, the
Allen Consulting Group (2012) found that the co-
responding police-mental health program they evaluated
had fewer referrals to hospital emergency departments
(52 % of cases) compared to a control area (82 % of cases).
In addition, they found that the length of stay in hospital
emergency departments for mental health patients referred
by the co-responding police-mental health program was
reduced by approximately 2 h compared to the control area
(Allen Consulting Group 2012).
However, other studies did not find that the co-
responding police-mental health program model reduces
hospital admissions. For example, in one co-responding
police-mental health program individuals are admitted to
the hospital in approximately 75 % of apprehensions under
the Mental Health Act (Landeen et al. 2004). Similarly,
Lamb et al. (1995) examined consecutive referrals and
found that of the initial 101 subjects, 80 were initially taken
to hospital and 73 were hospitalized. Further, in a six-
month follow-up of these individuals, 42 % of subjects
were re-hospitalized (Lamb et al. 1995).
Cost Effectiveness
The goals of the crisis teams are presented as humanitarian
rather than economic; however, there is some evidence that
the co-responding police-mental health programs are also
cost effective (Scott 2000). In 1989, Finn and Sullivan
reviewed eight law enforcement agencies and social ser-
vice systems arrangements and concluded that though
funding is an obstacle for these programs in the outset,
‘those holding the purse strings feel the arrangements are
sufficiently beneficial to have funded them without serious
hesitation for many years’’ (p. 13). The perceived effec-
tiveness discussed in this study has since been supple-
mented by more compelling evidence. According to the
supervisor in San Diego County’s second district, their co-
responding police-mental health program potentially saves
more than $2,000,000 a year in the western division of the
San Diego Police Department through decreasing jail costs
and officer savings by as much as $2,200 per contact (Cobb
1997 as cited in Rosenbaum 2010). In addition, another
study found the co-responding police-mental health pro-
gram to be less costly compared to a ‘service as usual’
control; however, the authors note that this finding must be
interpreted in the context of the assumptions that were
made to address data limitations (Allen Consulting Group
2012). A further study, by Scott (2000), found that on
average each person served by the co-responding police-
mental health program costs 23 % less, as measured
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through psychiatric hospitalization savings. However, as
Hubbeling and Bertram (2012) point out, this study did not
report statistical testing or confidence intervals. Further-
more, a cost analysis conducted by Baess (2005) found that
a police call costs $300 per call while the co-responding
police-mental health program call costs $190 due to a
reduction of hospital wait times and admissions.
Program Perception
A number of researchers have investigated the perception
of, and satisfaction with, the co-responding police-mental
health programs by staff, consumers, and community
stakeholders. For example, stakeholder consultations of a
co-responding police-mental health program in Victoria
(Australia) reported that ‘‘among the stakeholders con-
sulted in this project [i.e. the Area Mental Health Service,
Victoria Police, and Ambulance Victoria], there is wide-
spread support for improved inter-agency collaboration in
responding and managing mental health crises in the
community’’ (Allen Consulting Group 2012, p.vii). More
specifically, Saunders and Marchik (2007) surveyed 210
law enforcement patrol officers to assess their experiences
with, and benefit from, the co-responding police-mental
health program. They found that 86 % rated the program as
either ‘very good’ or ‘superior’. In particular, officers’
valued ‘being able to return to the street faster’ and the
‘benefit to clients assessed for MH [mental health] issues’.
Officers did suggest, however, that improvements to the
service be made by increasing availability and efficiency,
providing county officers with greater training, and
reducing response times (Saunders and Marchik 2007).
Similarly, officers in Framingham and Quincy (Massa-
chusetts) reportedly valued their co-responding police-
mental health program (Abbott 2011).
Other studies, however, have found low satisfaction of
the co-responding police-mental health program among
officers. In Knoxville, officers rated their preparedness for
EDP calls to be high (78.1 %); however, only 52.7 % of
officers rated their program as ‘moderately’ or ‘very
effective’ in meeting the needs of people with mental ill-
ness in crisis, only 51.9 % of officers rated their program as
effective in maintaining community safety, and only 7.3 %
of officers rated their program effective in minimizing the
amount of time patrol officers spent on mental health calls
(Borum et al. 1998). Furthermore, though Steadman et al.
(2000) found the co-responding police-mental health pro-
gram in Knoxville to have a low arrest rate (5 %), the
program was not perceived to be as effective as other
programs in reducing arrests. Accordingly, while 41.8 % of
officers at Knoxville reported their program was effective
in reducing arrests, 47.9 % of officers in Birmingham and
70.1 % of officers in Memphis believed their program was
effective at reducing arrests (Borum et al. 1998). Similarly,
Ratansi (2004) found that all officer groups reported that
responding to calls with mental health workers only
slightly improved the effectiveness of EDP response.
However, Ratansi (2004) also found that officers with the
highest number of training hours had more positive atti-
tudes towards being prepared and able to handle EDPs.
Consumer and community member perceptions of the
co-responding police-mental health program have also
been examined. Baess (2005) reported positive feedback
from service providers and families. Similarly, Ligon and
Thyer (2000) found that both consumers and family
members rated the co-responding police-mental health
program in DeKalb County, Georgia, favourably. Inter-
estingly, in one study, family members of consumers
reported higher level of satisfaction with the service on a
Client Satisfaction Questionnaire compared to consumers
(Ligon and Thyer 2000). However, no demographic
information of the family member and consumer groups
was collected, and, as the authors themselves note, the
sample size in their study was small (29 family members
and 15 consumers), and it is therefore difficult to know if
their sample is representative of clients and families in the
service area (Ligon 1997; Ligon and Thyer 2000).
Furthermore, in an ethnographic case-study that inclu-
ded group interviews and participant observation, Forchuk
et al. (2010) contrasted crisis service models in three
Ontario communities. They found that all three commu-
nities valued their crisis services. However, a number of
modifications were suggested including: wanting peer
support as part of crisis care; a ‘warm line’ that provides
support in addition to a ‘hotline’ that provides immediate
attention; including consumers and their families in the
collaborative framework of the crisis response; and
enabling family members to receive crisis support (For-
chuk et al. 2010). In Halifax, Kisely et al. (2010) found
participants report their co-responding police-mental health
program to be helpful in providing someone to talk to,
obtaining advice, and facilitating referral. As an example,
one participant wrote that ‘‘they [the co-responding Halifax
crisis team] got me through the winter of 2007’’ (Kisely
et al. 2010, p. 665). However, participants suggested that
the co-responding police-mental health program could be
improved by an expansion of service, greater availability,
and a more timely response (Kisely et al. 2010).
Hypothetical Mechanisms Underlying Program
We initially sought to conduct a realist synthesis of the co-
responding model literature (Kirst and O’Campo, 2012;
Pawson 2006), that is to review how, why, for whom, and
in what circumstances the programs work. However, the
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evidence concerning program mechanisms—that is the
critical ingredients of the program that is responsible for
the success or in some cases for the failure of the pro-
gram—contained in the existing literature was reported in
too few articles to undertake a complete realist review.
However, in reviewing the literature we were able to
generate some initial propositions about the mechanisms of
successful co-responding programs. Based on the literature
reviewed above, we identified two potential mechanisms
underlying key intended outcomes of co-responding police-
mental health programs, namely diversion of EDPs from
the criminal justice and hospital systems, and connecting
EDPs to community resources (Lamb et al. 1995; Stead-
man et al. 2000).
Focusing on reducing the number of arrests, it is
hypothesized that providing adequate mental health train-
ing for police officers (Baess 2005; Borum et al. 1998;
Forchuk et al. 2010), strong partnerships between police
and mental health program partners, and support from
within organizations to guide implementation of program
policies and activities (organizational buy-in) (Forchuk
et al. 2010; Rosenbaum 2010) are program components
that provide opportunities and resources to raise awareness
of mental health issues among police officers. These
aspects enhance police officers’ ability to recognize when a
mental health issue is a factor and that engaging the co-
response program is an appropriate course of action rather
than arrest. These mechanisms subsequently reduce the
need for officers to arrest individuals in crisis and facilitate
diversion of these cases away from the criminal justice
system (see Fig. 1).
A second potential mechanism explains the key program
outcome of diversion from hospitalization to health and
social services. This hypothetical mechanism posits that
programs with strong partnerships and collaboration across
police and mental health system sectors facilitate the cre-
ation of strong partnerships with community agencies
(Rosenbaum 2010; Steadman et al. 2000). Strong program
partnerships with community agencies increase police and
community awareness of the co-response program as a
resource, as well as facilitating ease of linkage and referral
of consumers to health and social services by co-response
programs (Borum et al. 1998; Wood et al. 2011). These
mechanisms increase utilization of the program and the
treating of people in crisis in the community, which shifts
practice norms to referral of consumers to community
services rather than hospitalization (see Fig. 2).
This review firstly sought to synthesize the literature on
seven desired outcomes of the co-responding police-mental
health programs. Accordingly, evaluations of the co-
responding police-mental health programs found that there
is some evidence that this program model has the potential
Fig. 1 Mechanisms involved in reducing the number of arrests
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to forge linkages with community services and mitigate the
burden on the justice system (i.e. through reducing arrest
rates and on-site handling time). Reducing ‘down time’ of
officers is not only important for efficiency but also for
police morale, as many officers find waiting in emergency
departments to be an ineffective use of their time (Borum
et al. 1998). The perception of the programs, particularly
among consumers and their family members, was also
found to be generally positive. Indeed, a recent study asked
mental health consumers in Melbourne (Australia) about
four different program models and found the co-responding
police-mental health program (the so-called ‘ride along
model’) to be the desired formal response (Boscarato et al.
2014). However, paradoxically, despite evidence that the
co-responding police-mental health program has a low
arrest rate and lower on-site handling time, many surveyed
officers did not believe that their co-responding police-
mental health program reduces the time officers spend on
calls, lowers the arrest rate, or improves the effectiveness
of EDP calls (Borum et al. 1998, Ratansi 2004). Collecting
program process and outcome data on a regular basis and
improved sharing of data with program team members is
important for gaining officers’ support for, and apprecia-
tion towards, co-responding police-mental health programs
(Allen Consulting Group 2012; Hollander et al. 2012).
In contrast, there have been limited evaluations (and
therefore limited evidence) regarding whether co-
responding police-mental health programs avert crisis
escalations and injuries, improve officers’ perception of
individuals who have a mental illness, or are cost-effective.
There is also mixed evidence regarding whether the co-
responding police-mental health programs reduce the
number of hospital admissions. The expectation that the co-
responding police-mental health program reduces hospi-
talizations should therefore be low. However, it is not
necessarily a shortcoming if individuals in crises are
directed to hospital services when hospital admission is an
appropriate response. It has also been argued that even if
the co-responding police-mental health programs do not
reduce the number of hospital admissions at all sites (as
some studies have shown), emergency care staff will still
spend less time evaluating, treating, and transferring
inappropriate referrals because EDPs have been pre-
screened and assessed in the community by co-responding
police-mental health programs’ healthcare workers (Allen
Consulting Group 2012; Finn and Sullivan 1989).
Given the increasing attention towards the management
of mental health crises in the community, it is important to
better understand whether the co-responding police-mental
health programs are achieving their desired outcomes, and
what might be the key ingredients of program success. As
co-responding programs differ in composition and activi-
ties, and operate in diverse contexts, examining the key
elements and mechanisms involved in program success can
inform program design and resource allocation. Two
potential mechanisms, thought to underlie intended
Fig. 2 Mechanisms involved in increasing diversion from hospitalization to health and social services
Adm Policy Ment Health
outcomes, were presented, and particular program activi-
ties thought to underlie the achievement of specific suc-
cessful outcomes were hypothesized. Namely, it was
hypothesized that co-responding police-mental health pro-
grams are likely to achieve outcomes such as reduced
arrests and increased diversion away from hospital to
community-based health and social services when they
have strong organizational buy-in from all partners, good
collaboration between police and health partners, provide
adequate mental health training for police officers, engage
community partners, and face fewer barriers when linking
individuals to referral services. An enhanced understanding
of mental health issues among police officers and increased
awareness of the co-responding model may lead to
improved ability to recognize when to utilize the program
when addressing EDPs in the community, emerged as
mechanisms in diverting these individuals from the crimi-
nal justice system by reducing the number of arrests. A
review of literature on the police-based (CIT) response
model has also highlighted similar key program elements
to facilitate program success including: collaborative
planning and implementation by partnering organizations,
organizational support, specialized training for law
enforcement personnel, and effective referral of consumers
to community supports and services (Reuland, 2010).
Another promising program element in police-based (CIT)
response models that may minimize officer down time and
mitigate arrests involves the use of psychiatric drop-off
centers (particularly ones with a no refusal policy for police
cases and streamlined intake) (Borum et al. 1998, p. 403;
Steadman et al. 2000,2001).
Challenges and Limitations of the Program Model
Glasgow et al. (1999) note that public health interventions
should be evaluated not only in terms of their effectiveness,
but also their reach, acceptability, implementation, and
maintenance. Although the co-responding police-mental
health program enjoys acceptability and has been imple-
mented in different contexts and jurisdictions, there is a
dearth of information on program sustainability and drift
over time, and valid concerns about program reach. Indeed,
as a result of the lack of clarity about the programs’ role
among community partners, lengthy response times (Bo-
rum et al. 1998) and lack of capacity (Ratansi 2004), this
program model responds to a relatively small proportion of
EDP calls in some settings and this raises concerns about
the programs’ added value. For example, the co-responding
police-mental health program in Knoxville (Tennessee)
only responded to 40 % of mental disturbance calls
(Steadman et al. 2000) while the co-responding police-
mental health program in Toronto (Ontario) only report-
edly responded to 11 % of mental disturbance calls
(Iacobucci 2014). Increasingly, the co-responding police-
mental health program is seen as potentially one of several
components of an adequate crisis response system for
people facing a mental health crisis, including warm and
hot lines, highly trained dispatchers, Crisis Intervention
Teams (CIT), and mental health crisis centers with
streamlined intake processes.
Regarding program implementation, there are several
challenges highlighted in the literature, including estab-
lishing a partnership (rather than ‘ownership’) between two
very different organizational cultures and perspectives, the
scarcity of police drop-off centers, working collaboratively
while upholding confidentiality, and forming appropriate
organizational structures to support joint police mental
health program operations (Bar-On 1995; Kirst et al. 2014;
Patterson 2010; Steadman et al. 2000). Finn and Sullivan
(1989) reviewed eight arrangements between law
enforcement agencies and the social service systems and
found that there have been problems initiating and sus-
taining these networks in some settings. Furthermore,
police officers begin with relatively little formal knowledge
and training about mental health problems and mental
health professionals begin with relatively little awareness
of law enforcement procedures and policies (Lamb et al.
1995), necessitating extensive and ongoing training for
both groups.
Despite the challenges and limitations of the program
model, this literature synthesis points to several strengths
that could potentially be built upon in efforts to design a
system of care that safeguards both individual and com-
munity safety as well as timely and appropriate connection
to mental health services and supports.
Recommendations for Practitioners
To support optimal care, avoid criminalization, and
improve mental health consumer experience, programs
should consider a number of factors impacting program
delivery. First, it is important to consider how best to
balance standardization of service delivery in a geograph-
ical area with optimal fit to the local context. Second,
teams should consider adopting common outcome mea-
sures and shared definitions to facilitate routine outcome
reporting and quality improvement efforts. Third, attention
should be given to the ongoing training needs of all police
officers, and mental health providers, and evidence sup-
ported standards for training and supervision should be
established. Last, but most important, for the model to
leverage its full potential, joint stewardship may be needed
to bridge the two disparate cultures and perspectives and
address each system’s limitation in managing crises and
safety in the most acceptable way. In this regard, engaging
stakeholders in discussions about the divergent tasks and
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roles of the co-responding police mental health program
workers is imperative during the development and evolu-
tion of the program (Patterson 2010).
Limitations and Future Research
The literature reviewed has a number of methodological
limitations, including few published studies, non-experi-
mental designs, and small sample sizes (Wood et al. 2011).
For example, examining officer’s perception (or stigma)
towards individuals who have a mental illness is chal-
lenging. Nevertheless, it is an important measure of the
quality of policing, and future studies should evaluate
attitude changes before and after the implementation of a
co-responding police mental health program (rather than
retrospectively surveying how introducing the program has
impacted officers’ perceptions). Furthermore, there are few
longitudinal studies that investigate the long-term impact
that co-responding police-mental health programs have on
EDPs such as continuity of care, arrests, or hospitaliza-
tions. For example, though the research indicates that the
co-responding police-mental health program reduces arrest
rates in the short-term, it is unclear whether the program
reduces arrests in the long-term (Lamb et al. 1995). Future
longitudinal evaluations should examine the long-term
impact of the program on arrest rates, hospitalization, and
service engagement.
Another difficulty with the available literature is that a
number of studies included in this review are dated or not
generalizable, as they draw from a specific local context
(e.g. Lamb et al. 1995). Given dynamic shifts in service
contexts and program model drift over time, it is necessary
to pursue high quality research to address fundamental
questions of program effectiveness and consumer experi-
ences with the program model. In particular, it is important
to identify the key ingredients of the program as well as
how the program works, for whom, and in what circum-
stances. Program drift over time creates an even greater
need to understand key elements to enable local adapta-
tions to optimize fit in different service contexts. However,
there remains a dearth of studies that investigate contextual
differences (Steadman et al. 1999). It would be valuable for
controlled research to test the mechanisms that were pre-
sented in this review. As Pawson (2006) explains, to
ascertain the evidence-base of policy it is important for
research to understand causation (i.e. how a program
achieve their effect), ontology (i.e. how a program works),
and generalization (i.e. how we can inform future policy
and practice).
It would also be beneficial for future research to expand
their scope of analysis. It is increasingly important to
expand on ‘convenience data’ to also include variables that
answer pertinent research questions on outcomes and
mechanisms. In order to do so, it would be necessary to not
only examine questions of efficacy, but it is also important
to assess other outcomes including program reach, adop-
tion (i.e. the representativeness of the setting), implemen-
tation (i.e. the extent that a program is delivered as
intended), and maintenance (i.e. of program-level mea-
sures and policies over time) (Glasgow et al. 1999). In
order to address these outcomes it would be helpful to link
hospital and justice data, while still protecting individuals’
anonymity. The extant literature does not consistently
report on the presence or absence of model elements in co-
responding police-mental health programs. There is a
substantial need for future research to understand co-
responding police-mental health programs’ mechanisms
and outcomes in order to better inform practice and policy.
In so doing, research that has examined the key model
elements and common obstacles of the Crisis Intervention
Team (CIT) model may serve as an informative template
(see Compton et al. 2010; Cross et al. 2014; Dupont et al.
2007; McGuire & Bond 2011; Reuland 2004). It is
becoming increasingly clear that improving the evidence
base of the field, and program effectiveness, requires col-
laborations between police, health agencies, and academics
(Dean et al. 2000; Matheson et al. 2005; Wood et al.
This review synthesized literature on co-responding police-
mental health programs and identified potential mecha-
nisms that may account for their success. Few quality
studies exist, pointing to the need for future research to
establish program outcomes and underlying mechanisms in
diverse contexts.
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... Two of the systematic reviews of co-responder models, including a number of quasi-experimental studies, indicated that these models either had a positive impact on arrests or had low arrest rates Shapiro et al., 2015). Study designs precluded conclusions on whether these models reduce arrest rates, however . ...
... In terms of programme facilitators, many studies indicated that increased inter-agency collaboration is key to model success (Bailey et al., 2018;Horspool et al., 2016;Lee et al., 2015;Puntis et al., 2018;Shapiro et al., 2015). Specifically, strong executive-level support and the creation of inter-agency committees to facilitate the integration of services is needed for effective implementation (Robertson et al., 2020). ...
... Service users reported negative experiences with police only models (which typically involved CIT officers), including fear for safety and being treated as criminals (Boscarato et al., 2014;Brennan et al., 2016;Lamanna et al., 2018). There is some evidence from systematic reviews to suggest that co-responder models may lead to lower rates of arrest, use of force and injury than policeonly models, however, evidence remains mixed and is subject to bias (Blais et al., 2020;Shapiro et al., 2015). Notably, co-responder models were related to decreased apprehensions under the Mental Health Act compared to police-only models across jurisdictions (Keown et al., 2016;Lamanna et al., 2018;Meehan & Stedman, 2012;Puntis et al., 2018;Semple et al., 2020), which likely enhanced service user experience and decreased unnecessary ED visits. ...
Police are the default first responders in most mental health crisis intervention models worldwide, resulting in a heavy burden on police, perceived criminalization of individuals with complex mental health needs, and escalation of aggression that resort to violence. Models, such as crisis intervention teams (CIT), and co‐response programmes aim to improve service user experiences and outcomes by providing mental health training to police, or pairing law enforcement officers with mental health clinicians, respectively. Despite these efforts, mental health‐related calls continue to result in negative outcomes, and activists and policymakers are advocating for non‐police models of crisis intervention. Evidence‐based practice in mental health crisis intervention is urgently needed. The present review’s main objective was to examine, synthesise and compare outcomes across police, co‐responder and non‐police models of mental health crisis intervention internationally using a rapid review framework. A systematic search of four electronic databases of studies published between 2010–2020 and a grey literature search was conducted, yielding (n = 1008) articles. A total of 62 articles were included in the present review. Studies were largely observational, lacking control groups and were of low‐moderate quality with a high potential for bias. Overall, there is little evidence to suggest that the CIT model impacts crisis outcomes. Co‐responder models evidenced improved outcomes compared to police only models, however, evidence was often mixed. Non‐police models varied significantly, and studies tended to be too low quality to make comparisons or draw conclusions, however, research on youth models and crisis resolution home treatment suggested positive outcomes. Findings highlight the need for high‐quality studies and policies to facilitate the implementation and evaluation of novel approaches not involving police. Cross‐sectorial collaboration and service user input are urgently needed to inform, develop, test and disseminate effective models of crisis intervention acceptable to service users.
... The "crisis intervention team" (CIT) approach emphasizes training police officers how to respond to individuals in crisis and connect them with appropriate services (19). In contrast, the "co-response" model involves structuring explicit partnerships between police departments and professional mental health practitioners so they can simultaneously respond to incidents involving mental health crises (20)(21)(22)(23). A third and less common approach either delays or foregoes on-scene police involvement in certain incidents by relying on "a new branch of civilian first responders known as 'Community Responders'" (5). ...
... The momentum behind the adoption of programs that seek to improve police interactions with individuals in mental health crises has motivated multiple empirical studies that seek to understand their impact. Several systematic reviews and meta-analyses have synthesized this evidence, particularly focusing on the more common CIT and co-response models (20,(24)(25)(26)(27)(28). In general, this empirical literature suggests that these program innovations have beneficial effects by reducing arrests and detention rates, but evidence is mixed on whether these programs are cost-effective. ...
... A less common but more marked innovation for responding to nonviolent individuals in crisis is to delay or forego police involvement by sending a health care team as first responders (i.e., a community response model). Although each of these programmatic models is grounded in a sensible theory of change, there is not currently credible, causal evidence on their effects (5,7,20,(24)(25)(26)28). ...
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Police officers often serve as first responders to mental health and substance abuse crises. Concerns over the unintended consequences and high costs associated with this approach have motivated emergency response models that augment or completely remove police involvement. However, there is little causal evidence evaluating these programs. This preregistered study presents quasi-experimental evidence on the impact of an innovative "community response" pilot in Denver that directed targeted emergency calls to health care responders instead of the police. We find robust evidence that the program reduced reports of targeted, less serious crimes (e.g., trespassing, public disorder, and resisting arrest) by 34% and had no detectable effect on more serious crimes. The sharp reduction in targeted crimes reflects the fact that health-focused first responders are less likely to report individuals they serve as criminal offenders and the spillover benefits of the program (e.g., reducing crime during hours when the program was not in operation).
... The goal of the CIT training programmes is to reduce injury (for the PwMI and the officer), arrest (Watson et al., 2008), and use of force, yet there is little empirical research that supports CIT training reducing officer use of force on PwMI (Morabito et al., 2012). However, the CIT programme has been more heavily evaluated than the co-responder models (Shapiro et al., 2015). ...
Recently, there has been an increased push for the adoption of alternative responses to policing. With mental health calls, these efforts take the form of co-responder models, in which mental health professionals respond to calls alongside police, or more recently behavioural health teams that respond alone. For any alternative, it is important to understand the prevalence of the problem, here measured as the volume of calls. However, measuring calls involving persons with mental illness (PwMI) has been historically problematic due to data ambiguity and missing context. We partner with the Burlington Police Department in North Carolina to better identify the full universe of calls involving PwMI. Using supplementary data sources and mental health keyword identification, we find that less than half of all calls involving PwMI are identified as such in the original call. Understanding the full universe of calls has implications for resource allocation, decisions to adopt alternate responses, and providing context for the current state of interaction between police and the population of PwMI.
People with mental health concerns are over-represented in police-involved deaths in Canada. Calls for alternative responses to people in crisis have generated interest in programs that partner police with mental health professionals. This review summarizes what is known about the effectiveness of co-response programs in meeting client and community needs. Methods followed PRISMA-ScR standards. Eight studies evaluating Canadian co-response programs were included. Co-response programs can reduce involuntary hospital transport, improve referrals, and decrease emergency department wait times. Research is needed to determine whether they reduce the use of force and meet client’s needs in the community.
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Disparities in victimization by law enforcement for both people of color and individuals with mental health disorders is gaining national attention following the deaths of George Floyd, Sandra Bland, TAmir Rice, and many others. Despite this, the discussion around the intersectionality of race, psychiatric illness, and law enforcement is still in its infancy, the purpose of this article is to discuss the confluence of race and psychiatric illness as vulnerabilities in various contacts with law enforcement in order to further highlight this issue and to ignite further needed research on this topic. Possible solutions such as police‐hiring practices, bias training, and trauma‐informed policing will be discussed.
The role of police in conducting wellness checks has received considerable public attention in Canada in recent years. Drawing upon data from both the computer-aided dispatch and records management systems of a mid-size police agency in Western Canada, we identify and then descriptively assess all wellness checks conducted in 2020 (N = 1,114 events). As part of our exploration, we explore the nature of these events, the characteristics of those involved, and the responses of the police. Our results reveal a series of patterns regarding the characteristics and outcomes of these events, including by ‘official’ versus ‘unofficial’ status. Our results also shed insight into the challenges of using police data for these kinds of research questions. By providing researchers, practitioners, and policymakers with an empirical analysis of wellness checks, we hope to contribute to evidence-based decision-making about these events moving forward.
This paper examines the role of the police in mental health work. It explores whether the calls to ‘defund the police’ can be the basis for fundamental reforms of mental health services and the police role. The paper outlines the roots of the calls to ‘ defund the police’ situating the perspective in the wider Black Lives Matter movement (BLM). The wider BLM movement seeks to overturn long standing racial and social injustices, including the disproportionate use of force against black citizens and racial biases within the Criminal Justice System. It goes further in that BLM calls for a shift in funding from policing towards an investment in welfare and community services. These calls are captured in the phrase ‘defund the police’. These calls have highlighted the police role in mental health, particularly, the police response to citizens in mental health crisis. The paper examines the police role in mental health work, highlighting the historic impact of policies of deinstutionalisation and more recently austerity and welfare retrenchment. In calling for this policy shift, campaigners have highlighted the need to significant investment in mental health services. The police role in mental health services increased because of the failings of community care ( Cummins, 2020a ). Police officers have increasingly become first responders in mental health crises. The paper, focusing on England and Wales, uses ‘defund the police’ perspective as a lens to examine long standing areas of concern. Police involvement in mental health emergencies is inevitably stigmatizing. There are also concerns from the police. This is an area of police demand that has grown of austerity and the wider retrenchment in public services. Police officers often feel that they lack the skills and knowledge required to undertake their role in mental health work. In addition, there is frustration generated by poor interprofessional working. Police officers on an organizational and individual level feel that they are often left ‘ picking up the pieces’ . There is a wide recognition that mental health services are failing to provide appropriate responses to those in crisis ( Wessley, 2018 ). As well as being an issue of human rights and social justice, these failures place vulnerable people at increased risk. All aspects of police work involve contact with people experiencing mental health problems. People with mental health problems are first and foremost human beings who should be treated with dignity and respect. They are also citizens, family members, carers and work colleagues. Having acknowledged that core value perspective, if we accept that police officers will be involved in mental health work, we should seek to limit their role as far as is possible. The paper concludes that it is likely that there will be always be some form of police involvement in mental health–related work. However, there is a need to limit this as far as possible.
High rates of criminal justice involvement among individuals with mental illness have led to collaborative efforts between law enforcement agencies and mental health providers to improve crisis responses and pathways to treatment. The development and implementation of these police-mental health collaborations (PMHCs) have received little attention in the literature, but these processes are crucial in understanding feasibility and sustainability. The PMHC discussed here is an interagency effort to identify individuals involved with law enforcement who have unmet behavioral health needs and engage them in services. Perspectives from leaders, service providers, and clients highlight the importance of developing PMHCs that support individuals with serious mental illness at multiple points, from initial crisis to independent management of treatment. In an environment where police responses to individuals with mental health and substance use disorders are increasingly scrutinized, it is critical to highlight and evaluate ways that behavioral health and law enforcement agencies work together to collaboratively address these problems.
Between 2009 and 2016, New Zealand Police experienced a disproportionate increase in lower-priority mental health-related calls. This exploratory study uses content analysis to identify characteristics of these calls, including reasons for calling police, advice and actions undertaken by communications centres staff, and actions undertaken by frontline officers. Four important findings emerge. First, there has been a significant increase in the proportion of mental health-related calls that did not involve reporting of an offence or emergency (increased from 48% in 2010 to 57% in 2016). Second, there was a significant increase in calls that were initiated by the person who appeared to be experiencing mental illness and distress during the time of the call (increased from 53% to 62%). Third, the way communication centres staff and frontline officers responded to mental health-related calls also changed over time. There was an increased tendency of communications centre staff advising the callers to call back if the situation escalates or if they require further assistance (which increased from 14% to 24%). Fourth, among the events attended by a police unit, there was an increase in the proportion of events where a frontline officer contacted a mental health agency (which increased from 6% of attended events to 10%). Moreover, transportation to a police station decreased (21.7% to 11%) while there were increases in the transportation of a person's home (2.7% to 6%). Transportation to a mental health facility averaged at 24.9% over the period.
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Although offenders with mental illness are overrepresented in the criminal justice system, psychiatric symptoms relate weakly to criminal behavior at the group level. In this study of 143 offenders with mental illness, we use data from intensive interviews and record reviews to examine how often and how consistently symptoms lead directly to criminal behavior. First, crimes rarely were directly motivated by symptoms, particularly when the definition of symptoms excluded externalizing features that are not unique to Axis I illness. Specifically, of the 429 crimes coded, 4% related directly to psychosis, 3% related directly to depression, and 10% related directly to bipolar disorder (including impulsivity). Second, within offenders, crimes varied in the degree to which they were directly motivated by symptoms. These findings suggest that programs will be most effective in reducing recidivism if they expand beyond psychiatric symptoms to address strong variable risk factors for crime like antisocial traits. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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This study compared communities with three models of crisis service: (a) police as part of a specialized mental health team, (b) mental health worker as part of a specialized police team, and (c) informal relationship between police and mental health crisis service. Rural and urban areas were examined and compared. Data included focus groups and participant observation. Analysis revealed that while all communities valued their crisis services, all identified limitations in responsiveness, access, and systems-related issues. Quick access to psychiatric beds was important to services. Rural communities had no public transportation, and an important police role was safe transportation. In rural communities, mental health workers were generalists because they had to be able to address situations on their own. In urban areas, transportation was more readily available, and more specialization developed among mental health team members.
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The State of Georgia passed legislation in 1993 to reform the public mental health system and directed that services be provided in the community whenever possible. In addition, the legislation mandates outcome studies including consumer satisfaction with services received. This study evaluated satisfaction with brief mental health, substance abuse, and mobile crisis services provided by a public crisis stabilization program in an urban setting. After services concluded, consumers (n=54) and family members (n=29) completed the Client Satisfaction Questionnaire (CSQ-8). The overall mean score of 27.6 compares favorably with similar outpatient services. An analysis of variance found that family members who received services from the mobile crisis program rated services significantly higher than two of the other three clients groups.
The manner in which people with mental illness are supported in a crisis is crucial to their recovery. The current study explored mental health consumers' experiences with formal crisis services (i.e. police and crisis assessment and treatment (CAT) teams), preferred crisis supports, and opinions of four collaborative interagency response models. Eleven consumers completed one-on-one, semistructured interviews. The results revealed that the perceived quality of previous formal crisis interventions varied greatly. Most participants preferred family members or friends to intervene. However, where a formal response was required, general practitioners and mental health case managers were preferred; no participant wanted a police response, and only one indicated a preference for CAT team assistance. Most participants welcomed collaborative crisis interventions. Of four collaborative interagency response models currently being trialled internationally, participants most strongly supported the Ride-Along Model, which enables a police officer and a mental health clinician to jointly respond to distressed consumers in the community. The findings highlight the potential for an interagency response model to deliver a crisis response aligned with consumers' preferences.
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 evidence-based practices for CIT, substantially increasing the empirical base of support for CIT.
As persons with mental illnesses and law enforcement become increasingly entangled, the collaboration of police and mental health service providers has become critical to appropriately serving the needs of individuals experiencing mental health crises. This article introduces the Crisis Intervention Team (CIT) Model as a collaborative approach to safely and effectively address the needs of persons with mental illnesses, link them to appropriate services, and divert them from the criminal justice system if appropriate. We discuss the key elements of the CIT model, implementation and its related challenges, as well as variations of the model. While this model has not undergone enough research to be deemed an Evidence-Based Practice, it has been successfully utilized in many law enforcement agencies worldwide and is considered a "Best Practice" model in law enforcement. This primer for mental health practitioners serves as an introduction to a model that may already be utilized in their community or serve as a springboard for the development CIT programs where they do not currently exist.
Seduced by the symbolic content of the coordination message, many senior administrators, social planners, and politicians advocate that the police and social work should work closer together. Examination of the critical properties of these occupations and of joint police‐social work programmes reveals, however, that the differences between them far outweigh their similarities. Moreover, these differences are not casual, but located in the culture and structure of each occupation, and in the structure of society as a whole. This analysis leads to the conclusion that proposed suggestions to better police‐social work relationships are unfeasible, and that it would be preferable if each occupation would simply fulfil its societal role on its own.