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Crisis Intervention Team Training

for Police Officers Responding


to Mental Disturbance Calls
Jennifer L. S. Teller, Ph.D.
Mark R. Munetz, M.D.
Karen M. Gil, Ph.D.
Christian Ritter, Ph.D.

Objectives: In recognition of the fact that police are often the first re- address this problem. One such col-
sponders for individuals who are experiencing a mental illness crisis, laboration is the crisis intervention
police departments nationally are incorporating specialized training for team (CIT) model, started in 1988 by
officers in collaboration with local mental health systems. This study ex- the Memphis Police Department
amined police dispatch data before and after implementation of a crisis (10). The CIT program provides in-
intervention team (CIT) program to assess the effect of the training on tensive training about mental illness
officers’ disposition of calls. Methods: The authors analyzed police dis- and the local system of care to patrol
patch logs for two years before and four years after implementation of officers, who then are available to re-
the CIT program in Akron, Ohio, to determine monthly average rates of spond to mental disturbance calls.
mental disturbance calls compared with the overall rate of calls to the The idea has spread nationwide, and
police, disposition of mental disturbance calls by time and training, and approximately 70 departments have
the effects of techniques on voluntariness of disposition. Results: Since formed their own CIT programs (per-
the training program was implemented, there has been an increase in sonal communication, Cochran S,
the number and proportion of calls involving possible mental illness, an October 9, 2004).
increased rate of transport by CIT-trained officers of persons experi- Although clearly intended to in-
encing mental illness crises to emergency treatment facilities, an in- crease officers’ skills in deescalation
crease in transport on a voluntary status, and no significant changes in of crises among persons with mental
the rate of arrests by time or training. Conclusions: The results of this illness, CIT partners may seek differ-
study suggest that a CIT partnership between the police department, ent—although complementary—out-
the mental health system, consumers of services, and their family mem- comes. Law enforcement may be
bers can help in efforts to assist persons who are experiencing a mental most interested in improving the
illness crisis to gain access to the treatment system, where such individ- safety of both officers and consumers
uals most often are best served. (Psychiatric Services 57:232–237, 2006) during potentially dangerous encoun-
ters, whereas mental health may fo-
cus more on decreasing inappropriate

P
olice officers are recognized as priate (5,6). The absence of collabo- arrests of persons with mental illness.
first responders for individuals ration between law enforcement and In this article, we examine disposi-
who are experiencing a mental mental health systems has been posit- tion of mental disturbance calls be-
illness crisis (1–4). In the absence of ed as one factor in the emergence of fore and after implementation of one
specialized training in mental illness the complex phenomenon known as city’s CIT program. The purpose of
and knowledge about the local treat- the criminalization of persons with the study reported here was to deter-
ment system, such crises may end in mental illness (7–9). mine whether CIT-trained officers
arrest and incarceration when referral Partnerships between law enforce- were more likely than non–CIT-
and treatment might be more appro- ment and mental health systems may trained officers to respond to calls in-
volving individuals with mental illness
who were experiencing a crisis by
Dr. Teller and Dr. Ritter are affiliated with the department of sociology of Kent State Uni- transporting the person to a health
versity, Kent, Ohio 44242 (e-mail, jteller@kent.edu). Dr. Munetz is with the Summit care facility and less likely to either
County Alcohol, Drug Addiction, and Mental Health Services Board in Akron, Ohio, and arrest the person or leave the person
with the Northeastern Ohio Universities College of Medicine in Rootstown. Dr. Gil is with at the scene. Furthermore, for cases
Akron General Medical Center and Northeastern Ohio Universities College of Medicine. in which an officer determined that
232 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2
transportation to a treatment facility access. Officers visited psychiatric implementation of the CIT program
was necessary, we examined whether emergency services, went into the by using SPSS, version 12.0. The
the transportation to treatment was community with case managers, and Akron Police Department provided
voluntary or involuntary, by officers’ visited a consumer-directed social data on the number of calls for assis-
CIT training status. center. They received extensive train- tance. All calls that were coded as
The program in Akron, Ohio, be- ing in verbal deescalation skills and mental disturbance calls by police
gan in May 2000 with the collabora- engaged in realistic role playing to department dispatchers from May
tion of the Akron Police Department; practice these skills in simulated 1998 through April 2004 were made
the Summit County Alcohol, Drug crises at the NEOUCOM Center for available to the research team. These
Addiction, and Mental Health Ser- the Study of Clinical Performance. calls included the call date, the time,
vices Board and its provider agen- Officers were encouraged to consid- whether CIT team members were
cies; the National Alliance for the er, when appropriate, linkage and re- present, police code corresponding
Mentally Ill (NAMI) of Summit ferral for care to the mental health to disposition of the call, and notes
County; the Summit County Recov- system as a preferable alternative to from the Akron Police Department
ery Project; and the Northeastern arrest. and emergency medical services.
Ohio Universities College of Medi- CIT-trained officers began pa- Notes were evaluated to determine
cine (NEOUCOM). Two major mod- trolling in the Akron community on disposition location and information
ifications were made to the Memphis May 27, 2000. Training was provided about which agency was in charge of
program to account for differences in annually for new team members. Ex- the call (the Akron Police Depart-
services available. Akron, unlike cluding officers who have been pro- ment, emergency medical services,
Memphis, has a freestanding psychi- moted or have retired, currently 66 or another agency, such as the coro-
atric emergency service, which means of 243 active patrol officers (27 per- ner, the local jail, or a mental health
that individuals who have a comorbid cent) are CIT trained (personal com- agency). Notes were consulted to de-
nonpsychiatric medical condition munication, Yohe M, July 29, 2004). termine whether the officer who
may be referred to a general hospital In addition to training for officers as transported the individual to a treat-
emergency department instead of or detailed above, refresher training ment facility initiated an involuntary
before going to psychiatric emer- sessions have been held annually commitment process.
gency services. In addition, Akron’s since 2003. These sessions are for The number of calls for assistance
emergency medical services dispatch supplementary mental health train- per month and the number of calls re-
a paramedic unit to emergency calls ing and to identify areas in program lated to a mental disturbance per
identified as involving persons with implementation where difficulties month were summed per year (May
mental illness. In general, emergency exist for officers and the people they through April), and the rate of mental
medical services are in charge of serve. Modified annually, the two- disturbance calls per 1,000 Akron po-
nonpsychiatric medical calls, and the day refresher course has included lice department calls per month was
police are in charge if a call is due pri- updates on legal and medical issues, calculated. Analysis of variance
marily to manifestations of mental ill- research results, advanced tech- (ANOVA) statistics were calculated.
ness without comorbid medical com- niques in negotiation and suicide If the means were significantly differ-
plications. As a result, paramedic prevention, and taser techniques, ent at the p<.05 level, one-way ANO-
lieutenants from the Akron Fire De- procedures, and qualification. VA Scheffé’s post hoc tests were run
partment were included in initial CIT officers handle situations they to identify categories of difference.
training. encounter on patrol or through dis- Compared with other tests, Scheffe’s
The first weeklong training oc- patch. Dispatchers evaluate emer- is a conservative estimate, because
curred in late May 2000 with 20 gency calls and have two codes for larger differences in means are re-
Akron police officers and three para- mental disturbance calls: suspicion of quired for significance.
medic lieutenants from the Akron mental illness and suicide attempt in Percentages and chi square statis-
Fire Department. All officers were progress. Once on the scene, respon- tics were calculated for the disposi-
volunteers and were screened by the ders may determine that the call does tions of calls by time and training.
training director to determine their not involve a person with mental ill- Time was dichotomized as either the
appropriateness for this team of offi- ness. Conversely, other codes—for two years before implementation of
cers who were most likely to en- example, fights—may involve a per- the program (May 1998 through April
counter individuals experiencing son with mental illness but may not 2000) or the four years after (May
mental illness crises. Communication be coded by dispatchers as a call re- 2000 through April 2004). Training
skills and being self-motivated to im- lated to a mental disturbance. was dichotomized as either CIT-
prove skills and knowledge about trained or non–CIT-trained. Analysis
mental illness were the prime selec- Methods of variance was calculated on the ba-
tion criteria for the program. Officers We obtained institutional review sis of disposition proportions. If the
received a 40-hour introduction to board approval from all applicable means were significantly different at
mental health and mental illness with agencies before beginning the proj- the p<.05 level, Scheffé’s post hoc
an intensive overview of the local ect. Data were analyzed for the two tests were run to identify categories
mental health system and its points of years before and the four years after of difference.
PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2 233
Table 1
Dispositions of mental disturbance calls for persons experiencing a mental illness crisis, by crisis intervention team (CIT) train-
ing status of police officers, for calls handled by either the Akron, Ohio, Police Department or emergency medical services

Transport to psy- Police inter-


chiatric emer- Transport to other Transport action, no need
gency servicesa treatment facility to jailb for transport Total

CIT training status N % N % N % N % N %

Before CIT program implementation 750 26.5 965 34.1 84 3.0 1,034 36.5 2,833 100
After CIT program implementation
Non–CIT-trained officers 1,126 26.9 1,447 34.6 100 2.4 1,512 36.1 4,185 100
CIT-trained officers 581 29.5 639 32.5 80 4.1 667 33.9 1,967 100
Total 2,457 27.3 3,051 34.0 264 2.9 3,213 35.8 8,985 100
a F=3.13, df=2, 8,982, p=.044; Scheffe’s test showed a significant difference between CIT-trained officers and the other two groups (p<.05).
b F=6.62, df=2, 8,982, p=.001; Scheffe’s test showed a significant difference between CIT-trained and non–CIT-trained officers after implementation of
the CIT program (p<.001).

Results known. Over the six-year period, al- plementation of the program, the
Proportion of mental most 25 percent of the 10,004 mental overall rate of transport to jail de-
disturbance calls disturbance calls resulted in trans- creased slightly, from 3.0 percent to
From May 1998 through April 2004, portation to psychiatric emergency 2.9 percent. When we compared the
the Akron Police Department re- services, and 31 percent resulted in two groups of officers after imple-
ceived 1,527,281 calls for service, of transportation to local hospitals or mentation of the program, CIT-
which 10,004 were related to mental another treatment facility. Thirty-two trained officers were more likely
disturbances. The average number of percent of the calls involved police than non–CIT-trained officers to
calls per month (21,212) was stable interaction with no need for trans- have transported persons with men-
over the six-year study period (data port. Almost 3 percent of the calls re- tal disturbances to jail (4.1 percent
not shown). The total number of calls sulted in an arrest. Slightly fewer compared with 2.4 percent), al-
per year increased slightly over the six than 8 percent resulted in no police though the difference was not signif-
years, although not significantly. The interaction, and 2 percent involved icant. When CIT-trained officers’ in-
two years before implementation of some nontreatment transport; in less teractions were compared with those
the program and the year of imple- than .5 percent of the calls the dispo- of the other two groups, CIT-trained
mentation were significantly different sition was undetermined. officers were also more likely to have
from the last two years studied We continued our analyses with transported persons with mental dis-
(p<.006). There was an absolute in- four disposition categories: transport turbances to psychiatric emergency
crease in the number of calls identi- to psychiatric emergency services, services and less likely (although not
fied as mental disturbance calls and in transport to another treatment loca- significantly less) to have transport-
the rate of calls related to mental dis- tion, transport to jail, and police in- ed them to other treatment facilities.
turbances per 1,000 calls for assis- teraction with no transport. The oth- CIT-trained officers were also less
tance (F=9.39, df=5, p≤.001) as well er three categories were not analyzed, likely to have interactions involving
as a proportional increase (F=15.86, because these three disposition cate- no need for transport than were oth-
df=5, 66, p≤.001). gories do not appear relevant to un- er officers, either before or after im-
derstanding police interaction with plementation of the CIT program,
Disposition of calls for individuals who are mentally dis- but, again, the difference was not
mental disturbances turbed. Eliminating these categories significant.
Initially there were seven disposition decreased the sample size by about The fact that emergency medical
categories: transport to psychiatric 10 percent to 8,985. services were in charge in the case of
emergency services; transport to an- some of the calls may have masked
other treatment location, such as an Disposition by officers’ the effects of training, because there
area hospital or detoxification facility; CIT training status may not be opportunities to use
transport to a jail; police interaction Table 1 is a cross-tabulation of the deescalation techniques in emer-
with no need for transport (for exam- four disposition categories by time gency settings. Table 2 shows dispo-
ple, giving advice, assisting, or talking and training: before the CIT pro- sitions by officers’ CIT training sta-
to the person); other transportation gram, non–CIT-trained officers after tus after removal of these nonpsychi-
(including to a shelter or residence); implementation of the CIT program, atric medical calls (N=4,367). With
no police interaction (for example, and CIT-trained officers after imple- these calls excluded, there was no
the officer was unable to locate the mentation of the CIT program longer a significant difference in ar-
individual); and disposition un- (χ2=21.58, df=6, p=.001). After im- rest rates between the three groups,
234 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2
Table 2
Dispositions of mental disturbance calls for persons experiencing a mental illness crisis, by crisis intervention team (CIT)
training status of police officers, for calls handled by the Akron, Ohio, Police Department

Transport to psy- Police inter-


chiatric emer- Transport to other Transport action, no need
gency servicesa treatment facilityb to jail for transportc Total

CIT training status N % N % N % N % N %

Before CIT program implementation 336 25.8 174 13.4 84 6.5 706 54.3 1,300 100
After CIT program implementation
Non–CIT-trained officers 510 26.6 236 12.3 100 5.2 1,071 55.9 1,917 100
CIT-trained officers 377 32.8 183 15.9 80 7.0 510 44.3 1,150 100
Total 1,223 28.0 593 13.6 264 6.0 2,287 52.4 4,367 100
a F=8.98, df=2, 4,364, p<.001; Scheffe’s test showed a significant difference between CIT-trained officers and the other two groups (p=.001).
b F=4.04, df=2, 4,364, p=.018; Scheffe’s test showed a significant difference between CIT-trained and non–CIT-trained officers after implementation of
the CIT program (p=.019).
c F=20.697, df=2, 4,364, p<.001; Scheffe’s test showed a significant difference between CIT-trained officers and the other two groups (p<.001).

which suggests that training status Second, with the community’s knowl- fects may explain this difference, giv-
did not affect arrests. However, CIT- edge of the CIT program and the par- en that recognition of symptoms of
trained officers were significantly ticipation of NAMI, callers may have mental illness and knowledge of op-
more likely than either of the other been more likely to acknowledge the tions for treatment are part of CIT
two groups to take mentally dis- involvement of a person with mental training.
turbed persons to psychiatric emer- illness. Since the program began, The study showed that trained offi-
gency services and less likely to be family members have reported that cers are less likely to end calls without
involved in calls for which there was they are more comfortable calling the arranging for transport of the person
no need for transport. Compared police to request help for a loved one, involved. This issue is complex. Police
with non–CIT-trained officers for and consumers of mental health serv- officers on the scene have consider-
the period May 2000 through April ices have reported calling the police able discretion (1,11). For officers in
2004, CIT-trained officers were sig- to request help for themselves or general, the less time-consuming
nificantly less likely to be involved in their peers. course is to rule out an emergency
calls for which there was no need to A number of findings suggest that and resolve the call without arranging
transport the individual. the program is meeting the desired transport. CIT-trained officers pre-
Before implementation of the CIT outcomes for both sides of the part- sumably appreciate the fact that time-
program, 10.6 percent of people who nership. Compared with nontrained ly intervention in the treatment sys-
were transported for treatment were officers, trained officers are more tem may prevent future emergencies,
transported on an involuntary legal likely to transport a person for treat- even if the situation at hand does not
status. There was a significant de- ment than they were before the pro- mandate transport. On the other
crease in the involuntariness of trans- gram was implemented. Training ef- hand, CIT-trained officers may use
port after implementation of the pro-
gram for both non-CIT- and CIT-
trained officers, as can be seen from Table 3
Table 3.
Voluntariness of transport to treatment among persons experiencing a mental ill-
Discussion ness crisis responded to by officers of the Akron, Ohio, Police Department, by of-
Since the CIT program began, there ficers’ crisis intervention team (CIT) training statusa
has not been an increase in the vol- Voluntary Involuntary Total
ume of all calls, but the absolute
number of mental disturbance calls CIT training status N % N % N %
and the proportion of such calls have
Before CIT program
increased. We suspect at least two
implementation 456 89.4 54 10.6 510 100
possible explanations for this increase After CIT program
in the number of calls related to men- implementation
tal disturbances after implementation Non–CIT-trained officers 697 93.4 49 6.6 746 100
of the CIT program. First, the dis- CIT-trained officers 533 95.2 27 4.8 560 100
Total 1,686 92.8 130 7.2 1,816 100
patchers may have been more aware
and better prepared to assess a call as a F=7.05, df=2, 1,813, p=.001; significant difference between pre-CIT and both non–CIT-trained
involving a person with mental illness. (p=.025) and CIT-trained (p=.001) officers after implementation of the CIT program.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2 235


their training to deescalate and coun- appeared after calls handled by ditional comparison group. Despite
sel individuals so that no further emergency medical services were ex- these limitations, the findings are
emergency intervention is needed. As cluded from the analyses. Emer- important.
CIT has evolved in Akron, the police gency medical services handled 54 In addition, future research should
and mental health systems have been percent of calls attended by consider the effects of the circum-
developing outreach programs so that non–CIT-trained officers both be- stances surrounding the call. A com-
people who may not need emergency fore and after the CIT program was plementary study that examined qual-
mental health intervention receive implemented but handled only 42 itative CIT-trained officers’ field re-
appropriate mental health follow-up. percent of calls attended by CIT- ports (manuscript in preparation) had
The effects of such programs on the trained officers. Removal from the similar findings, suggesting that al-
rate of calls that do not involve the data of primarily nonpsychiatric though CIT programs may have a sig-
arrangement of transport remain to medical calls, for which officers lack nificant impact on police referral for
be seen. At this point, however, it ap- discretion about disposition, clari- treatment and decreased use of force
pears that the significant difference in fied the differences between the and involuntary commitment, these
the rate of calls that did not involve groups of officers. CIT-trained offi- programs may not reduce arrests of
transport between CIT-trained and cers’ arrest rates were not signifi- people with mental illness. Only a
non–CIT-trained officers reflects a cantly different from those of the study of the circumstances of each ar-
desired outcome. other officer groups, but the CIT- rested individual, the nature of the
We cannot explain with certainty trained officers transported mentally charges, and the officer’s rationale for
the observation that after implemen- disturbed individuals to treatment arrest will help explain these findings.
tation of the CIT program there was a facilities more often. Future examination of narrative re-
decrease in involuntary transports for Furthermore, it is likely that Akron ports on each CIT encounter will ad-
both CIT- and non–CIT-trained offi- arrest rates are influenced by offi- dress these questions.
cers. It may be that the emphasis dur- cers’ knowledge of the Mental CIT programs require a partner-
ing training on use of verbal deescala- Health Court postarrest diversion ship between law enforcement and
tion techniques to avoid escalation of program. The Akron Mental Health mental health systems as well as con-
crises filtered throughout the depart- Court began in January 2001, shortly sumers of mental health services and
ment, or it may be that CIT-trained after the start of the CIT program their families. Each stakeholder
officers are referred the more chal- (12,13). This court is for misde- group may desire overlapping but
lenging cases, which could mask the meanants with severe and persistent somewhat different outcomes. It is
effects of training. In any case, all mental illness who receive intensive likely that CIT programs will differ
stakeholders perceive this outcome as community-based treatment in lieu depending on the mental health and
a positive one. of incarceration. Court personnel criminal justice systems’ community
The apparently higher rate of ar- participate in CIT training to explain resources. As data accumulate on the
rest by CIT-trained officers was the program and to encourage offi- effectiveness of CIT programs, com-
unanticipated. Mental health sys- cers to refer the individuals they ar- munities will need to decide whether
tems support CIT programs in part rest to the mental health court. the outcomes warrant the consider-
because they view the programs as Knowledge of the program and the able investment in the program. If
prearrest diversion programs. Police fact that it may help individuals who CIT enhances the safety of both offi-
agencies, on the other hand, em- may otherwise be resistant to treat- cers and consumers but does not re-
brace the CIT program as a means of ment to live successfully in the com- duce the arrest rate, for example,
enhancing officer and community munity may result in CIT-trained of- will courts and jail administrators
safety. Through CIT training, offi- ficers’ choosing arrest in selected cas- support it?
cers may learn when referral to the es. The interaction of prearrest diver-
mental health system is most effec- sion programs such as the CIT pro- Conclusions
tive and when arrest may be prefer- gram and postarrest programs such The implementation of a crisis inter-
able. As noted above, it is possible as the mental health court should be vention team (CIT) program for po-
that dispatchers are sending CIT of- the subject of future research. lice officers has led to an increased
ficers to the most challenging mental Given that these results are not number and proportion of calls rec-
disturbance calls, for which officers based on experimental data, it is not ognized by police dispatch as poten-
may have less discretion as to possible to make causal assertions tially involving mental illness. Train-
whether to arrest the individual. about the effects of police training ing has led to increased transport of
That this might be the case could be on dispositions. That is, officers were persons who are experiencing a men-
supported by the fact that the initial- not randomly assigned to training. tal illness crisis to emergency evalua-
ly significantly higher arrest rate by Furthermore, officers were acting as tion and treatment facilities, and
CIT-trained officers disappeared their own controls by using the pre- transport is more likely to be on a vol-
and differences in significance be- CIT program as a comparison group. untary basis compared with officers
tween CIT-trained and other officer Ideally, we would have liked to have who have not participated in the
groups in both transport to other similar data from a community that training. This finding suggests that
treatment and no need for transport did not have a CIT program as an ad- the CIT partnership between the po-
236 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2
lice department, the mental health Woody (Ret.), Sgt. Michael Yohe, Michael Journal of Law and Psychiatry 20:469–486,
Carillon, Lt. Michael Prebonick, and 1997
system, consumers of services, and
Chief Michael T. Matulavich. The authors 6. Dupont R, Cochran S: Police response to
their family members can help in ef-
also thank the following students who as- mental health emergencies: barriers to
forts to assist individuals who are ex- sisted in data cleaning: Natalie Bonfine, change. Journal of the American Academy
periencing a mental illness crisis and Sue Drexel, Marcee Jones, Ashley Kilmer, of Psychiatry and the Law 28:338–344,
interacting with the criminal justice 2000
Kris Kodzev, Marnie Salupo Rodriguez,
system to gain access to the treat- Dana Sohmer, and Joyce Wall. 7. Steadman HJ, Stainbrook KA, Griffin P, et
ment system, where such individuals al: A specialized crisis response site as a core
element of police-based diversion programs.
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This research was supported by the Ohio 4. Vermette HS, Pinals DA, Appelbaum PS: July 2000
Mental health training for law enforcement
Department of Mental Health (grant professionals. Journal of the American 12. The Akron Municipal Mental Health Court
02.1176) and the Ohio Office of Criminal Academy of Psychiatry and the Law Mission Statement and Protocol. Akron,
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ficers of the Akron Police Department for health workers: the decision to arrest or re- and Rewards Program, Akron, Ohio, Akron
their assistance and patience: Lt. Michael fer to mental health agencies. International Municipal Court, 2001

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PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ February 2006 Vol. 57 No. 2 237