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December 2, 2020
Quarterly Opinion
Harold A. Pollack
Amy C. Watson
Apr 13, 2021
Mar 10, 2021
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The deaths of Robert Saylor, Laquan McDonald, Quintonio LeGrier, Dantre Hamilton, Walter Wallace and so many others underscore the repeated failure of America’s first-response system to safeguard the well-being of Americans who experience behavioral crises.[1] Many such tragedies reflect split-second decisions, and at times missteps, by police officers responding to 911 calls. Seeking to reduce these risks, police departments have expanded Crisis Intervention Team (CIT) officer deployment and de-escalation training. Underlying these tragedies and renewed efforts, however, is the context in which law enforcement officers have become the main responders to behavioral crises, sometimes the only immediate avenue by which people can access care. Family members, reading the headlines, may not call 911 when they require such assistance, or they may hesitate until a crisis has escalated to the point where violent encounters with first-responders are more likely.
Responding to community demands to reduce the police footprint in behavioral crises, cities are being pushed to develop safer and less-coercive approaches to emergency encounters. Co-responder models offer one such approach. Inclusion of a mental-health-trained co-response team has been associated with improved de-escalation, reduced stigma, and improved speed and clarity of pathways to mental health treatment.[2] Crisis teams that do not include police provide an option that allows families to feel safer requesting assistance before a situation escalates to the point of danger. While limited, the research on mobile crisis teams suggests benefits similar to those of co-responders.[3] Evaluation of Eugene, Oregon’s CAHOOTS model suggests that non-law-enforcement crisis teams can be safely deployed for many 911 calls.[4]
Such efforts are critically important—and nowhere near enough. The best first-response system, absent strong social service and mental health systems to back it up, will do little to meet the behavioral health and social service needs of community members.
To understand why, ask yourself a simple question: What happens a day, a week, a month after that crisis 911 call? Sadly, the most common answer is simple: Nothing—at least until the next call. What might be called our second-response system is a huge blind spot, and a proper focus for the new Biden administration.
Consider the following episodes:
Basic safety and de-escalation principles can help first-responders manage each of these incidents. Yet, the same question arises in each case: Then what?
Where is the follow-up in that group home to assess staffing levels and training? Who is asking about whether proper procedures were followed in the hours before that 911 call? Who is checking on the well-being of the other staff and residents?
What about calls to the family home? About one-third of parent-caregivers for young men with fragile X syndrome are injured by their sons; when such injuries occur, they are often repeat occurrences. [5] Who’s helping that family develop a plan that might prevent the next crisis?
CIT officers might transport that homeless man from the park to a local ER for assessment, but who follows up when he is discharged two hours later with a pamphlet listing various shelters and mental health agencies? Interviews with officers indicate this is all too common. Many are frustrated with the lack of effective health system response.[6] Some may conclude: “At least if I take him to jail, he won’t be back tonight at that same park bench generating another 911 call.” Still others may ask: “Why are we involved here at all?”
First-responders can hopefully revive the woman who overdosed, but what happens later, given the high fatality rate among individuals following a nonfatal overdose?[7]
In each case, improved first response is critical, but insufficient. When mental health service systems are deficient, police and emergency medical services become the main, sometimes only, available interventions to address behavioral crises, leaving fundamental issues unaddressed.
The work of follow-up is not for first responders. These are tasks for an organized social service response[8]—what might be called the second response to 911 calls. The Biden administration can use the tools at its disposal—particularly Medicaid—to do better.
Proper services require secure and durable financing within our complex multi-payer system.[9] As a practical matter, Medicaid is central because many, if not most, people who require crisis services are Medicaid-enrolled or, at least, Medicaid-eligible. The federal government can offer an enhanced Medicaid match or behavioral health waivers to states that submit crisis management plans to improve the local infrastructure of behavioral health care, capacity, and quality. Such plans should include mental health and social service quality standards, alongside proper provider reimbursement to ensure genuine service access. States also can make greater use of mental health and addiction parity laws to push private payers to provide proper coverage.
State plans could include expanded coverage for supportive housing and related services, and broadened eligibility for assertive community treatment (ACT) for people with addiction or other disorders typically excluded from such services. Such plans should include concrete steps to improve pay, job quality, training, and staffing for the behavioral health direct care workforce, coupled with payment structures that incorporate greater quality assurance to help reduce future need for crisis response. Medicaid agencies also can collaborate with the Department of Justice to support cities, such as Chicago, seeking to improve behavioral crisis response under pertinent Consent Decrees.
No single measure will prevent all tragedies in first response. Taken as a whole, this portfolio of investments can have substantial impact. The Biden administration faces many higher-profile challenges, but few offer the same opportunity to make a real difference.
Acknowledgment: Research underlying this essay was supported through NIMH grant R01MH117168. The views expressed are those of the authors and not those of any funder or collaborating agency.
[1] Pollack, HA and Humphreys, KN, Reducing the frequency and severity of incidents between police officers and people with psychiatric and substance use disorders, invited submission, Annals of the American Academy of Political and Social Science. Forthcoming.
[2] Puntis S, Perfect D, Kirubarajan A, et al. A systematic review of co-responder models of police mental health ‘street’ triage. BMC Psychiatry. 2018;18(1):256. Published 2018 Aug 15. doi:10.1186/s12888-018-1836-2
[3] Dyches, Hayne, Biegel, David E, Johnsen, Jeffrey A, Guo, Shenyang, & Min, Meeyoung Oh. (2002). The Impact of Mobile Crisis Services on the Use of Community-Based Mental Health Services. Research on Social Work Practice, 12(6), 731–751. https://doi.org/10.1177/104973102237470
[4] White Bird Clinic (2020) Crisis Assistance Helping out on the Streets (CAHOOTS) Media Guide. Accessed 11/28/2020 https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf
[5] Wheeler AC, Raspa M, Bishop E, Bailey DB Jr. Aggression in fragile X syndrome. J Intellect Disabil Res. 2016;60(2):113-125. doi:10.1111/jir.12238
[6] Wood JD, Watson AC, Barber C. What can we expect of police in the face of deficient mental health systems? Qualitative insights from Chicago police officers [published online ahead of print, 2020 Sep 23]. J Psychiatr Ment Health Nurs. 2020;10.1111/jpm.12691. doi:10.1111/jpm.12691
[7] Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020
[8] Wood JD, Watson AC, Barber C. What can we expect of police in the face of deficient mental health systems? Qualitative insights from Chicago police officers [published online ahead of print, 2020 Sep 23]. J Psychiatr Ment Health Nurs. 2020;10.1111/jpm.12691. doi:10.1111/jpm.12691
[9] SAMSHA (2020) National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation. U.S. Department of Health and Human Services (HHS). Rockville, MD.
Harold A. Pollack, PhD, is the Helen Ross Distinguished Service Professor at the University of Chicago. He is faculty codirector of the University of Chicago Health Lab. He researches services for severely disadvantaged populations for individuals at the interface between Medicaid and the criminal justice system.
Amy C. Watson, PhD, is a professor at Helen Bader School of Social Welfare at the University of Wisconsin-Milwaukee. Watson has worked extensively on issues involving the intersection of the criminal legal and mental health systems, in Chicago and around the country. For the past two decades, her research has focused on police encounters with persons with mental illnesses and the Crisis Intervention Team (CIT) model. Recently, she served on the De-escalation Work Group of the Chicago Police Accountability Task Force and serves on the Mayor’s Mental Health Steering Committee on an ongoing basis. She serves on the CIT International Board of Directors, currently as president of the organization. Her prior professional experience includes working as a Probation Officer on a team serving clients with serious mental illnesses and as a Forensic Social Worker/Mitigation Specialist working on death penalty cases. She has a BA in Criminal Justice from Aurora University and a AM and PhD from the University of Chicago School of Social Service Administration.
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