Recommendation area ▸

Mental Health & Substance Abuse

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.

What We Know ▸

Council Recommendations ▸

Recommendation 37

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.

Recommendation 38

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.

Recommendation 39

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.

Recommendation 40

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.

Recommendation 41

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.

Recommendation 42

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.

Recommendation 43

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 ▸

[1] Ruiz, J., & Miller, C. (2004). An exploratory study of Pennsylvania police officers’ perceptions of dangerousness and their ability to manage persons with mental illness. Police quarterly, 7(3), 359-371. https://doi.org/10.1177/1098611103258957

[2] Wells, W., & Schafer, J. A. (2006). Officer perceptions of police responses to persons with a mental illness. Policing: An International Journal of Police Strategies & Management. 29(4), 578-601. http://dx.doi.org/10.1108/13639510610711556

[3] Yang, S. M., Gill, C., Kanewske, L. C., & Thompson, P. S. (2018). Exploring police response to mental health calls in a nonurban area: A case study of Roanoke County, Virginia. Victims & Offenders, 13(8), 1132-1152. https://doi.org/10.1080/15564886.2018.1512540

[4] James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. U.S. Department of Justice. https://bjs.ojp.gov/content/pub/pdf/mhppji.pdf

[5] Belenko, S., Hiller, M., & Hamilton, L. (2013). Treating substance use disorders in the criminal justice system. Current Psychiatry Reports15(11), 1-11.

[6] Office of National Drug Control Policy. ADAM II: 2012 annual report. Washington, DC: The White House; 2013.

[7] Zarkin, G. A., Cowell, A. J., Hicks, K. A., Mills, M. J., Belenko, S., Dunlap, L. J., & Keyes, V. (2015). Lifetime benefits and costs of diverting substance-abusing offenders from state prison. Crime & Delinquency, 61(6), 829-850.

[8] Han, B., Compton, W. M., Blanco, C., & Colpe, L. J. (2017). Prevalence, treatment, and unmet treatment needs of US adults with mental health and substance use disorders. Health affairs, 36(10), 1739-1747.

[9] Lattimore, P. K., Steffey, D. M., Gfroerer, J., Bose, J., Pemberton, M. R., & Penne, M. A. (2014). Arrestee Substance Use: Comparison of Estimates from the National Survey on Drug Use and Health and the Arrestee Drug Abuse Monitoring Program. In CBHSQ Data Review. Substance Abuse and Mental Health Services Administration (US).

[10] Brecht, M. L., Anglin, M. D., & Lu, T. H. (2003). Estimating drug use prevalence among arrestees using ADAM data: An application of a logistic regression synthetic estimation procedure. US Department of Justice, Office of Justice Programs, National Institute of Justice. https://www.ojp.gov/pdffiles1/nij/grants/198829.pdf

[11] National Institute on Drug Abuse. (2018, August 15). Comorbidity: Substance Use and Other Mental Disorders [Infographic]. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/trends-statistics/infographics/comorbidity-substance-use-other-mental-disorders

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[20] https://www.newsobserver.com/news/local/crime/article257454503.html

[21] Watson, A. C., Compton, M. T., & Pope, L. G. (2019). Crisis response services for people with mental illnesses or intellectual and developmental disabilities: A review of the literature on police-based and other first response models. Vera Institute. https://www.vera.org/downloads/publications/crisis-response-services-for-people-with-mental-illnesses-or-intellectual-and-developmental-disabilities.pdf

[22] Davis, R., Lebron. M., & Reuland, M. (2021). How small law enforcement agencies respond to calls involving persons in crisis? Results from a national survey. National Police Foundation. https://www.policefoundation.org/wp-content/uploads/2021/01/Small-Agencies-Crisis-Response-Survey-020120214-1.pdf

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[26] Alegria, M., Zhen-Duan, J., Shaheen O’Malley, I., & DiMarzio, K., (2022). A new agenda for optimizing investments in community mental health and reducing disparities. American Journal of Psychiatry, 179(6), 402-416. https://doi.org/10.1176/appi.ajp.21100970

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[28] Zealberg, J. J., Santos, A. B., & Fisher, R. K. (1993). Benefits of mobile crisis programs. Hospital & Community Psychiatry, 44(1), 16-17. https://doi.org/10.1176/ps.44.1.16

[29] IACP and University of Cincinnati Center for Police Research and Policy. (n.d.). Assessing the impact of mobile crisis teams: A review of research. https://www.theiacp.org/sites/default/files/IDD/Review%20of%20Mobile%20Crisis%20Team%20Evaluations.pdf

[30] Isselbacher, J. (2020, July 29). As mobile mental health teams work to de-escalate crises, some warn their models still rely on police partnerships. Stat News. https://www.statnews.com/2020/07/29/mobile-crisis-mental-health-police/

[31] Kisely, S., Campbell, L. A , Peddle,  S., Hare, S., Pyche, M., Spicer, D., & Moore, B. (2010). A controlled before-and-after evaluation of a mobile crisis partnership between mental health and police services in Nova Scotia. Canadian Journal of Psychiatry, 55(10), 662–668. https://doi.org/10.1177/070674371005501005.

[32] Dempsey, C., Quanbeck, C., Bush, C., & Kruger, K. (2019). Decriminalizing mental illness: Specialized policing responses. CNS Spectrums, 25(2), 181-195. https://doi.org/10.1017/S1092852919001640

[33] Watson, A. C., Compton, M. T., & Pope, L. G. (2019). Crisis response services for people with mental illnesses or intellectual and developmental disabilities: A review of the literature on police-based and other first response models. Vera Institute. https://www.vera.org/downloads/publications/crisis-response-services-for-people-with-mental-illnesses-or-intellectual-and-developmental-disabilities.pdf

[34] Abramson, A. (2021, July 1). Building mental health into emergency responses: More cities are pairing mental health professionals with the police to better help people in crisis. https://www.apa.org/monitor/2021/07/emergency-responses

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[57] Zarkin, G. A., Cowell, A. J., Hicks, K. A., Mills, M. J., Belenko, S., Dunlap, L. J., & Keyes, V. (2015). Lifetime benefits and costs of diverting substance-abusing offenders from state prison. Crime & Delinquency, 61(6), 829-850.

[58] National Coalition for the Homeless (NCH). (2009). Mental Illness and Homelessness. http://www.nationalhomeless.org

[59] Roy, L., Crocker, A. G., Nicholls, T. L., Latimer, E. A., & Ayllon, A. R. (2014). Criminal behavior and victimization among homeless individuals with severe mental illness: a systematic review. Psychiatric Services65(6), 739-750.

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