The Problem ▸
The criminal justice system is ill-equipped to provide the services and treatment needed for those suffering from mental illness and addiction. Yet, in the vast majority of communities in the United States, law enforcement is the only option for initial response to individuals in crisis. Officers often have few options or resources to resolve these situations other than resorting to formal criminal justice sanctions, including taking these individuals into custody where they are unlikely to receive the appropriate treatment for their health issues.
Contacts between police officers and persons with perceived mental illness (PwPMI) pose significant challenges. Surveys suggest that a substantial proportion of officers feel they lack the skills and training or were not qualified to handle calls involving PwPMI.[1] [2] At the same time, some research shows that calls involving mental health-related circumstances account for a disproportionate share of use of force events.[3] About one in four people suffering from mental health problems have a history of arrest.[4] Poorly handled police-community contacts involving PwPMI can lead to negative public sentiment, unnecessary hospital visits, repeated contact with the criminal justice system (criminalization of an illness), ineffective treatment, and inefficient use of limited police resources. Law enforcement interactions with PwPMI are compounded by broader social challenges such as the stigma associated with mental illness and substance abuse, a lack of social safety nets for people in crisis, and limited access to mental health or drug-abuse treatment services. These limitations often force law enforcement to be the primary, and in many places only, government resource available to people experiencing a crisis.
Similarly, law enforcement encounters with individuals experiencing substance use disorders also pose significant challenges. Substance use is very common among people who become involved in the criminal justice system.[5] [6] However, access to drug treatment services, both for the public at large and for justice-involved individuals, is extremely limited. For example, approximately 50% of state prisoners meet the criteria for a diagnosis of drug use, but only about 10% reported receiving any kind of drug treatment.[7] Only 9% of individuals with co-occurring mental health and substance use disorders receive both mental health care and substance use treatment.[8]
Overall, diverting individuals with mental health and substance use disorders from the criminal justice system to community or corrections treatment services is a significant and urgent issue in the United States.
Report Sections ▸
The National Institute on Drug Abuse estimated that of the 42.1 million adults with mental illness, about 18% also had a substance use disorder.[11] The comorbidity rate is considerably higher among justice-involved individuals. About half of male detainees with a severe mental disorder also tested positive for drug use at arrest,[12] and almost three-quarters of female jail detainees with severe mental disorders also met the criteria for at least one substance use disorder.[13]
Contrary to popular belief, research suggests that just over 1% of total law enforcement calls for service involve PwPMI.[14] [15] [16] This research, however, may be undercounting PwPMI-involved events because mental health issues tend not to be reliably recorded in law enforcement agency records.[17] Despite the fact that PwPMI-involved calls are a small percentage of overall agency activity, they tend to disproportionately involve young males[18] and are more likely to end in negative outcomes such as a use of force.[19]
Crisis response programs include police-led models that prepare officers to respond to persons in crises (e.g., the Crisis Intervention Team (CIT) model) and co-responder programs that rely on active collaboration between police and mental health professionals. Police and health providers generally hold positive but mixed perceptions of co-responder teams. Despite concerns over roles and responsibilities, police generally held positive opinions of co-responder programs and believed these programs helped people obtain necessary health services [20] while acknowledging having to address potential safety issues of having unarmed civilian responders present during potentially dangerous situations. At the same time, mental health providers voiced concern that some events might be more effectively handled with mental health professionals alone.[21]
Many communities lack programs to provide a non-policing alternative or co-responder model, wherein mental health professionals assist the police during incidents involving persons in crisis. Although some research has been conducted in larger urban jurisdictions, less is known about the use of these models in smaller, suburban, and rural communities. A 2021 survey conducted by the National Policing Institute found that smaller and rural communities struggle with personnel, training, and community-based resource limitations for implementing such strategies, particularly those that depend on community-based organizations and treatment services.[22] Further, more rigorous evaluations are needed to better understand the impact of alternative or co-responder models on outcomes, including arrest, injury, use of force, subsequent criminal justice contacts, and long-term mental health outcomes.[23]
Diversion – or directing people from the criminal justice system and into health services – might not be feasible without a substantial investment of resources. Most co-responder or community-based crisis response programs have limited availability and do not operate full-time.[24] In many nonurban and rural jurisdictions, community-based or specialized resources for dealing with PwPMI are often limited, leaving the police to respond to those experiencing crisis.[25] Even in communities with sufficient mental health resources, people of color experience more barriers to resources and poorer outcomes than their White peers.[26]
As a non-police response mechanism, mobile crisis teams (MCTs) are housed within the mental health system and consist of mental health professionals who respond to behavioral health crisis calls in the community. Several early evaluations suggested that MCTs can increase community-based service use, reduce hospital-based mental health service use, and link people to community-based care after an emergency department admission.[27] [28] The primary downside of MCTs is limited capacity and a long response time.[29] MCTs implemented in various cities still involve police collaboration to some extent, and therefore their efficacy as a non-police response mechanism remains limited.[30]
Overall evidence suggests that co-responder teams are effective in reducing criminal justice involvement for PwPMI.[31] [32] Studies have found that co-responder teams: 1) better connect clients to mental health services, 2) reduce the number of hospital transports and admissions, and 3) increase the likelihood of individuals remaining in the community, as opposed to being transferred to emergency departments or jails.[33] [34] However, evidence to support co-responding teams’ impact on the number of arrests, detentions, or the prevalence of repeat contact among clients remains limited.[35]
CIT for officers can improve their knowledge and disposition toward de-escalation[36] and may increase the use of referrals to community services.[37] Outcomes such as arrests, use of force, and injuries, are difficult to ascertain; the evidence on these outcomes is less conclusive. A meta-analysis of seven evaluations found that CIT did not impact arrest, use of force, and injuries. Still, there has also been considerable variation across CIT implementations which limits the ability to make direct comparisons.[38] Cost savings associated with CIT depend on a variety of characteristics (e.g., hospital admissions, arrests, and other outcomes) and on the timeline considered (i.e., short- versus long-term gain).
Police response to persons in an acute mental health crisis has raised concern about the lack of standardization, oversight, and documentation that goes along with field-based decision-making. Because officer discretion is a key component of the decision-making process, their response could be influenced by personal beliefs, stigma, and bias related to mental illness, a person’s history of substance use, and race and ethnicity. Crisis response programs can help standardize officers’ decision-making through training on program standards, agency policy, and local laws. Because crisis response training improves officer understanding of mental illness and substance use disorders, their decision-making abilities should consequently be improved as well. Some research has found that CIT training is associated with officers’ decision to transfer individuals to mental health resources rather than jail.[39]
Crisis response programs largely focus on individuals with mental health problems. These programs result in increased referrals and linkage to community-based services.[40] When a crisis response program includes addressing substance use disorders, it leads to increased use of treatment services[41] and hospitalization.[42] [43] Unfortunately, the overall use of treatment services still tends to be low.[44] Recipients of crisis response programs who were re-referred following their initial treatment were more likely to have substance use disorders, indicating more complex needs for the subset of individuals with co-occurring mental and substance use disorders.[45] [46]
Research suggests that persons with substance abuse disorder and co-occurring mental illness can be diverted from the criminal justice system with increased access to services, increased time in the community, and reduced jail days with no additional risk for re-arrest or psychiatric symptoms.[47] [48] [49] [50] There is stronger evidence that post-arrest diversion programs can improve criminal justice and drug use outcomes[51] [52]; research on pre-arrest diversion, however, is more limited. One systematic review of diversion programs found that they were less effective for males, frequent drug users, members of racial and ethnic minority groups, and those who had lower educational attainment or lacked social stability.[53] Treatment completion can be associated with positive outcomes, but these programs often face challenges in maintaining participant involvement over time.[54] [55] Increasing service linkage and delivery are key to enhancing these deflection and diversion programs.
Studies suggest that diversion programs that help individuals post-arrest can lead to cost savings, but pre-arrest diversion programs can be associated with higher costs.[56] [57] This is primarily because treatment costs are higher in community-based service programs. Developing affordable, long-term community-based service options is key to improving the efficacy of diversion programs and reducing criminal justice contact for individuals experiencing substance use disorders.
According to the National Coalition for the Homeless, 20-25% of the homeless population in the United States experiences some form of severe mental illness.[58] Moreover, adults experiencing homelessness and severe mental illness are more likely to come into contact with the criminal justice system.[59] Some police agencies have formed homeless outreach teams or specialized units that respond to homelessness-related calls. The units coordinate with shelters, advocates, and other service providers to connect people experiencing homelessness to support services. However, there is a current lack of evaluative studies on the effectiveness of these specialized units for increasing the number of referrals and transports to housing and health services and decreasing arrest rates among the homeless population.[60]
Institute a Public Health Approach to Substance Use Disorders
Non-violent individuals with substance use disorders (SUDs) should be diverted from the criminal justice system to community-based treatment services. Public health approaches, rather than zero-tolerance or single-approach policies, should be used to prevent and reduce substance use disorders within the community.
Remove Barriers to Treatment
Barriers to obtaining drug-treatment services, such as a lack of services or facilities and being uninsured or underinsured, should be identified and minimized. These barriers are particularly salient for individuals that are frequently in contact with the criminal justice system.
Research, Design, and Implement Alternatives to Arrest
Research is needed on the design, implementation, and evaluation of alternatives to arrest, including pre-arrest deflection, diversion, community views on diversion, SUD treatment, the impact of decriminalization of certain drugs, and how non-arrest interventions impact involvement in the criminal justice system, particularly with respect to any potential racially disparate impact. It is crucial to understand what programs work, how to best implement them, and what barriers prevent successful implementation, including stigma, treatment capacity, funding, and disparities in decision-making by police.
Implement and Evaluate Non-Police Crisis Response Teams and Co-Responder Programs
Local non-police crisis response teams (also referred to as alternative responders) should respond to persons in crisis, stabilize the situation without relying on the criminal justice system interventions, and connect them to resources and treatment. Research should be conducted on how to build this capacity, particularly outside of urban centers. Where models are currently implemented, research should determine what works and the community conditions that influence effectiveness.
Improve Responses to People Experiencing Homelessness
Punitive approaches to people experiencing homelessness must be minimized through collaborations by the public and private sectors to identify and fund programs to solve the root causes of homelessness. Research is needed to evaluate the effectiveness of existing programs, such as homeless outreach teams in law enforcement agencies, and to identify best practices, including training protocols, and particularly, which program components are best performed by police officers and which would be better performed by other experts. Data collection, analysis, and sharing must be improved regarding the experiences of individuals experiencing homelessness when they encounter service providers, including law enforcement.
Develop Alternate Strategies for Addressing Nuisance Offenses
Low-level offenses, such as illegal vending and panhandling, should be decriminalized, and alternative non-punitive strategies should be developed to address the disparate racial impact of arrest, which forces people into a cycle of monetary damage caused by fines and fees and that can also result in incarceration.
Ensure Officer Training to Address SUDs, Mental Health Crises, and People with Disabilities
Recognizing that alternatives to police-response models cannot be implemented immediately or in all places, agencies should implement current best training practices in de-escalation techniques, addressing substance-use disorders, responding to mental health crises, and recognizing and responding to people with physical and developmental disabilities.
Further Research ▸
More rigorous evaluations are needed to understand the impact of different crisis response models on outcomes such as arrest, injury, use of force, subsequent criminal justice contract, and long-term mental health benefits. More long-term evaluations are needed to assess the efficacy of proactive programs that prevent PwPMI from coming into contact with the criminal justice system and that may improve proactive service delivery.
Research is needed to develop effective, sustainable mental health response and care strategies for small and rural communities with limited resources for alternative response strategies. These communities tend to have fewer resources than urban areas, and additional challenges presented by extended travel times can undermine otherwise effective strategies.
Future studies should evaluate the efficacy of crisis responses that do not include sworn law enforcement responses. Both implementation and outcome evaluations are needed. Additional focus must be placed on program elements and how those elements are implemented. More rigorous research is needed to understand the efficacy of crisis response and diversion programs, especially for individuals with co-occurring mental health issues and substance use disorders. Current research shows that while these diversion and treatment programs have promise in improving outcomes for individuals with SUD, the benefits were not consistently observed. Most existing studies are not methodologically strong.
More research is needed on pre-diversion interventions. Research is particularly scant on pre-booking diversion programs and the characteristics that increase effectiveness. To the extent that diversion programs increase service linkage without negatively affecting public safety, these programs may offer viable alternatives to criminal justice responses. Nonetheless, the feasibility of this approach should be considered given that substance use and health services might not be readily available in small and rural jurisdictions.
Additional research is needed to understand the effect of crisis response programs and diversion on racial disparities and collateral consequences of criminal justice involvement for individuals with mental health and substance use disorders. Initial law enforcement response can save an individual’s life in an overdose episode, and access to substance abuse disorder treatment while in custody can reduce overdose-related death. However, individuals are at a high risk of relapse if there is not an appropriate continuity of care.
Citations ▸
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