homeless mental health

People with mental illness are more likely to experience poverty, homelessness or a substance use disorder and to have co-occurring conditions.

Mental Health Emergencies, Law Enforcement and Deflection Pathways

By Tammy Jo Hill and Amber Widgery | Feb. 9, 2022 | State Legislatures News | Print

Mental illnesses can pose a significant burden to society but have not historically been treated with the same degree of urgency as physical illnesses. For years, public health professionals have called for, and incorporated when possible, the promotion of mental health as an important aspect of their more standard disease prevention and control efforts. The American Public Health Association has supported mental health research for decades to develop and foster policy and practice that support mental health, physical health and the well-being of diverse and vulnerable populations.  

But challenges in mental health care and crisis response systems have often left emergency responders, including law enforcement, unprepared to address mental health situations. Today, a person experiencing a mental health crisis is more likely to encounter law enforcement than to receive treatment or crisis intervention. Due to lack of access to alternatives, law enforcement can spend one-fifth of its time responding to and transporting individuals with mental illness to emergency departments or jails.

A person experiencing a mental health crisis is more likely to encounter law enforcement than to receive treatment or crisis intervention.

Lack of treatment availability has led people who experience mental illness to be incarcerated four to six times more than the general population. This is not to say that people with mental illness are more likely than anyone else to commit violent acts. In fact, those with severe mental illness are 10 times more likely than the general population to be victims of a violent crime.

Individuals with mental health challenges encounter law enforcement because of disproportionate enforcement and disparities within the mental health system. In addition, people with mental illness are more likely to experience poverty, homelessness or a substance use disorder and to have co-occurring conditions.

An Ongoing Challenge

A contributing factor to the decrease in mental health treatment availability nationwide began in the 1950s with the movement to deinstitutionalize mental illness. That policy change was appealing from both a fiscal and civil rights perspective because it emphasized short-term, community-based treatment. However, it ultimately resulted in fewer state hospital beds for people experiencing a mental health crisis, something community supports were unable to handle.

Nearly 65 years later, treatment access for individuals with mental health and substance use disorders continues to present a challenge for many communities. Communities face low capacity for mental health treatment, lack developed mental or behavioral health crisis response systems, and are short of resources even when people are incarcerated. At least 83% of people in jail with mental health issues did not receive treatment after admission.

As state and federal actions have highlighted in recent years, connecting behavioral health and public health systems allows policymakers to better leverage resources across sectors often operating independently. Aligning infrastructure across systems can improve the ability to address priority health problems and use limited resources more efficiently. In recent years, law enforcement agencies have begun seeking greater cooperation with behavioral health systems due to a number of reported challenges, including a lack of:

  • Alternatives to 911.
  • Mental or behavioral health training, tools and support for 911 dispatchers.
  • Sufficient workforce of mental or behavioral health responders.
  • Training on mental or behavioral health challenges for law enforcement.

A Collaborative Framework

Law enforcement and other first responders are turning to deflection pathways to mitigate these reported challenges. Deflection pathways help connect individuals who have substance use or mental health issues to community-based treatment and services as an alternative to making an arrest or taking no action. These collaborations provide law enforcement officers greater awareness of community-based treatment options and resources and access to alternatives to jail.

Experts in the field have recognized five alternative pathways to incarceration, including self-referral, active outreach, post-overdose outreach, prevention, and intervention measures. Experts report deflection pathways better connect individuals to behavioral health treatment, recovery, housing, case management and a broader set of health and social services. Research shows that arrest or even short-term incarceration can destabilize a person’s life by disrupting routine, housing arrangements, health care access and even family or social connectedness. Ultimately, it can increase the risk of recidivism. Deflection helps prevent these disruptions. While information and resource sharing for all five pathways can benefit communities and system collaborations, prevention and intervention pathways offer a unique alignment with existing behavioral and public health systems.

Collaboration in Practice: The Role of Legislatures

As of June 2021, the Legislative Analysis and Public Policy Association reported that 25 states have varying laws pertaining to deflection programs. Of the 25, 13 have laws supporting a programmatic focus for individuals with mental health conditions or substance use disorders, and 18 laws mention prevention or intervention deflection.

Prevention programs can be led by law enforcement or co-responder teams but help individuals who are not facing or are not subject to facing criminal charges. The programs rely on stabilization centers, where law enforcement officers can take individuals experiencing a mental health crisis for treatment, instead of taking them to an emergency department or jail. In 2020, for example, Michigan passed legislation to create crisis stabilization units designed to prevent or deescalate behavioral health crises or reduce symptoms on an immediate, intensive and time-limited basis. Washington passed similar legislation in 2021 to create and fund statewide crisis stabilization center hubs to provide triage, real-time bed availability for all behavioral health needs, suicide prevention services, care coordination and referral coordination among community supports.

Pathway

Program examples

Self-Referral

Angel Initiative

Active Outreach

PAARI (Police Assisted Addiction and Recovery Initiative)

HOT (Homeless Outreach Team)

Post-Overdose

QRT (Quick Response Team)

DART (Drug Action Response Team)

Prevention

LEAD (Law Enforcement Assisted Diversion)

STEER (Stop, Triage, Engage, Educate and Rehabilitate)

intervention

CNN (Civil Citation Network)

CIT (Crisis Intervention Team)

Co-Responder Program

A more common community-based prevention program is the Law Enforcement Assisted Diversion program. Known as LEAD, the program consists of a team with specialization in law, health, housing, business and law enforcement that works both to prevent individuals from entering the criminal justice system and to reduce racial disparities in enforcement. More specifically, the program seeks to orient local government response to safety and health-related challenges, improve public safety and public health research regarding harm reduction interventions, sustain alternative funding treatment options, and strengthen the relationships between law enforcement and the community. A 2015 evaluation of the program revealed 58% of individuals who participated in LEAD were less likely to be arrested than those who went through the traditional criminal justice system. Originating more than 10 years ago in Seattle, the program has grown to include 42 communities in 21 states.

Intervention programs are similar to prevention programs in that they are led by law enforcement or co-responder teams, but the intervention takes place before criminal charges are filed because law enforcement believes that an alternative response would be appropriate. The programs can include models such as co-responder programs, crisis intervention teams and mobile crisis teams.

Mobile crisis teams comprise mental health professionals trained to help stabilize individuals during law enforcement encounters and crisis situations. Teams can respond to law enforcement or mental health calls. Since September 2019, at least 13 states have Medicaid-funded mobile crisis teams, and six others have mobile crisis teams funded through non-Medicaid means. For example, effective July 2021, Indiana passed legislation to coordinate 988 crisis hotline centers with mobile crisis teams when necessary.

Denver’s STAR (Support Team Assisted Response) program was created in 2020 as a partnership among local mental health centers, hospitals, the department of public health and law enforcement. STAR engages individuals experiencing crises related to mental health issues, poverty, homelessness and substance abuse. In its first year, the program diverted over 1,300 calls from law enforcement, resulting in no arrests and increased connection to needed services.

Successful treatment for justice-involved individuals includes promising evidence-based programs and practices that address mental illness, substance use risk and social factors. A combined approach between mental or behavioral health, public health and criminal justice systems offers the opportunity for policymakers to focus on the underlying causes of incarceration and address factors that contribute to cycles of incarceration and recidivism among people with mental illness while helping to improve general community safety.

Tammy Jo Hill is a policy specialist in NCSL’s Health Program. Amber Widgery is a program principal in NCSL’s Criminal Justice Program.

This project is supported by the John D. and Catherine T. MacArthur Foundation and the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. The CDC support is part of a financial assistance award totaling $200,000 with 50% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. government.

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