Dispatch Triage, Alternative Responders and Co-Response:

Ending Police-Only Responses
To Mental Health 911 Calls

Communities United Against Police Brutality

Dispatch Triage, Alternative Responders, and Co-Response:

Ending Police-Only Responses to
Mental Health 911 Calls

Communities United Against Police Brutality

Cover art, tables and graphics designed by Abigail Grewenow

This white paper is dedicated to Archer Amorosi, Benjamin Evans, Kobe Heisler, Travis
Jordan, Keaton Larson, Phil Quinn and others who lost their lives at the hands of law
enforcement during a mental health crisis.
With deep appreciation to the volunteers who spent many hours researching, writing,
editing and reviewing this white paper. Our goal is to end the practice of police-only
contacts for people in mental health crisis through presenting evidence and practical
information to enable the necessary changes. We believe we have achieved this goal.
--Volunteers with the Mental Health Working Group of
Communities United Against Police Brutality
August 2020

As someone who’s been a mental health practitioner for over 35 years, I
cannot recommend this position paper strongly enough. Individuals and
our society at large are still suffering from the broken promises of the mental
health system’s de-institutionalization process that began in the 1980s and
has flooded our streets, our prisons, and our homes with people who cannot
access the mental health care they desperately need. Then, when these
people with chronic mental health challenges are in their most desperate
moments of crisis, their need is often met with a visit from the police, which
further threatens their life and their well-being.
We need a different strategy. This paper is a serious, well researched
analysis of this problem that presents a vision of a better way: responding to
mental health emergencies with mental health professionals. I encourage
you to read it, and endorse these proposals.
Rev. Daniel Wolpert, M.A., M.Div.
Executive Director, Minnesota Institute of Contemplation and Healing

i

PREFACE
Communities United Against Police Brutality (CUAPB) is a Minnesota all-volunteer
grassroots organization that provides advocacy for survivors of police misconduct and
the families of people killed by police. We work to address the underlying causes of
unjust and harmful policing. Part of that work is research to help communities
understand relevant problems and seek better solutions.
This paper addresses field contact between police and people experiencing mental health
issues. This is a narrow focus on a key crossroad in time. These contacts are the common
points of divergent outcomes that lead to consequences for vulnerable persons, the
criminal justice system, and the community. It is time to take a fresh look at how these
contacts are handled, who handles them, and how to enable alternative responses when
appropriate. This paper challenges the common reflex to simply provide more police
training and casually accept the problems that arise thereafter. It is time to ask: Why are
police officers responding? Why a police-only response? Why aren’t police collaborating
on-scene with mental health professionals more often?
These questions are at the heart of the crisis created by the ongoing surge in police
contacts with persons who suffer from mental illness. In a September 22, 2017,
PoliceOne.com article, Booker T. Hodges, a veteran Minnesota law enforcement officer,
explored the relevant questions. His words are an apt starting point for this paper.
I have been a Crisis Intervention Team (CIT) coach for over a decade and believe
the current push for more mental health care training for police officers is a good
thing in part. I say in part because after years of experience and research, I do not
believe that law enforcement should be responsible for responding to non-violent
mental health calls.
As a profession, we are problem solvers. The public and elected officials know this,
so they keep heaping societal problems on us with the expectation that we solve
them. It is time we start saying no.
There are two reasons why I believe society should stop having police officers
respond to non-violent mental health calls:
1. Cops lack adequate mental health care response training
The average psychologist has between 10-12 years of college education in addition
to 3,000 hours of supervised training. A licensed mental health care professional
has between 7-8 years of college education in addition to hundreds of hours of
supervised training.
By comparison, a police officer who attends a CIT course receives 40 hours of
formalized training. Most police officers receive far less than 40 hours training
afforded to those who attend CIT training.

ii

Yet despite this gap in training, society expects police officers to show up and
handle mental health calls with the same precision and expertise of a mental health
care professional. This is an unrealistic expectation.
We are setting police officers up for failure by continuing to send them on calls
that, in spite of our best efforts, we can never train them well enough to handle.
2. Law enforcement brings the tail of the criminal justice system
There is a consensus within society that the criminal justice system is not the
appropriate place to handle those who suffer from mental illness.
In light of this, it makes no sense to send police officers—who bring the tail of the
criminal justice system with them—on calls involving non-violent mentally ill
individuals.
The chance of a non-violent mentally ill person being interjected into the criminal
justice system increases when they come into contact with police. Our jails are full
of people suffering from mental illness who have no business being there, yet
society keeps sending them because there is no other place for them to go.1

1

2 reasons cops should not respond to non-violent mental health calls. Hodges, Booker. Police1.
Lexipol. September 22, 2017. https://www.policeone.com/patrol-issues/articles/421707006-2reasons-cops-should-not-respond-to-non-violent-mental-health-cal

iii

TABLE OF CONTENTS
Page

I.

Executive Summary

vii

Introduction

1

A) Law Enforcement Response to Mental Health Crises

3

B) Law Enforcement Officers as de facto Mobile Mental Health Crisis Workers

3

C) The Scope of the Problem

5

D) The Comparison That Matters: Police Officers vs. Mental Health Professionals

9

E) Our Scope: A Narrow Focus on the Point of Contact with Police

12

II.

Key Principles

15

Principle 1: An on-scene mental health response is the proper response to a
mental health problem.

15

Principle 2: Avoid police-only contacts with people in mental health crisis.

15

Principle 3: “The right service at the right place at the right time” creates
efficiencies and improves outcomes.

16

Principle 4: Collaboration is key—“separate silos” is the problem.

16

III.

The Police-Centered Status Quo—A Brief History

17

A) The Trap

17

B) Into The Soup

17

C) Laboratories of Democracy Stir

19

D) Growth Without Sunshine

20

IV.

Foundations for Failure

A) Lack of Effective Dispatch Triage

23
23

1) The Police Obligation to Respond – Never Real and Being Withdrawn
2) Dispatch Triage at the Police Dispatcher Level (e.g. CAHOOTS)
B) Stand-Alone CIT—Exaggerated Competencies and Separate Silos
1) CIT’s Core Elements Are Not Patient Centered
2) The Excuse To Avoid Co-Response or Alternative Response

26

iv

3) Territorial Tendencies Result in More Investment in CIT
4) The CIT Paradox
C) Refusal to Involve Alternative Responders

34

D) The Odd Effort to Misrepresent Follow-Up Services As Co-Response

34

E) Follow-Up Schemes Intended to Support Entrenched Police-Only Response

34

1) Rule Out Cost-Saving Deflections
2) Myth of a Clinician Labor Shortage
3) Betray Early Episode SMI Sufferers
4) Delay Care and Degrade Effectiveness
5) Are Risky
6) Business Model Told Them to Do It
7) Maintain a Failed Status Quo
F) Dedicating Officers to Do Social Work Follow-Up Visits

39

G) LEAD Programs and Mental Illness

39

H) Telepsychology, Where Chosen for Convenience Only

44

I) Ambulances and EMTs Instead of Licensed Mobile Mental Health Crisis Workers

44

J) Using Under-Qualified Workers for Mobile Mental Health Crisis Response

44

1) CAHOOTS
K) Promises to Collaborate Without Formal Policy and Mechanisms
V.

Foundations for Success

A) General Concepts
1) Multi-Layered Response Schemes That Prioritize Collaboration at First
Contact
2) Dispatch Triage

45
47
47

3) Alternative Responders—911 Mental Health First Responders
4) MN’s County Crisis Response Teams: Ideal Alternative and Co-Response
Option
5) Co-Response and Mental Health Co-Responder Teams
6) Statutes, Medical Assistance, and Insurance Requirements
B) Considerations for Rural Areas
1) Dispatch Triage and Alternative Response
2) Rural Co-Response
3) Co-Location

62

v

4) Telepsychology for Rural Collaboration
C) Start-Up Resources for Evidence Based Approaches

64

1) Advocates Inc. of Massachusetts - Technical Assistance Center
2) Law Enforcement Learning Sites
VI.

Specific Approaches for Success

67

A) Deflection and Prevention Before the Call to 911

67

B) Dispatch Triage—Examples

67

1) Ramsey County Deflection to County Crisis Response Team
2) Abilene (TX) Deflection to Crisis Response Team
3) Harris County 911 Crisis Call Diversion Program
4) Mental Health Nurses in U.K. Emergency Call Centers
5) Dallas Deflects at 911 to RIGHT Teams to Avoid Police Response
6) Other Examples of Dispatch Triage at 911 Emergency Call Centers
C) Alternative Responders—911 Mental Health First Responders

69

1) Ramsey County Mental Crisis Response Teams
2) Psychiatric Emergency Response Team (PAM) – Stockholm
3) CAHOOTS Teams – Eugene, Oregon
D) Post-Booking Diversion

81

E) Co-Location

81

F) Co-Response Options

81

1) New to the U.S.: Three-Person Officer/Clinician/EMT Co-Response Teams
2) LAPD and Houston: Very Large City Programs
3) St. Paul, Gainesville, and Other Mid-Sized Programs
4) Multi-Jurisdictional Programs Enable Suburbs and Smaller Cities To Share
Teams
5) Co-Response with Officers, EMTs and Mental Health Workers
6) A-PACER in Victoria, AU
7) Co-Response by Non-Embedded Clinicians, (a.k.a. Separate Response)
VII.
VIII.

The Labor Market for Key Mental Health Professionals

Co-Occurring Conditions, Integration, and the Need for Quality Mobile
Response
A) Co-Occurring Conditions and Factors

85
87
87

vi

B) Care Integration Versus the Law Enforcement Silo

88

C) The Community-Based Approach to Care Management and Coordination

91

D) High Quality Initial Co-Response and Alternative Response

92

IX.

Funding Innovation

95

A) Acknowledging Obstacles to Success—An Essential Starting Point

96

B) Simultaneous Funding of Both Alternative Response and Co-Response Options

97

C) Getting City and County Political Support and Funding

98

D) Dedicated Revenue Streams

99

1) Special Sales Tax
2) Special Tax Levies and Local Mental Health Board Systems
E) State Government Funding

102

F) Federal Government Funding

104

G) Private Funding and Support

105

H) Savings and Efficiencies

105

1) Costs of Police-Only Crisis Response
2) Hidden Benefits and Savings
X.

Moral and Ethical Considerations

113

A) Legal is Not Always Ethical or Moral

113

B) Allowing Fear to Overcome Compassion

114

C) Beyond Control—Valuing Autonomy

115

D) Acting on a Moral and Ethical Imperative

115

XI.

Concluding Statements and Recommendations

117

Glossary

119

References

135

vii

EXECUTIVE SUMMARY
Law enforcement officers have many contacts with persons living with mental illness.
Many of these contacts are unnecessary and avoidable. Unfortunately, such contact has
become an accepted status quo. In the past several years, a marked increase in the number of
mental health-related calls has burdened police agencies. Using police officers in this role has
also burdened emergency rooms and filled the jails. Now, there is wider recognition that
police officers are wholly inadequate in the role of de facto mobile mental health crisis
workers. Using police officers in this way has resulted in greater suffering and tragic
outcomes for vulnerable persons.
This paper examines the game-changing reform options that can be applied from the time
of 911 call intake to the arrival of responders on-scene. 911 systems will always receive some
mental health-related calls and some police contacts are unavoidable. However, a mental
health crisis is a medical emergency deserving a medical response – even if the response is
initiated through 911 emergency systems. The goal should be to minimize the use of policeonly responses to emergency calls involving a mental health crisis.
Three clear avenues exist for improving upon the status quo: 1) robust dispatch triage to
deflect calls away from police contact whenever possible, 2) rapid on-scene alternative
responder options that utilize highly skilled mental health professionals, and 3) well-utilized
co-response options to get mental health professionals on-scene in circumstances where a
police presence cannot be avoided. Efforts to bypass 911 systems altogether are essential but
outside the scope of this paper. Dispatch triage involves the training and practices needed to
enable 911 dispatchers to deflect calls to alternative mobile mental crisis responders. Where
there is no law enforcement function or public safety concern, these calls should be deflected
to non-police mobile mental crisis responders.
Any non-police crisis response must utilize highly qualified mental health professionals
and provide rapid on-scene response. Unfortunately, many relevant police contacts are
unforeseen or unavoidable. Sometimes there is a reported safety concern, a criminal
component, or the mental health aspect becomes apparent only after police arrive on-scene.
In such cases a co-response option should be utilized whenever possible. The co-response
option is an indispensable parallel means of preventing police-only contacts with persons in
mental health crisis. Implementing dispatch triage and the parallel response options can
reduce waste of taxpayer funds. These silo-breaking reforms can be part of larger campaigns
to integrate service delivery for high utilizers of medical and emergency services. Those with
co-occurring disorders, including substance use disorder, will be especially well served by
these changes.
Funding such reforms is possible because they create efficiencies and address a public
need. The status quo, which has normalized the use of police as de facto mobile mental crisis
response workers, must yield to more patient-centered approaches. This is both a practical
and moral imperative for our society.

viii

I. INTRODUCTION

I.

1

INTRODUCTION

In Minnesota, in a three-week period between November and December 2018, five
people experiencing mental health crises were killed during encounters with law
enforcement.2 Nationally, fully 50% of people killed by police had a disability.3 4
Don’t get me wrong, I have the highest respect for police officers and those who
serve our communities and our countries. But when statistics show that half the
people you’re shooting are people with a mental health problem, not a criminal
problem, that’s really eye-opening.5
Furthermore, people with untreated mental illnesses are a staggering 16 times more
likely to be shot and killed by police.6
These shocking statistics point unequivocally to the need to limit police-only contacts
with people experiencing mental health crises. Yet in this country, for a variety of
reasons, police have become de facto mental health crisis responders.
The most striking change in the care of persons with mental illness in the United
States in the last three decades has been the transfer of responsibility from mental
health professionals to law enforcement officers. It is now well-known that jails and
prisons have become the de facto frontline “inpatient units” for seriously mentally
ill persons. What is less well known is that law enforcement officers are now
functioning as the frontline “outpatient system.”7
But the police – who are trained to give orders and use force when they feel
endangered – are generally ill-equipped to handle people with mental health
challenges.8

2

CUAPB Stolen Lives. https://www.cuapb.org/stolen_lives
Half Of People Killed Have Disability. https://www.nbcnews.com/news/us-news/half-people-killed-policesuffer-mental-disability-report-n538371
4
Across Nation, Unsettling Acceptance When Mentally Ill in Crisis are Killed.
https://www.pressherald.com/2012/12/09/shoot-across-nation-a-grim-acceptance-when-mentally-ill-shotdown/
5
Half of Police Shootings Involve People with Mental Illness. https://psychcentral.com/blog/half-of-policeshootings-involve-people-with-mental-illness/
6
People with Untreated Mental Illness 16 Times More Likely to be Killed By Police.
https://www.treatmentadvocacycenter.org/key-issues/criminalization-of-mental-illness/2976-people-withuntreated-mental-illness-16-times-more-likely-to-be-killed-by-law-enforcement7
2013 Treatment Advocacy Center Report.
https://www.treatmentadvocacycenter.org/storage/documents/2013-justifiable-homicides.pdf
8
To Stop Police Shootings of People with MH Disabilities. https://theconversation.com/to-stop-policeshootings-of-people-with-mental-health-disabilities-i-asked-them-what-cops-and-everyone-could-do-tohelp-126229
3

I. INTRODUCTION

2

Police are poorly trained to fill the role of first responder for people experiencing mental
health crises. This is understandable because it takes years of training and experience to
become a mental health provider. Furthermore, the role of police in society is to
determine if a crime has occurred, investigate individuals’ involvement in the crime, and
gather evidence for prosecution. By necessity, they approach their work from a public
safety perspective. Even specialty training such as Crisis Intervention Training (CIT) is
not adequate to allow police officers to replace qualified mental health professionals in
addressing mental health crises.
"Officers are simply not the most qualified people to respond to a mental health
crisis," ACLU-MN Executive Director John Gordon said in a statement9
The current system of police-only response to mental health crisis calls is not only
dangerous but practically guarantees that people fall through the cracks by not getting
mental health care when they need it. They become heavy utilizers of police and
emergency services.
Run-ins with the police were a regular occurrence for many of my clients, with
officers often knowing them by name. They were overwhelmingly poor, and poor
people with mental illnesses are also likely to experience homelessness and
substance abuse—issues that place them at increased risk of police contact and
incarceration.10
Time for Real Solutions
Psychiatric disease is one of the few medical conditions in US public healthcare for
which treatment is routinely deferred until people become so sick they require
emergency hospitalization and intensive care. Serious mental illness (SMI) is also a
disease for which intervention is routinely left to nonclinical facilities such as jails,
prisons or homeless shelters. This twin dysfunction has the disastrous outcome of
producing a large population of acutely ill people who revolve, untreated or undertreated, through the healthcare and social and criminal justice systems.11
It is time to do something different and to humanize people in a mental health
crisis.
—Tessa Andrews, mother of Keaton Larson, who was killed by Stillwater
police in his home while in a mental health crisis12
9

Stillwater Mom Speaks Out. https://patch.com/minnesota/stillwater/stillwater-mom-speaks-out-after-sonshot-killed-police
10
Where Police Violence Encounters Mental Illness. https://www.nytimes.com/2016/01/13/opinion/wherepolice-violence-encounters-mental-illness.html
11
Revolving Door of Serious Mental Illness in Super Utilization.
https://www.treatmentadvocacycenter.org/storage/documents/smi-super-utilizers.pdf
12
Stillwater Mom Speaks Out, op. cit.

I. INTRODUCTION

3

A system that enables appropriate responses to mental health crisis calls must include
dispatch triage, deflection to a mobile mental health crisis team whenever possible, and
co-response when deflection is not possible. Such a system avoids a police-only response
to these calls.
A. Law Enforcement Response to Mental Health Crises
Law enforcement has frequent, often unavoidable, contact with persons experiencing
mental health crises. The scale of this problem can be reduced by deflecting these
interactions away from police through better practices at 911 call centers. This paper
explores this option in depth.
Unfortunately, many mental health-related police contacts will continue to occur through
necessity or unforeseeable circumstances. Survey data indicates that 30% of the police
contacts that result in a transport to care are made during regular patrol, not on mental
health-related calls for service.13 Two Minnesota cases highlight this situation. Both
Dominic Felder and David Smith were killed by police dispatched to disturbance calls.14
15
Both victims were unarmed. In cases where unavoidable police contact occurs, onscene co-response by mental health professionals can enable the response to quickly
evolve into a professional crisis care response.
The status quo in the U.S. does not promote deflection to mental health clinicians or realtime co-response. When calls for service have a mental health aspect, there is broad
failure to deflect those calls to teams comprised of mobile mental health professionals.
There is also systemic resistance to real-time, on-scene co-response by mental health
professionals. This should not be the case.
B. Law Enforcement Officers as De Facto Mobile Mental Health Crisis Workers
Decades ago, the process of de-institutionalization greatly reduced the number of
persons confined to state mental hospitals. But deinstitutionalization is half the story. The
old system of confinement was supposed to be replaced with an large and effective
system of community-based care. This failure promoted policies and practices that
increasingly leveraged police officers as de facto mobile mental health crisis workers.16
Thus, responding officers become gatekeepers to proper mental healthcare.17
There are a number of consequences of this paradigm. Community members in mental
health crisis are at elevated risk of physical harm. There is reduced access to and efficacy
13

Road Runners, p. 28. https://www.treatmentadvocacycenter.org/storage/documents/Road-Runners.pdf
Dominic Felder Verdict. https://www.mprnews.org/story/2010/10/25/excessive-force-verdict
15
David Smith Verdict. http://www.startribune.com/feb-7-2012-man-s-death-puts-minneapolis-police-tacticunder-scrutiny/138821999/
16
Police as Streetcorner Psychiatrist.
https://www.sciencedirect.com/science/article/abs/pii/016025279290010X?via%3Dihub
17
Heyman, I., & McGeough, E. (2018). Cross‐Disciplinary Partnerships Between Police and Health
Services for Mental Health Care. 25(5–6), 283–284. doi: 10.1111/jpm.12471
14

I. INTRODUCTION

4

of crisis and stabilization services. Specifically, officers who do not collaborate on-scene
create the potential for avoidable trauma, police use of force, incarceration, costly
ambulance transfers, revolving door emergency room visits, inappropriate dispositions,
and poor handoffs to mental health workers or stabilization services. There is real
potential for waste and missed treatment opportunities.
Inefficiencies and lack of deflection to or collaboration with mental health clinicians are
symptoms of a “separate silo” response to co-occurring conditions often experienced by
people in crisis. The failure to increase collaboration and to utilize proper expertise is an
expensive mistake for taxpayers. The focus on managing the problem “downstream” of
initial contact creates burdens that could have been mitigated with reforms like dispatch
triage and on-scene collaboration when police make first contact.
The least-inspired approaches to the problem, and its consequences, tend to focus on
expanding budgets within the existing frameworks of operation. Bartkowiak-Theron and
Asquith have shared a better way of thinking about the problem and its consequences. 18
They have added their voices to previous calls for collaboration between the mental
health system and police agencies. They sought to identify the conceptual dissonance
that continues to frame the debate about law enforcement and public health. This
“conceptual dissonance” is the problem as much as any policy, practice, law, or budget
limitation:
The divide between law enforcement and public health is futile. The everyday
‘reality’ of police officers and health professionals in their interactions with
vulnerable people is a constant reminder of how law enforcement and public health
are inextricably linked. However, the siloed operationalization of vulnerability in
current policies is counterproductive. Addressing the layers of universal human
vulnerability and situational vulnerability presented in every law enforcement or
public health encounter requires the abandonment of siloed policies and practices. It
also requires the operationalization of collaborative partnerships as core business,
which are budgeted and integrated in strategic directions. Policing and public
health organizations could inculcate an ethics of care as a first step in moving
beyond selective approaches currently adopted. Public safety and public health have
long been linked at the practice level but estranged at the level of the concepts and
policies underpinning these practices. Reframing the critical issues facing both
public health and law enforcement through the lens of vulnerability may provide
the building blocks required to create space for more productive law enforcement
and public health synergies and fewer instances of dissonance.

18

Bartkowiak-Théron, I. & Asquith, N.L. (2017) Conceptual Divides and Practice Synergies in Law
Enforcement and Public Health: Some Lessons From Policing Vulnerability In Australia, Policing and
Society, 27:3, 276-288, DOI: 10.1080/10439463.2016.1216553

I. INTRODUCTION

5

It is a truism for those providing crisis services that outcomes and efficiency are
optimized by providing THE RIGHT SERVICE, AT THE RIGHT PLACE, AND AT THE
RIGHT TIME. This paper seeks to challenge the reader to overcome “conceptual
dissonance” and question how the above truism (and the implied goal) can be applied to
law enforcement field contacts involving mental illness.
C. The Scope of the Problem
In most counties in the United States the largest mental healthcare facility is the county
jail. Furthermore, the police are filling a primary role as de facto mobile mental health
crisis workers.
Police departments have become a de facto arm of the American mental-health
system. Research suggests that about 2 million people with serious mental illness
are booked into jails in the United States each year. A 2016 review of studies
estimated that 1 in 4 people with mental illness has a history of police arrest. The
Treatment Advocacy Center, a nonprofit that studies topics related to mental health,
has calculated that the odds of being killed during a police encounter are 16 times as
high for individuals with untreated serious mental illness as they are for people in
the broader population.19
These realities are due, in great part, to under-resourcing of the mental healthcare system
in the United States. However, it is equally true that inadequate efforts have been made
to deflect patients from contact with police and divert persons with mental illness from
incarceration. Persons with serious mental illness (SMI) represent 4% of the population
but 17% of the jail population.20
One reason this vulnerable population is overrepresented in jails is the enforcement of
quality of life violations. Co-occurring conditions such as substance use disorder (SUD)
and homelessness are common and problematic.21 Longer lengths of incarceration are
also a factor.22 Lack of treatment and poor treatment in the jail setting set up this
population to experience a “revolving door” cycle of contact with the criminal justice
system.23

19

Police and Psychiatrist Team. https://beta.washingtonpost.com/national/health-science/police-encountermany-people-with-mental-health-crises-could-psychiatrists-help/2018/07/20/20561c26-7484-11e8-b4b7308400242c2e_story.html?noredirect=on
20
Serious Mental Illness in Jails and Prisons.
https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-in-jails-and-prisons.pdf
21
Mental Health Problems of Prison and Jail Inmates. https://www.bjs.gov/content/pub/pdf/mhppji.pdf
22
More Mentally Ill People in Jails and Prisons Than Hospitals.
https://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf
23
MI Revolving Door. https://www.calhospital.org/sites/main/files/fileattachments/grand_jury_mental_illness_website_0.pdf

I. INTRODUCTION

6

The results of this system-wide failure are clear. Los Angeles County, California,
currently operates a jail that is the largest mental health facility in the United States.24
The incidence of mental illness within some county jail systems can be very high. A 2014
spot survey of the population in the Hennepin County Jail showed a 52% incidence of
mental illness.25 26
Somewhat ironically, county jails are the sector of the criminal justice system that is
making a noticeable effort to link into the care continuum for mental illness and
substance abuse treatment. There are more psychiatric services being offered within jails,
and special jail units are being constructed. Tragedies and liability have been a factor in
this, but so too has the realization that treatment reduces recidivism. Whatever the
rationale, no one believes jails offer adequate care, much less appropriate environments,
for this population. The best overall outcomes (including taxpayer benefits) come from
avoiding the incarceration of persons with mental illness. Unfortunately, while jails
become de facto mental health institutions, there continues to be far too little investment
and innovation “upstream” at the point of police contact.
Upstream-downstream thinking has great relevance for jail-SMI interventions.
Much of current jail diversion efforts focus on post-booking interventions such as
mental health courts, mandated treatment, and mental health probation. All of these
represent downstream interventions trying to rescue people who have already flowed
into the criminal justice system. Although necessary, such efforts alone are not
sufficient. We also need to be looking for upstream prevention strategies that can
help to intercept and divert the flow of persons with SMI into local jails.27
Much is at stake when police have contact “upstream” of the other systems. These
contacts often happen at times of deep crisis. For the person in crisis, this police contact
can be a life-altering event—for good or ill. There is the risk of trauma, use of force,
arrest, monetary punishments (fines, court fees), and tragedy. There is also tremendous
opportunity to help people if innovative methods and collaborations are applied. These
collaborations, at these key moments in time, are even more important when there are cooccurring conditions such as substance abuse. Preventing harm at this point can have a
cascading positive affect on multiple government systems. The important thing,
however, is to help the person get through a psychiatric crisis or emergency.

24

More Than Half of LA Inmates Mentally Ill. https://laist.com/2020/01/07/mentally-health-jail-ladiversion.php
25
Mental Illness Far Higher in Hennepin County Jail. http://www.startribune.com/mental-illness-inhennepin-county-jail-far-higher-than-previous-estimates-new-study-finds/394483221/
26
Mental Health Services in County Jails.
https://robinainstitute.umn.edu/sites/robinainstitute.umn.edu/files/mn_leg_auditors_report.pdf
27
When Political Will is Not Enough. (p. 12) http://www.safetyandjusticechallenge.org/wpcontent/uploads/2015/05/White-Paper-hjs-jpm-final.pdf

I. INTRODUCTION

7

The opportunity to help people was very much on the mind of the Pitkin County, CO,
Undersheriff, Roy Ryan, when his department began a collaborative on-scene
police/mental-health-professional response program:
“I also appreciate that our community’s initial contact with their public servants
will not be enforcement-minded as much as it will be big-picture problem solving,
knowing that many of the people we contact are struggling with other, much larger,
issues than the reason for our contact,” Ryan said.28
Police contacts with persons in mental health crises are nothing new. Back in 1979,
academic researchers began to refer to the “gray area” of police work, where the law and
order function blends with informal work to help vulnerable people in need. One
thought leader of the time went so far as to label police the “secret social service.”29
Teplin called police “street-corner psychiatrists” due to their routine interactions with
persons living with mental illness.30 In fact, most police contacts with persons with
mental illness are firmly within the “gray area” where there is no criminality, no
violence, and no need for emergency apprehension.31 As a society we responded to these
“gray area” contacts by adding more police training. That simple solution was woefully
inadequate.
In these modern times, the evolution of public policy toward complete and effective
“care continuums” can and should be applied to police contacts. Police contacts should
be considered nodes in the care continuum for persons with SMI. Failing to do so will
ensure that critical opportunities to help people will be missed or poorly leveraged.
There are some metrics that describe the scope of the problem of police being used as de
facto mobile mental crisis workers. Law enforcement agencies have been seeing the
number of mental health-related calls for service increase dramatically over recent
years.32 33 34 35 36

28

Mental Health Assistance Now Available During Police Encounters.
https://www.aspendailynews.com/news/mental-health-assistance-now-available-during-policeresponse/article_e7cfdafe-9246-11e9-a8b6-abf0e499a7f0.html
29
Punch, M. Secret Social Service. 1979, Sage Publications.
https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=66566
30
Teplin, L.A., & Pruett, N.S., op. cit.
31
Wood, J. & Watson, A. Improving Police Interventions. http://dx.doi.org/10.1080/10439463.2016.1219734
32
Police Calls Involving Mental Health in St. Paul Have Doubled.
https://www.twincities.com/2018/03/31/new-st-paul-mental-health-officers-look-at-policing-differently/
33
Brooklyn Park PD Adopts Vitals. https://thevitalsapp.com/announcements/brooklyn-center-police-launchapp
34
Wichita PD Explosion of Growth. https://www.ksn.com/news/local/an-explosion-of-growth-wichita-pd-onmental-health-calls-taxing-on-officers/
35
Lakeville PD Follow Up on Mental Health Calls. http://www.startribune.com/lakeville-police-team-formedto-follow-up-on-mental-health-calls/307636751/
36
NYPDs Mental Illness Response Breakdown. http://nymag.com/intelligencer/2019/03/special-reportnypds-mental-illness-response-breakdown.html

I. INTRODUCTION

8

The number of police calls for service involving mental illness is certainly large and yet
difficult to pinpoint with precision. Many such calls are hidden under call descriptors
having nothing to do with mental illness. This problem with police record management
and dispatch systems was first described by CSGJC in 2002 and remains unaddressed.37
Thus, there is little value in the call tally estimates based on call descriptors that suggest
only 7%–11% of calls have a mental health aspect.38 Newer estimates, created when
officials explore the call records in minute detail, reveal the real scope. For example, the
St. Paul Police Department (SPPD) demonstrated that the number of calls “hidden” in
non-related call descriptors in 2016 was greater than the number of calls for service
recorded under mental health-related call descriptors.39 Notably, the SPPD’s total tally of
mental health-related calls in 2016 was 21,049. This was 33% of the total number of calls
for service.
Back in 2014, the Minnesota Chiefs of Police Association documented the trend of
increasing police contacts with persons in mental health crisis.
According to a 2014 MCPA survey, approximately 95 percent of Minnesota law
enforcement agencies say such calls have increased over the last five years with 20
percent of agencies saying the calls more than doubled in the last five years.40
It was part of a national trend that only worsened. Some jurisdictions realized that a very
large percentage of calls have a mental health aspect. In Albuquerque, a large police
survey showed that mental health was the primary factor in 33% of calls.41 Locally, the
2015 Annual Report of the St. Anthony Police Department included a frank description of
how often their officers encounter mental illness.
Training officers to deal with mental and behavioral health issues was a priority this
year. Calls for assistance, welfare checks, disturbances, domestics, run-aways,
medicals and other like service calls, places a front-line officer on over 50% of the
calls in direct contact with drug impaired, mentally unstable, mentally ill,
psychotic, suicidal, and others in crisis.42
While county jails are the largest mental healthcare institutions in many counties, it
seems apparent that law enforcement agencies, as a group, are the major suppliers of
mobile mental health crisis services in many U.S. counties. Police contacts are usually so
great in number that they dwarf the capacity of local county mobile mental crisis

37

CSG Consensus Report, p. 64. https://csgjusticecenter.org/publications/the-consensus-project-report/
PCSO Creates MH Crisis Unit. https://www.wfla.com/news/pasco-county/pasco-sheriff-creates-new-unitto-tackle-mental-health-crisis/
39
Police Calls Involving MH in St. Paul Have Doubled, op. cit.
40
MCPA Legislative Update. https://mcpa.memberclicks.net/assets/Magazine/final_spring_2016.pdf
41
Police Perceptions Albuquerque. https://www.cabq.gov/mental-health-response-advisorycommittee/documents/survey-of-police-officers-for-calls-for-services-as-mental-illness.pdf
42
St. Anthony PD 2015 Annual Report, p. 14. https://www.savmn.com/Archive/ViewFile/Item/52
38

I. INTRODUCTION

9

response teams. With call volumes exploding, many law enforcement agencies are eager
to escape the trap that old practices have created.
Unfortunately, some police agencies are hesitant to embrace on-scene collaborative
solutions or deflection options. These intractable agencies typically seek “downstream”
public investments to ease the burden of handling mental health contacts without
collaboration. There is, frankly, too much at stake for our communities and vulnerable
individuals to allow those who fear innovation and collaboration to prevail.
D. The Comparison That Matters: Police Officers vs. Mental Health Professionals
In Minnesota, the mental health credentials required to respond to a mental health
emergency are defined by statute.43 The lead worker in a mobile crisis response team
usually has a master’s degree in social work (MSW) with appropriate state licensure
(LICSW). Mental health crisis workers become licensed by completing 4000 hours of
supervised experience and passing an exam.44 Hiring for the positions is highly
competitive. Successful applicants bring additional qualifications including being bi- or
multilingual, certified to conduct substance abuse (Rule 25) assessments, and/or have
additional experience in the field.45 There is a significant path to earning the right to be a
mental health professional employed as a mobile mental health crisis responder.
By contrast, standard preparation for police officers who come in contact with persons in
mental health crisis is Crisis Intervention Team (CIT) training. This is a 40-hour
certification course for peace officers designed to improve empathy, de-escalation skills,
and the ability to recognize symptoms of mental illness.46 There is no prerequisite
requirement for experience, education, or even interest in the subject; agencies often
make it mandatory. There is no requirement for periodic re-training to maintain the
certification. Lastly, this training emphasizes approaches that are often in conflict with
the nature and substance of other ongoing police training and socialization.47
It should be no surprise that results in the field often reflect officers’ relative lack of
expertise. In the field, officers’ core training tends to fills in gaps in knowledge and
perception.

43

MN Statute 256B.0624 creates the requirements which utilize the terms Mental Health Professional and
Mental Health Practitioner. See Glossary for definitions of these terms.
https://www.revisor.mn.gov/statutes/cite/256B.0624
44
MN Board of Social Work LICSW Requirements. https://mn.gov/boards/socialwork/applicants/applyforlicense/licsw.jsp
45
MN Rule 9530.6615. https://www.revisor.mn.gov/rules/9530.6615/
46
CIT Core Elements. http://cit.memphis.edu/pdf/CoreElements.pdf
47
Police Command and Control Culture is Often Lethal. https://www.aclu.org/blog/criminal-lawreform/reforming-police/police-command-and-control-culture-often-lethal-especially

I. INTRODUCTION

10

Being overwhelmed can cause people with psychiatric and intellectual disabilities to
shut down. If this behavior is interpreted as obstinate, it can lead to arrest, detention
or police aggression.
People with these disabilities are also often disbelieved by the police. A woman I
interviewed – who communicated slowly due to her disabilities – said she called 911
on her boyfriend for hitting her. But the police believed the boyfriend’s story that she
was the violent one and arrested her instead.
“When they find out that you’re not capable of understanding what’s going on, it’s
a free for all,” another interview subject told me.48
Added concern arises from the pervasive warrior ethos that has spread throughout police
culture. Recently, police administrators have attempted to supplant this with the concept
of police as guardians.49 The following is a quote from a 2016 Police Executive Research
Forum publication:
Several forum participants noted that while the traditional approach to police hiring
has skewed heavily toward the “warrior” aspects of the profession, agencies today
need to focus attention on recruiting and hiring for the “guardian” role that police
officers must be prepared to play. In fact, some forum participants argued that
agencies should concentrate most of their attention on ensuring that applicants
coming into the system have the necessary qualities of the guardian, because the
warrior elements of the job can be taught.50
However, the “warrior problem” persists, and it poisons officers’ ability to manage
contacts with persons in mental health crisis.51 Seth Stroughton, an ex-law enforcement
officer turned university law professor, is a well-known critic of the “warrior
perspective.”52
From their earliest days in the academy, would-be officers are told that their prime
objective, the proverbial “first rule of law enforcement,” is to go home at the end of
every shift. But they are taught that they live in an intensely hostile world. A world
that is, quite literally, gunning for them. As early as the first day of the police
academy, the dangers officers face are depicted in graphic and heart-wrenching
recordings that capture a fallen officer’s last moments. Death, they are told, is
48

Police Encounters Gone Wrong. https://nationalinterest.org/blog/buzz/police-encounters-gone-wrongdraw-attention-mental-health-issues-96161
49
Minneapolis Bans Warrior Training. http://www.startribune.com/minneapolis-to-ban-warrior-training-forpolice/508756392/
50
Hiring 21st Century LEO.
https://digitalcommons.cedarville.edu/history_and_government_presentations/190
51
Time to Rethink MN Police Training. https://www.minnpost.com/community-voices/2016/07/it-s-timerethink-minnesotas-system-police-education-and-training/
52
Law Enforcement’s Warrior Problem. https://harvardlawreview.org/2015/04/law-enforcements-warriorproblem/

I. INTRODUCTION

11

constantly a single, small misstep away. A recent article written by an officer for
Police Magazine opens with this description: “The dangers we expose ourselves to
every time we go [on duty] are almost immeasurable. We know this the day we sign
up and the academy certainly does a good job of hammering the point home.” For
example, training materials at the New Mexico Police Academy hammer that point
quite explicitly, informing recruits that the suspects they will be dealing with “are
mentally prepared to react violently.” Each recruit is told, in these words, “[Y]ou
could die today, tomorrow, or next Friday”…
For Warriors, hypervigilance offers the best chance for survival. Officers learn to
treat every individual they interact with as an armed threat and every situation as a
deadly force encounter in the making. Every individual, every situation—no
exceptions…
From the warrior perspective, the solution is simple: the people with whom officers
interact must accede, respecting officers’ authority by doing what they are told. The
failure to comply is confirmation that the individual is an enemy for the Warrior to
vanquish, physically if necessary. And this creates avoidable violence.
The “warrior problem” doesn’t lead to avoidable use of force in every instance, but it
certainly can play a role when officers encounter a person who is non-communicative,
agitated, or acting erratically. It only adds to the evidence indicating that it is folly to use
police as stand-alone, de facto mobile mental health crisis workers.
To be fair, consideration should be given to the psychological burdens placed on police
officers by failing to implement “dispatch triage” and collaborative response models.
Persons performing crisis response work are subject to Secondary Traumatic Stress (STS),
which can eventually lead to a diagnosis of Post-Traumatic Stress Disorder (PTSD).
Mental health professionals have long understood this problem. Researchers have found
that many social workers are likely to experience at least some symptoms of STS, and
when working with traumatized persons, as many as 15% may even eventually meet the
diagnostic criteria for PTSD. The burnout rate of social workers is reportedly 39%.53
Police officers face just as much stress and might come to the task of a mental healthrelated call with trauma from many types of experiences. Even routine encounters in
policing can create STS in many officers. Ellen Kirschman, Ph.D., a licensed clinical
psychologist specializing in police and public safety, is one of many who see a cause for
concern.
Ellen Kirschman, Ph.D.:
There are approximately 900,000 sworn officers in the United States. According to
some studies, 19% of them may have PTSD. Other studies suggest that
53

Social Worker Burnout. https://sophia.stkate.edu/cgi/viewcontent.cgi?article=1806&context=msw_papers

I. INTRODUCTION

12

approximately 34% suffer symptoms associated with PTSD but do not meet the
standards for the full diagnosis.
This is pretty alarming. An officer with PTSD cannot think clearly. He is probably
hyper vigilant, has a short fuse, may not be sleeping well because of nightmares,
might be policing in a reckless manner, constantly triggered by reminders of the
event, self-medicating, or making such great efforts to avoid a similar situation that
he isn’t doing the job properly.54
Mobile mental health crisis response is difficult work. Both groups of workers—police
officers and mobile mental crisis social workers—can be affected by STS, but the officer
group differs in how they are selected, trained, and supervised. This affects how each
group copes with psychological burdens of their jobs.
New research from the Buffalo School of Medicine and Biomedical Science points to
links between police brutality and pre-existing post-traumatic stress disorder
(PTSD) in the officers themselves.
For the public, the danger of police officers developing PTSD comes from an
increased startle response, suspicion, and aggressiveness. These tendencies can make
officers more likely to lash out at the public and result in the deadly overreactions
that sometimes occur.55
The growing scope of the problem has garnered attention from researchers, law
enforcement, and even the public.56 57
One shocking video tells the story of a CIT-trained officer whose own traumatization
overcame his training. Ofc. Bryant is a CIT officer and de-escalation trainer who acted
out the worst-case scenario of a traumatized officer’s behavior and almost killed his own
son.58
Add this to the list of reasons law enforcement officers do not deserve the burden, or
responsibility, of handling mental health-related calls absent on-scene collaboration with
mental health professionals.
E. Our Scope: A Narrow Focus on the Point of Contact with Police
This writing explores the specific circumstances in which police are so often used as de
facto mobile mental health crisis workers in our communities. We will examine potential
54

Cops and PTSD. https://www.psychologytoday.com/us/blog/cop-doc/201811/cops-and-ptsd
Officers with PTSD. https://www.psychologytoday.com/us/blog/talking-about-trauma/201511/officersptsd-greater-risk-police-brutality
56
Work Environment and Officer PTSD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974929/
57
2017 Police Suicides. https://www.lawofficer.com/2017-police-suicides-continuing-crisis/
58
CIT Officer Loses Control. https://youtu.be/QT4_EXD-PtU
55

I. INTRODUCTION

13

reforms with a focus on dispatch triage and collaborative methods to reduce the use of
police in this capacity. The focus of this paper is to improve outcomes for contacts made
in the window from 911 call intake to the arrival of a police officer on scene. This scope
does not cover the necessary and commendable efforts to prevent the use of the 911
systems for mental health crises. Those efforts are extremely important, and this
discussion is not an endorsement for using the 911 system.
Both public policy planning and the implementation of reforms should be done with
clear adherence to guiding principles. One purpose of this paper is to illuminate the need
for ethical and moral principles to guide the decision-making that determines who
responds to mental health crises in the community. It is no small irony that, in this case,
the most patient-centered approaches can often create the greatest efficiencies and cost
savings.
This discussion must involve multiple systems: the criminal justice system, the mental
health service provider system, and broader social services systems. Within each of these
separate spheres, there exist innumerable related and very important issues and
dilemmas. We must be aware of how potential reforms affect, or are affected by, issues in
the broader systems. Finding better approaches may mitigate problems “downstream.”
This matters a lot, but to be useful this paper must also focus on ameliorating the issues
at hand. Improving service “upstream”—at the point of police contact—is the essential
and logical place to start in this imperfect collection of systems.
We will also explore the costs and harm resulting from the status quo. Fortunately,
significant savings and improved outcomes can be realized through common-sense
reform. Research data and cost savings statistics will be presented.
The needs of the patient remain central throughout this work, including needs based on
complicating effects of co-occurring conditions. Thus, our recommendations will not be a
simple checklist of reforms each community is different. There will be differences in
demographics, population density, and the availability of provider and social services.
All these considerations must play a part in creating improved service that is also faithful
to guiding principles. We ask readers to resist cynicism, to revive a stagnant debate on
the status quo, and to have the courage to advocate for change. The ultimate goal must be
better policies and practices to drive better outcomes for people whose mental illness
brings them in contact with law enforcement.

I. INTRODUCTION

14

II. KEY PRINCIPLES

15

II. KEY PRINCIPLES
Policy debates around police contact with persons in mental health crisis are often
centered on questions of what contacts are necessary and what reforms are possible. As
the previous criticisms suggest, many agree it is unfortunate that the status quo has made
police officers de facto mobile mental health crisis workers. But agreement often ends
there.
One way to spur the collective imagination and draw new life to this debate is to start
from a set of principles. We offer an example set of principles here. By centering debate
on a set of principles, parties can draw on common values to identify why improvements
are needed and how to define success.
Principle 1: An on-scene mental health response is the proper response to a mental health
problem.
The role of police officers in our society is to determine if a crime has occurred, determine
who was involved in that crime, and gather evidence for prosecution. Police officers are
trained to recognize signs of criminal conduct. Mental health crisis often presents with
behavioral components. These must not lead to entanglement in the criminal justice
system.
Much as one doesn’t call a barber when a plumber is needed, people in mental health
crisis need mental health professionals, not law enforcement officers.
Principle 2: Avoid police-only contacts with people in mental health crisis.
A mental health crisis may not always be recognized for what it is. Police officers may be
called to scenes such as “disturbances” when people perceive that criminal conduct is
afoot. There may be instances where people in crisis are self-injurious or potentially
injurious to others. Police may have a role in addressing these situations, but they should
never be the only professionals on the scene.
When addressing mental health crises, response priorities should be:
1. Mobile mental health crisis team response
2. Co-response by mobile mental health crisis workers and police officers
The goal in addressing mental health crises in the community should always be to avoid
police-only contacts.

II. KEY PRINCIPLES

16

Principle 3: “The right service at the right place at the right time” creates efficiencies and
improves outcomes.
Ambulance services were developed to address medical emergencies in the community,
treating some illnesses and injuries in the field, and stabilizing and transporting people
with more serious medical issues to facilities for more advanced care.
Mobile mental health crisis teams operate in much the same way. Some individuals can
be stabilized in the community and connected to services that help them remain stable.
For others, the crisis is more acute and requires more advanced care, often in a facility.
Mental health professionals have the expertise to make those assessments. By contrast,
police officers—even those with specialty mental health crisis training—often default to
transporting people experiencing mental illness to emergency rooms or mental health
drop-off centers. These transports can exacerbate mental illness, are often unnecessary,
and create added expense. They are a poor use of community resources when lesser
interventions may have been all that were needed.
Principle 4: Collaboration is key—“separate silos” is the problem.
Although every county in Minnesota has a mobile mental health crisis team, they are
almost always kept at arms-length by law enforcement agencies. Rarely are these mobile
mental health crisis teams brought on-scene. The result is a separate-silo mindset where
these agencies fail to work together meaningfully.
The hallmarks of true collaboration include dispatch triage with 911 call centers
deflecting calls to mobile mental health crisis teams, co-location whenever possible,
established mental health worker/police officer teams, and regular joint meetings and
training.

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY
A. The Trap
It is worth considering how police became de facto mobile mental healthcare workers. It
is a role that was partially forced on them. It is also because their own culture has been
slow to embrace change and collaboration.
For years people excused the status quo by pointing to the inadequacies of the mental
health provider system. In fact, the perpetually underfunded provider system has used
the off-budget substitution of police officers for mobile mental health workers as a
crutch. With police helping fill this gap in care, the provider system is free to invest
resources elsewhere. To be clear, no amount of money invested in the mental healthcare
provider system (a.k.a. providers) could prevent all contacts between police and persons
with mental illness. There are a huge number of these police contacts (many go
undocumented) and some are unavoidable. Within this paradigm, advocacy groups and
law enforcement have sought ever more funding for training to support the role of law
enforcement as de facto mental health workers.
At the other end of these police contacts are the consumers of mental health services who
deserve mobile responses that utilize mental health workers. Much of the public wants to
move beyond the old status quo but is generally offered no alternatives to this
inappropriate use of police officers.
For years no one seems satisfied with the status quo, yet it persisted.
B. Into the Soup
This trap of circumstances includes a soup of bureaucracies and opposing organizational
cultures. Consumers who have contact with law enforcement often need the services of
multiple public and private organizations to manage their illness and co-occurring
conditions. Ideally, there would be cross-system integration and collaboration to help
people stay connected and stabilized. In the past, provider system integration and
collaboration with law enforcement didn’t exist. The predictable result has been
inefficiency, bad patient outcomes, and occasional tragedies. An important consequence
of law enforcement not collaborating with providers is the missed opportunities to
provide the best possible mental healthcare service when it is needed most.
Meanwhile, law enforcement has invested heavily in training. Police have purchased
ever greater volumes of Crisis Intervention Team (CIT) training. Ostensibly this enables
them to handle calls better and more quickly. Police came to rely on ambulances to
shorten call times by transporting people to hospital emergency departments. The
standard operating procedures seemed to appease some advocacy groups and the public.

17

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

Approximately five to six years ago most law enforcement agencies reported the
beginning of what would become an alarmingly rapid increase in annual call totals
having a mental health component. The cause of this is uncertain, but may be due in
large part to CIT training expanding officers’ ability to recognize signs of mental illness.
Regardless of the cause, the effect was a growing prevalence of mental illness in the
county jail populations. Police directed ambulances to deliver more and more people to
hospital emergency departments. Law enforcement agencies saw larger portions of their
budgets go toward time-consuming mental health-related calls. As criticism increased,
police agencies began to value CIT training for its public relations benefit. Predictably,
this benefit was undermined by embarrassing use of force incidents.59
To indemnify themselves and to simplify dispatch, police departments began to get more
of their patrol officers CIT certified. Overwhelmed by its role as alternative mobile
mental health crisis providers, law enforcement reported that it needed politicians and
the underfunded mental healthcare system to provide relief. Law enforcement described
a wish list within CIT Program doctrine: emergency departments that accommodate
rapid drop-off; drop-off centers to replace hospital emergency departments altogether;
provider volunteers to train officers; and political support of CIT programs.60 Law
enforcement used their political clout to lobby for public investment to support them in
their inappropriate role.
In Minnesota and elsewhere, jails were transformed into mental health facilities while
law enforcement insisted it needed support and relief in its role as de facto mobile mental
crisis responders.61 62 The Hennepin County Health Department responded by giving
law enforcement much of what it wanted. The county supplied mental health workers for
the jail and built a $13.3 M secure workhouse and a drop-off center on Chicago Avenue.63
Various mental health advocacy groups, local politicians, and law enforcement have
recently pushed for a doubling down on CIT and the paradigm of police as mobile
mental health crisis workers. The Minnesota Legislature funded a $13.2 M facility that
served, in great part, to house a non-governmental training organization called MN CIT
that provides police CIT training.64 The legislature also created a $12 M trust fund to

59

What Happened to CPD CIT training? https://www.motherjones.com/politics/2016/01/chicago-policeprogram-was-supposed-prevent-deaths-quintonio-legrier/
60
CIT Core Elements, op. cit.
61
County Expands Crisis Centers. https://www.latimes.com/local/lanow/la-me-ln-mental-health-diversion20141112-story.html
62
Hennepin County Steps Up Plans. http://www.startribune.com/hennepin-county-aims-for-treatment-notjail-for-mental-illness/392256331/
63
Hennepin County Builds Drop Off Facility. http://www.startribune.com/hennepin-county-plans-to-build-itsfirst-secure-mental-health-facility/489066261/
64
New Paradigm, Not New Building. https://www.minnpost.com/community-voices/2018/03/police-crisisintervention-training-we-need-new-paradigm-not-new-building/

18

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

subsidize more of the very expensive CIT training that is now mandated for all
Minnesota police officers.65
Meanwhile, news outlets continued to report on the growing number of police shootings
of persons in mental health crisis across the state.66 67 68
The latest chapter in this story of a broken status quo was written by reporters who
informed the public that Minneapolis police were directing ambulance personnel to
administer Ketamine to patients, some of whom were in mental health crisis at the time.69
Despite the bad headlines and budget problems, many of Minnesota’s policy makers
resisted innovation, deferring to entrenched bureaucracies and ivory tower advocates.
Some of these advocates seemed to have lost their objectivity after years of partnering
with police in the political sphere and in private training sessions.
C. Laboratories of Democracy Stir
A milestone was reached in 2002 with the release of the Consensus Project Report by the
Council of State Governments Justice Center.70 This document provided 47 policy
statements to improve how the criminal justice system responded to persons with mental
illness. Since then the Justice Center has worked in concert with the US-DOJ to help local
police implement proven reform models.71
The real challenges to the status quo have come in places like California, Massachusetts,
Colorado, and Kansas, where police and county administrators began to explore how
they might have police and mental health professionals collaborate in the field. It is an
old idea given new life in an era of surging mental health-related police calls. The new
expansion of collaborative response models was made possible by early efforts like the
LAPD’s co-response program that began in 1993 and the Ashbury, MA, co-responder
program dating back to 2003.72 73 74

65

MN Lawmakers Police Better Training. https://www.mprnews.org/story/2016/04/11/police-mentally-illtraining-law
66
Severe Mental Health Crises End in Fatal Encounters.
https://www.mprnews.org/story/2018/11/29/several-mental-health-crises-end-in-fatal-encounters-with-mncops
67
Phil Quinn Killing by St. Paul PD. http://www.startribune.com/st-paul-man-killed-in-officer-involvedshooting-is-identified/329566071/
68
A Cry For Help Ended in His Death. https://www.mprnews.org/story/2019/11/21/a-cry-for-helpsummoned-the-police-and-ended-in-his-death
69
Ketamine at request of MPD. https://www.nytimes.com/2018/06/16/us/ketamine-minneapolis-police.html
70
CSG Consensus Report, op. cit.
71
Council of State Governments Justice Center. https://csgjusticecenter.org/about-jc/
72
LAPD mental evaluation unit. http://www.lapdonline.org/detective_bureau/content_basic_view/51704
73
LA National Model. https://www.csmonitor.com/USA/Justice/2015/0615/In-Los-Angeles-a-nationalmodel-for-how-to-police-the-mentally-ill
74
Regional Effort Better Equips Cops. https://www.metrowestdailynews.com/news/20181027/regionaleffort-better-equips-officers-for-behavioral-health-disorders

19

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

In Colorado in 2016, the legalization of marijuana funded $7.1 M for criminal justice
reforms involving behavioral health.75 76 In San Diego, a county-wide co-response
program called San Diego County Psychiatric Emergency Response Team (PERT),
flourished.77 78 Places like Johnson County, KS, followed the PERT example and initiated
an 11-city multi-jurisdictional collaborative co-responder service.79 80 The LAPD and
Houston PD are particularly interesting because they have multi-layered mental health
units that cover dispatch triage, field triage nurses, co-responder teams, and follow-up
teams. These programs are described in section VI. LAPD has assisted scores of law
enforcement agencies to implement reforms for improving service on mental healthrelated contacts. Some agencies adopt reforms that are less transformational. Other
agencies have adopted models that are more revolutionary and truly challenge the status
quo. The level of public awareness and the quality of the public discussion are often
deciding factors in how much the status quo is challenged.
D. Growth Without Sunshine
Most states, including Minnesota, now have cities that have adopted reform models for
improving police service to persons in mental health crisis. However, growth in use of
collaborative response models has been disadvantaged by the lack of a strong central
organization to outline standards and best practices. While CIT International and its local
partners enforce standards for CIT programs, there is nothing to prevent wide disparities
in how reform response models are implemented locally. Initiatives are often created and
administered with little public transparency. The public is rarely given much
opportunity for input into the design and implementation of specialized police
responses. Even mayors and city councilors seem uncertain of exactly what is being
proposed or how it gets administered.
A key reason for this situation is the free rein given to law enforcement in choosing the
scope and nature of initiatives. Politicians and advocates for persons with mental illness
often reflexively ignore the origins of the status quo and allow law enforcement to
proceed without public input or oversight. This is a grievous error and an abdication of
responsibility by those who should be advocating for persons with mental illness.
Without outside influences, law enforcement is free to concentrate on its own priorities.
75

Support SB17-207. https://files.constantcontact.com/812722f9001/2edf93e6-b7fb-427f-b7f0dca19e9dabf9.pdf
76
Policy Action Network Newsletter. https://myemail.constantcontact.com/Policy-Action-NetworkNewsletter.html?soid=1102181462552&aid=ZHy6miUK0TI
77
Escondido PERT. https://police.escondido.org/pert.aspx
78
San Diego Blue Print for Mental Health Reform.
https://www.sdcda.org/Content/Preventing/Blueprint%20for%20Mental%20Health%20Reform.pdf
79
Eleven Johnson County Cities to Partner. https://csgjusticecenter.org/eleven-johnson-county-ks-cities-topartner-a-mental-health-co-responder-with-law-enforcement/
80
Overland Park PD Co-Responder Project.
https://www.jocogov.org/sites/default/files/documents/CMO/Overland%20Park%20Coresponder%20Program%20Evaluation.pdf?fbclid=IwAR3gvfMuCvvsx6bs33GQFQU4WAMBXYPbczNc2DY
jXnOc7lQhGXmJ8LurEds

20

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

These generally include a public relations effect, reduced call times, and reduction of
expensive cyclical contacts. Initiatives must address the local police priorities to be
viable—BUT they must also be effective. Any programs adopted should prioritize aiding
persons with mental illness who have contact with police.
It is worth noting that other cultural institutions have failed to challenge the law
enforcement dominance over reform efforts. The news media deserve criticism for scant
and shallow reporting. Academia has also played a role. American researchers, especially
within the field of criminology, have a long history of fashioning conclusions based
simply on surveys of the opinions of officers in the field. Much of the research has
focused on creating efficiency within the criminal justice system while mostly ignoring
the plight of the mentally ill. Much of this work was done in an effort to refine and
validate Crisis Intervention Team (CIT) training. This narrow focus by many American
academics helped further entrench law enforcement in their inappropriate role of de
facto mobile mental health crisis workers. Today CIT training remains a practice that is
not evidence based (per outcomes) because research results rest mostly on survey
responses of police officers.
Yet, some objective research was and is being conducted on real deflection, diversion,
and collaborative police responses. Groundbreaking collaborative response projects
going back 30+ years have flowered into well-researched best practices. Today, law
enforcement is looking “beyond CIT” to implement these practices.
We should be living in a golden era of police reform with respect to contacts involving
mental illness and co-occurring conditions. Much has been learned from academic
research, field experience, and pilot projects. Data has solidified understandings and new
technology has aided responsiveness. Some projects are applying powerful lessons and
tools to improve outcomes. Others fall short of what can and should be done. We are not
always applying the fruits of research and hard experience to create the best outcomes
for persons with mental illness who have contact with police. This can only happen when
the needs of the mentally ill are prioritized and public discourse allows objective truths
to overcome subjective bureaucratic impulses.

21

III. THE POLICE-CENTERED STATUS QUO—A BRIEF HISTORY

22

IV. FOUNDATIONS FOR FAILURE

IV. FOUNDATIONS FOR FAILURE
This section identifies practices that reflect a failure to move beyond the status quo to
improve police contacts with people experiencing mental illness. These are the
approaches that shun collaboration and use officers as de facto mobile mental health
crisis responders. See section VI for a discussion of models and approaches that improve
service via collaboration.
In April of 2018, Ronal Serpas, the former Chief of the New Orleans Police Department
shared his thoughts at a mental health and criminal justice reform conference. Serpas is a
Professor in Practice at the Criminology and Justice Department of Loyola University
New Orleans. Serpas voiced his astonishment and frustration with the status quo and
offered the following:
I am a fan and a believer in CIT. We’ve been doing de-escalation since 1980 when I
first went to the police academy. Can it get better? Of course, it can get better. Can
CIT be helpful? Of course, it can be helpful. But, in some ways I am very
concerned that if we see that as the answer and we see that as the solution we are
nowhere even scratching the surface of this problem…
Tonight, when we go to sleep almost anywhere in America… the police officer
riding by themself…will be a male or female…somewhere around 25 years
old…almost unilaterally with no formal college education. In this august room of
people who are trying their very best to figure out the most complex circumstances
in our existence today with mental health…we are going to go to sleep tonight and
hope and pray that at 2 o’clock in the morning the least educated, with the fewest
alternatives, is going to make the exact right choice every time they find someone in
a crisis.
Isn’t that a bit embarrassing?...
Give officers alternatives to arrest, not CIT only, not de-escalation only. I mean an
alternative where they don’t even go to the door. Give them alternatives to arrest as
a community and they’re going to take that opportunity…
We have limited police time, we have limited prosecution time, and we have limited
prison beds. And, one of the things we have said at Law Enforcement Leaders since
Oct. 15 when we launched…we are imprisoning people we are mad at versus
people we are scared of.81
A. Lack of Effective Dispatch Triage
Dispatch triage is one of the most straightforward ways to avoid unnecessary law
enforcement contact with persons experiencing mental illness. This simply refers to
deflecting calls for service to more appropriate responders. Decision-making should
81

Serpas Urges Alternative Responses. https://youtu.be/p5JmL0fIOFU

23

IV. FOUNDATIONS FOR FAILURE

occur at the 911 call center, ideally with the active participation of a mental health
professional. When call screening shows it is appropriate, calls can be deflected to an
alternative responder. The alternative service might be a county mobile mental health
crisis team, a homeless outreach team, or other public and private social services. If
circumstances make the police presence is unavoidable then another option would be a
co-responder team.
Missing this opportunity for deflection to mental health clinicians burdens law
enforcement unfairly while failing the people who need help most. Breaking the
“separate silos” trap to create collaboration and deflection at 911 call centers creates
efficiencies and improves service at a key upstream point.
1.

The Police Obligation to Respond—Never Real and Being Withdrawn

The Duty to Protect is very limited in law and jurisprudence. In general, police officers
have a general obligation to protect the populace but there is no obligation to protect or
rescue any individual person. This concept is summarized as a general duty to all citizens
but no duty to any one citizen.82
This is established common law throughout the United States. It has been solidified by
court precedents, including the U.S. Supreme Court decision in DeShaney v. Winnebago
County Dept. of Social Services. There are only a few exceptions where a Duty of Care
can exist. These exceptions exist where a government agent has a unique relationship
with an individual (e.g. as employer).
What matters here is that police are free to recognize any perceived moral obligations but
are NOT bound by law to respond to 911 calls for assistance. This includes police calls for
service that have a mental health component. In fact, the act of responding to a call is the
main route to creating liability for officers and policing agencies. This is because a Duty
of Care (i.e. potential liability) is created when police place a person in custody or utilize
any police tactics that create hazard (a.k.a. state-created danger).
This logic is evident in recent news of California police departments not responding to
calls for service that might involve suicidal persons.83 The law does not require them to
respond. On the other hand, responding creates risk, especially if a person attempts
“suicide by cop.” The stakes have been raised by a new willingness of courts and juries to
make officers criminally accountable for wrongful use of force.
“Some police departments around the country have shifted how they respond to
suicide calls,” said Andy Skoogman, executive director of the Minnesota Chiefs of
Police Association.

82

CIF Suicide Calls Presentation. https://mcpa.memberclicks.net/assets/NEWSLETTER/CIF%202020.pdf
Police Fear Suicide by Cop. https://www.latimes.com/california/story/2019-08-09/suicide-calls-californiacops-stopped-responding
83

24

IV. FOUNDATIONS FOR FAILURE

“There are agencies across the country that are simply not showing up or they’re
showing up to the call, determining that the individual is not a threat to anyone
other than him or herself, and they’re leaving,” Skoogman said. “That’s a drastic
departure to how law enforcement has responded to those calls in the past.”84
The Minnesota legislature has recognized this dynamic and in 2009 changed state
statutes to permit 911 dispatch services to refer calls directly to mental health crisis
teams.
403.03 911 SERVICES TO BE PROVIDED.
Subdivision 1. Emergency response services.
Services available through a 911 system must include police, firefighting, and
emergency medical and ambulance services. Other emergency and civil defense
services may be incorporated into the 911 system at the discretion of the public
agency operating the public safety answering point. The 911 system may include a
referral to mental health crisis teams, where available.85
This evolution of thinking in Minnesota law enforcement is now happening across the
nation. The deconstruction of arguments for why police respond to mental health calls is
an opportunity for those who seek reform. Now is the time for communities to demand
911-based dispatch triage to prevent unnecessary police contacts with people
experiencing mental health crisis.
2.

Dispatch Triage at the Police Dispatcher Level (e.g. CAHOOTS)

When dispatch triage is conducted downstream of 911 call centers, within the police
bureaucracies, there is a clear pattern of defaulting to the police-only response. This
circumstance naturally leads to far less transparency and community oversight.
The much-publicized CAHOOTS Program in Eugene, Oregon has operated as an
alternative response that is controlled at the police dispatcher level. Communities
considering emulating this program should avoid this critical flaw. Having deflection
happen at the 911 call center upstream of police dispatchers is essential to remove these
efforts from control and management by law enforcement.
When Portland initiated Project Respond, which relied on police dispatch to deflect calls
to alternative responders, they were disappointed to find that 70% of calls were not
deflected but continued to be responded to with the old police and ambulance
partnership approach.86 Simply creating an alternative response option does not ensure
that it will be utilized. For this reason, dispatch triage must happen at the 911 call center
level.
84

MN Cops Rethink Suicide Calls. https://www.mprnews.org/story/2019/12/11/minnesota-cops-rethinkhow-to-respond-to-suicide-calls
85
MN Statute 403.03 https://www.revisor.mn.gov/statutes/cite/403.03
86
Portland MH Providers Bring Cops. https://news.streetroots.org/2019/05/03/portland-mental-healthresponders-alternative-police-usually-bring-cops

25

IV. FOUNDATIONS FOR FAILURE

B. Stand-Alone CIT—Exaggerated Competencies and Separate Silos
The Crisis Intervention Team (CIT) is a program centered on training provided to police
officers. The basic training lasts 8 hours but 40 hour training and advanced training are
also offered. It is sensible to provide officers with some relevant training. This training is
meant to help officers recognize signs of mental illness and to de-escalate. Too often the
CIT programs focus solely on the training of officers and resist innovations and
collaborations that break the separate silos status quo. Avoiding field collaboration with
mental health clinicians is technically a misapplication of the CIT model. CIT is carefully
described as an approach that promotes collaboration and community involvement. Here
we must explore the hard fact that some CIT programs are less than as advertised.
There is significant variation in how CIT is taught, how fully individual officers “buy in,”
and in the effect it has on performance. Local media and politicians may heap praise on
any CIT effort but its effectiveness should not be assumed. As described in a previous
section, researchers managed to show that CIT is “evidence-based” only in terms of
creating positive feedback from officers. Academia consistently reports that CIT is NOT
an evidence-based practice in terms of improving outcomes for persons in mental health
crisis.87 Minnesota researchers Peterson and Densley have recently added to this chorus
with their own research:
This study reviews 25 empirical research articles that have examined the impact of
Crisis Intervention Team (CIT) training over the past 10 years. Overall, little can
be said about the effectiveness of CIT training due to varying outcomes, a reliance
on self-report data, lack of comparison or control groups, and inadequate follow-up
data. Results of this systematic review of 25 studies demonstrated a mix of positive
and negative results, and a focus on urban environments. The impact of officer
characteristics and community resources on outcomes is unknown. This review
indicates that additional research is necessary before CIT training can be
considered an evidence-based practice that should be widely implemented. New
training protocols that incorporate empirical research and are responsive to the
resources in individual agencies and communities may be more effective.88
Many communities have embraced the false hope that CIT training fully prepares officers
to address the challenges of dealing with people in even severe mental health crisis. They
might also assume individual CIT programs all rise to their billing as “more than just
training” by creating community partnerships and collaboration. In actual
implementation, these parts of the model are often underdeveloped or non-existent.89
87

Watson, A., Compton, M. & Draine, J. (2017). The Crisis Intervention Team (CIT) Model: An EvidenceBased Policing Practice? Behavioral Sciences & the Law. 35. 10.1002/bsl.2304.
https://www.ncbi.nlm.nih.gov/pubmed/28856706
88
Peterson, J. & Densley, J. (2018). Is Crisis Intervention Team (CIT) Training Evidence-Based Practice? A
Systematic Review, Journal of Crime and Justice, 41:5, 521-534, DOI: 10.1080/0735648X.2018.1484303
89
DOJ Investigation of Chicago PD.
https://archive.org/stream/chicago_police_department_findings/chicago_police_department_findings_djvu.t
xt

26

IV. FOUNDATIONS FOR FAILURE

Excellent branding has enabled local officials to use CIT training as a convenient,
unassailable response to calls for reform. CIT training has become the presumptive
panacea—the beginning and end of all discussions about police contacts with persons in
crisis. When this happens, the CIT program becomes an abstraction which inevitably fails
to deliver. In jurisdictions where CIT dominates decision-making, the response to failure
is to double-down on CIT training and “buy in.” This is where CIT’s elevated status
constrains the debate about what is possible. CIT programs very often neglect two key
reforms: alternative response (deflection to non-police mental health clinicians) and onscene co-response with mental health clinicians.
The strengths and weaknesses of CIT are not happenstance. To understand how CIT fits
into the overall solution, we must accept the fundamental truth that it is a management
tool for police administrators that also purports to help people in need. This admittedly
stark description is necessary to understand how CIT subculture can skew the decisionmaking process. The CIT doctrine, as described in the CIT Core Elements, places great
emphasis on improving police operations.90
1.

Stand-Alone CIT—CIT’s Core Elements Are Not Patient Centered

The Core Elements of CIT mention police call times specifically in several places and
never suggest a consideration of what is best for the clients.
“In addition, policies should be set to ensure minimal turnaround time for the CIT
Officers, so that it is less than or equivalent to the turnaround time in jail.”91
The importance of call time is also emphasized in the requirement that police be given a
place to drop off people regardless of any clinician’s assessment or the subject’s finances.
“To ensure CIT’s success, the Emergency Mental Health Receiving Facility must
provide CIT Officers with minimal turnaround time and be comparable to the
criminal justice system. The facility should accept all referrals regardless of
diagnosis or financial status.”92
This disregard for the needs of people in crisis was revealed in a 2017 study by Peterson
and Densley. Their study documented that 80% of individuals transferred to a
psychiatric intake unit are never admitted.
After conducting interviews at a local psychiatric intake emergency unit, we
discovered that over 80 percent of individuals were never admitted. Instead, they
were turned back around into the community because they did not present a threat
to self or others, thus didn’t meet criteria for an emergency hold. Police send people
to the hospital largely because they don’t want to be held liable should something
bad happen once they leave the scene. But most of the time, individuals that police
90

CIT Core Elements, op. cit.
Ibid.
92
Ibid.
91

27

IV. FOUNDATIONS FOR FAILURE

send to the hospital are back home within hours, with a hefty ambulance bill for
their troubles.
We also found that 60 percent of addresses that had one crisis call had another
crisis call that same year. Several group homes in the area, designed specifically to
provide mental health treatment, were calling the police on a daily basis. Police
were being asked to Band-Aid a broken mental health system.
A fancy new police training center won’t fix this.93
The Core Elements advise mental health professionals to seek roles as CIT instructors but
don’t mention deflecting calls to mobile mental health crisis teams.
“These professions provide treatment, education and training that result in a wide
dissemination of knowledge and expertise to both individuals with a mental illness
and patrol officers undergoing CIT training.”94
2.

Stand-Alone CIT—The Excuse to Avoid Co-Response or Alternative Response

The result of collaboration in training but separate silos in the field is sometimes a
presumption that police officers can morph into social workers. This means police
administrators and officers often choose less collaboration. A fatality at the hands of an
Omaha, NE, police officer led local reporters to look into the reluctance of police to
collaborate on-scene with the Douglas County Crisis Response Team. They found that
officers rarely collaborated, partly because of their CIT training.
Police officers have a host of resources at their disposal when they encounter people
with mental illness, but in order for them to work, officers have to use them.
Omaha Police Officer Anthony Nguyen used to call the crisis team when he had a
situation that fell into a gray area: the person wasn’t technically threatening
himself or others enough to warrant protective custody, but Nguyen didn’t feel
comfortable leaving him alone.
After a few years on the force, Nguyen took the weeklong mental health training
that helped him understand people in mental crisis and how to handle those
situations.95
The reporting included statistics showing that on-scene collaboration was rare.
Omaha officers filled out 1,193 forms. Those forms indicated the crisis team was
called during fewer than 30 of the 1,193 incidents—2.4 percent during that
period.96
93

Peterson, J. and Densley, J, op. cit.
CIT Core Elements, op. cit.
95
Omaha Police Have Options. https://www.omaha.com/livewellnebraska/omaha-police-have-options-onmental-health-calls-but-available/article_676485ec-9db7-547b-aa84-d796cd33abdd.html
94

28

IV. FOUNDATIONS FOR FAILURE

This seems to be a typical level of on-scene collaboration. In Salt Lake City, UT, a report
by KUTV News revealed that the county Mobile Crisis Outreach Team was called to corespond with police about 80 times per month even though police said 1 in 7 calls were
mental health related. This indicates a 2–3% rate of on-scene collaboration.97
CIT’s much touted collaborative aspect is mostly relegated to the training room by
conflicts with police efficiency priorities. This conflict was obliquely described in a Police
Chief Magazine article by Nick Margiotta, a veteran Phoenix Police Department member,
CIT Coordinator for the Phoenix Metro Region, Board Secretary for CIT International,
and NAMI Arizona Advisory Board Member. It is proven that having a mental health
professional’s expertise on-scene provides multiple benefits to the person in crisis and
greatly reduces unnecessary transfers. Margiotta, however, explained that co-responding
with a local county mobile crisis team might not have “relevance to CIT.”
For communities with mobile behavioral crisis services or for those communities
seeking to create this level of care, it is important to consider how these services can
meet the needs of law enforcement when they are dealing with a behavioral health
crisis. To make sure that the service has relevance to CIT, the key is for mobile
community crisis response teams to be readily available to respond to a police
request in a prioritized manner and free law enforcement from the scene as quickly
as possible [emphasis added]. This level of responsiveness is needed to increase the
likelihood that police will utilize mobile crisis services, thus increasing the
opportunity to stabilize individuals safely at home, when appropriate.98
Margiotta’s view is conventional wisdom within law enforcement. The very reason for
CIT’s existence has been rooted in the fact that non-embedded county mobile mental
health teams were found to have response times that were too long to be effective onscene partners with law enforcement. For decades, CIT proponents have referenced the
work by Borum (1998) and Steedman (2000), which described inadequate response times
of underfunded, non-embedded clinicians.99
Years have passed and new officers continue to use this excuse despite the existence of
innovative solutions. The Omaha situation described above provides more ready
reference to field reality:
“...the Crisis Response Team could have been dispatched to deal with a mentally ill
man who died in June after an early morning encounter with Omaha police officers.

96

Ibid.
Utah Police on Front Lines of Lack of MH. https://kutv.com/news/local/in-crisis-utah-police-on-the-frontlines-of-the-lack-of-mental-health-care
98
Five Legged Stool. https://www.policechiefmagazine.org/the-five-legged-stool-a-model-for-cit-programsuccess/?ref=84d53c861e50b658985bf7b63f4e6d1f
99
Police Perspectives.
https://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=1567&context=mhlp_facpub
97

29

IV. FOUNDATIONS FOR FAILURE

‘If they would have came out, it wouldn’t have ended the way it did,’ Lt. Colene
Hinchey said. ‘We missed the opportunity, and it went bad.’
‘I always encourage people to call Douglas County Crisis Response Team if needed
when the time is appropriate,’ Hinchey said.
Alcantara said an officer’s decision against bringing in the crisis team also may
come down to time. … ‘I think that’s where a lot of times officers aren’t calling out
to the resources that we have because it’s time-consuming.’”100
In the source article for this quote, Ofc. Alcantara describes a collaborative reform used
elsewhere that she hopes her PD will implement. In 2018, Omaha’s Police Department
implemented that very reform to enable more co-response after a deadly incident in
which a mentally-ill man was tased 12 times and punched in the head 13 times. Cities
often implement measures to enable co-response only after preventable tragedies.
Having an incident where someone dies. This is the most frequent antecedent to
change, though this is not in and of itself sufficient for change to happen. Most
often, the person with mental illness is the individual who dies following police
intervention.101
If your city is one of those that remains an enclave of CIT-only thinking, then you simply
have not yet experienced the incident that forces change.
3.

Stand-Alone CIT—Territorial Tendencies Result in More Investment in CIT

A precursor to tragedy might be a police department giving all its officers CIT training.
This approach is a public relations win for many departments. Sam Cochran, the police
major who helped create CIT, offered his explanation of how police administrators were
using CIT:
Cochran and the other program leaders worry that politicians are using the name of
CIT to make it look like they are taking the issue seriously without being willing to
do the long-term work that it takes to make the program successful.
“Everybody wants to feel comfortable that new training is being introduced with
the expectation that we’re all going to live happily ever after,” said Cochran. “It’s a
quick fix—the other things that have to take place are a little more challenging.”102
The problems multiply when CIT becomes primarily a management tool for police
administrators. Having a CIT certification in every squad car simplifies staff scheduling
and aids dispatch to calls. It also means officers with less experience and less motivation
for handling mental health-related calls will be thrust into situations where their
100

Omaha Police Have Options, Op. cit.
Study in Grey And Blue. https://cmha.bc.ca/wp-content/uploads/2016/07/policereport.pdf
102
Milwaukee Training Misses Mark.
https://www.jsonline.com/story/news/investigations/2018/06/08/resentful-officers-dub-mental-healthprogram-hug-thug/680618002/
101

30

IV. FOUNDATIONS FOR FAILURE

inexperience can lead to tragedy. Not all officers have the knowledge or interest to deal
effectively with someone in a mental health crisis.
“’Many officers are not ready or interested or do not have the disposition,’ the
board of the international CIT program warns in a position paper posted in January
on the organization’s website.
‘For these officers, valuable training time and resources may not only be wasted on
them if they are mandated to sit through the 40-hour course, but their attitudes can
disrupt the class,’ the experts warn. ‘Even worse, an agency may send an officer
who is not interested or does not have the right disposition.’”103
When the Portland Police Bureau (PPB) insisted on CIT training, they required every
patrol officer to get 40 hours of training. The result for the PPB was a deterioration of
performance and a spate of tragedies. In fact, the results of training the wrong officers or
all officers were astoundingly bad.
That’s what happened in Portland, Ore. Many officers there considered a CIT
assignment a burden, and officers tapped for duty looked at their role as nothing
more than transporting people in crisis to the hospital, Watson said. Tensions
between resentful officers and people with mental illness flared. Nine people with
mental illness were killed in six years.
The 2006 death of James Chasse Jr., 42, was particularly gruesome.
Chasse, who suffered from delusions, was beaten by officers, sustaining over 20
broken bones, a punctured lung and a torn spleen. After police initially denied him
medical attention, he was put in the back of a police cruiser where he died on the
way to the hospital.
“In a good faith effort to address this, they decided to train all of their officers,”
Watson wrote to Barrett. “It did not go well.”
In the following four years, the Portland Police Bureau used deadly force against
people with mental illness 14 more times.
In one instance, officers repeatedly tased a naked man in his own apartment for not
complying with commands and reportedly running at the officers. It turned out he
was not attacking them—nor was he mentally ill. He was in diabetic shock, and
coming to the officers for help.104
The situation in Portland came to the attention of the U.S. Department of Justice, which
conducted an investigation in 2011. DOJ investigators described how CIT training had
backfired within the Portland police culture.

103
104

Milwaukee Training Misses Mark, Ibid.
Milwaukee Training Misses Mark, Ibid.

31

IV. FOUNDATIONS FOR FAILURE

We found that PPB officers often do not adequately consider a person’s mental state
before using force and that there is instead a pattern of responding inappropriately
to persons in mental health crisis, resulting in a practice of excessive use of force,
including deadly force, against them. Furthermore, our review of incident reports
and interviews with officers and community members shows little or no indication
that the officers considered, or were even aware of, the many tools available to them
to resolve interactions with individuals in mental health crisis using less force.105
Despite the failures in Portland, police in Milwaukee and other cities went forward with
expensive plans to certify their entire forces in CIT. It was a cynical reach for the easy
public relations win and the aforementioned simplification of operations. Milwaukee
spent $1.2M on police CIT training but failed to get “buy in” from many officers.
Meanwhile, some officers took to calling the existing program “Hug-a-Thug” and
griped that it was not their jobs to be “street psychiatrists,” Pasch said.
The growing resentment began to take a toll on the training with fewer classes
offered.
“A lot of the momentum was lost,” Pasch said.
In the days after Hamilton was killed, Flynn tried to deflect any criticism that
police need to be better prepared to deal with the growing number of people with
mental illness who are not properly treated.106
4.

Stand-Alone CIT—The CIT Paradox

CIT training can be useful in those times when police do not have mental health
professionals on hand to co-respond or take over the contact. CIT, ironically, has become
the very reason why our mental healthcare system routinely allows the substitution of
police response for a mental healthcare provider response or co-response. This paradox
occasionally gets criticism. The $850M ThriveNYC Initiative is billed as an attempt to fill
strategic gaps in mental health services and coordinate mental healthcare activities across
agencies. A few note that it does not fill the gap in mental healthcare response that is
being filled by police:
One question they might ponder is: What would it look like to have a mental health
care system that didn’t rely on police officers to serve as its first responders?107
The CIT paradox was evident with the 2016 death of John Birkeland in Minnesota. The
police department should have been prepared because they had responded to his
previous “mental outbursts.” One of the officers even had some police training to
prepare him for such mental health situations.108 What followed was an interaction that
105

DOJ Investigation of Portland Police. https://www.portlandoregon.gov/police/article/469399
Milwaukee Training Misses Mark, op. cit.
107
Don’t Pretend Every Cop Can Play Social Worker. https://nypost.com/2019/04/03/dont-pretend-everycop-can-play-social-worker/
108
There Has to Be a Better Way. https://www.mikegreg.com/blog/there-has-be-better-way
106

32

IV. FOUNDATIONS FOR FAILURE

apparently utilized almost none of the lessons police training is intended to imbue. There
was little attempt to de-escalate with Birkeland, who suffered from untreated mental
illness and was quite drunk (blood-alcohol level 0.28 ).109
The situation became deadly when they sent in a police dog that viciously attacked the
man while he cowered in the back of a deep closet. Video revealed that these officers
escalated their use of force and shot Mr. Birkeland without ever considering how an onscene collaboration with a mental health professional could be helpful.110
De-escalation and “slowing down” are advertised to be part of CIT training for such
encounters. Yet, the choice to break down the apartment door and send a police dog to
attack were justified in civil court on the basis of fulfilling a “caretaker” role—“to protect
the occupant from imminent injury.” The Birkeland shooting was another example of
relevant officer training failing to create better results. Ironically, his state senator never
considered alternatives to police response but simply used his death as a reason to author
(and pass) another legislative bill providing even more state funding for CIT training.111
Likewise, the 2014 shooting of Joe Zontelli in Duluth illustrates how police use of force
training can nullify any benefits of CIT. Zontelli was a suicidal man who barricaded
himself behind an interior door of his house. Officers broke down the door and had a
police dog attack. A knife Zontelli intended for self-harm was turned on the attacking
dog and officers then fired their weapons.112
But when officers broke down the door, saw Zontelli had a knife, shot him twice and
then claimed they had feared for their lives, some say the line between public and
private vanished. Advocates say any officer-involved shooting is a matter of public
interest.113
Police training failed Joe Zontelli on multiple occasions. He had previously been beaten
by CIT-trained Officer Adam Huot in the mental health ward of St. Luke’s Hospital.
To gain compliance, the officers began delivering strikes, with PO Huot hitting him
five (5) or six (6) times with a closed fist. At that point in time, the subject’s head
was against the floor and it sustained injury.114
Within the public files of an arbitration resolution for Ofc. Huot, an arbitrator wrote that
he considered the Zontelli beating one of the “major misuses of force” by that officer. The
police department attempted to terminate this officer based in part on his failure to
internalize relevant training, including his CIT training.
109

Roseville Police Won’t Be Charged. https://www.twincities.com/2016/07/07/roseville-police-no-chargesshooting-death-mentally-ill-man/
110
Birkeland v. Jorgenson et al. https://law.justia.com/cases/federal/districtcourts/minnesota/mndce/0:2017cv01149/163727/67/
111
MN Lawmakers Police Better Training, op. cit.
112
MN Lawmakers Police Better Training, op. cit.
113
Body Cam Footage is New Legal Battleground. https://www.theguardian.com/usnews/2015/jan/01/duluth-police-body-camera-footage-legal-battleground
114
Adam Huot mediation. https://mn.gov/bms/documents/BMS/134813-20180622-Duluth.pdf

33

IV. FOUNDATIONS FOR FAILURE

When cross-examined, PO Huot stated, he is familiar with the department’s use of
force and code of conduct policies; he was well trained on same, as well as having
received 40 hours of VDIIC training in 2015. Benefits derived from the latter
included managing verbal abuse and bullying, defusing confrontations, de
escalating violence, building cooperation and collaboration and more. (City Exhibit
13) In summary, he verbalized, the course dealt with winning subject cooperation
through verbal techniques and reducing the need to use force. However, Officer
Huot also remarked, with the passage of time, he could not recall many of the
specific lessons taught in the CIT course he had taken and, as well, he could not
recall many of provisions in the Code of Conduct.115
When properly trained, CIT is supposed to provide officers with the ability to recognize
symptoms and behaviors of mental illness. If true, then this recognition should lead to
routine on-scene collaboration with mental health professionals. The dearth of such
collaboration reveals a critical failure in stand-alone CIT implementation.
C. Refusal to Involve Alternative Responders
Whenever possible, police officers and dispatchers should not refuse requests for an
alternative to a police-only response to calls involving mental illness. This is especially
true when family members reach out for assistance to get help for a loved one in crisis.
Expediency is a very poor excuse to avoid providing the right service, at the right place,
and at the right time.
D. The Odd Effort to Misrepresent Follow-Up Services as Co-Response
The public wants co-response and alternatives to police-only response. Some officials,
notably in Hennepin County, Minnesota, attempt to appease the public by pretending
that follow-up services are, in fact, co-response. The problems with this are obvious.
Clinicians who make follow-up contact days after police initially make contact are doing
follow-up work, not co-response to a crisis call. Police officers accompanying social
workers to perform follow-up work doesn’t constitute co-response to crisis calls. The
long-standing definition of co-response refers to real-time responses to police calls for
service. Unfortunately, it is necessary to provide this clarification.
E. Follow-Up Schemes Intended to Support Entrenched Police-Only Response
Consider a scenario in which a serious auto accident yields a police response but no
response by EMTs or paramedics. Most people would find this unacceptable. People
want mental health professionals to respond on-scene to assist loved ones experiencing a
psychiatric emergency. Academic research shows that consumers prefer deflection to
mental health clinicians or co-response over a police-only first contact.116 117

115

Adam Huot mediation. Ibid.
Boscarato, Lee, Kroschel, et al., Consumer Experience of Formal Crisis-Response Services and
Preferred Methods of Crisis Intervention. doi: 10.1111/inm.12059
116

34

IV. FOUNDATIONS FOR FAILURE

Now consider the plight of a hiker who falls off a cliff and suffers internal injuries. It
would be unthinkable for a poorly trained rescuer to tell this hiker that medically trained
rescuers can visit the next day. Providing the right response at the right place and at the
right time is just as important in psychiatric emergencies as in other medical
emergencies. Follow-up schemes that avoid real-time co-response or deflection to an
alternative responder effectively substitute police response for a mental health response.
For more complicated mental health-related calls, police are woefully under qualified to
stand in as substitutes for mental health professionals. Follow-up schemes are a sad
betrayal of those who are experiencing the depths of a mental health crisis and need the
right response.
Non-behavioral medical emergencies, such as heart attacks, strokes and nonvehicular accidents are often handled by the 911 system. But rather than
dispatching a police officer, an ambulance is sent. A law enforcement response to a
mental health crisis is almost always stigmatizing for people with mental illnesses
and should be avoided when possible. Whenever possible, mental health crises
should be treated using medical personnel or, even better, specialized mental health
personnel.118
Follow-up schemes entangle the law enforcement officers as gatekeepers to treatment
and prevent first-contact community treatment by actual mental health professionals. By
substituting police response for a mental health response, the mental health crisis is
approached as if it were criminal. One type of follow-up scheme for mental health calls is
simply an extension of a police-led diversion program for persons who have committed
actual chargeable offenses.
Avoiding real-time deflection to or co-response with mental health clinicians is not
excused by increased investment in downstream services like case management. Police
officers should not be the gatekeepers to those needed services. Moreover, in that
gatekeeping role police officers introduce real potential for harm, wasted resources, and
missed opportunities. Follow-up schemes that avoid deflection or co-response maintain a
key gap in care that adversely affects downstream efforts to stabilize people in need.
1.

Follow-Up Schemes Supporting Police-Only Response Rule Out Cost-Saving
Deflections

There is broad agreement that community-based treatment saves taxpayer money.119
Real-time community-based clinician care via alternative response or co-response also
117

Evangelista, Lee, Gallagher, et al., Crisis averted: How Consumers Experienced a Police and Clinical
Early Response (PACER) Unit Responding to a Mental Health Crisis. International Journal of Mental Health
Nursing (2016) 25, 367–376. doi: 10.1111/inm.12218
118
Mental Health America Position Statement 59. https://www.mentalhealthamerica.net/issues/positionstatement-59-responding-behavioral-health-crises
119
MHLN Blue Book 2018. https://mentalhealthmn.org/wp-content/uploads/2017/05/2018-MHLN-BlueBook.pdf

35

IV. FOUNDATIONS FOR FAILURE

results in more efficient wraparound services or intensive case management follow-up.
This is lost with follow-up schemes.
Follow-up services don’t address the risk of arrest and incarceration when police respond
alone to mental health calls. Follow-up services don’t change the fact that co-occurring
substance abuse adds great complexity to calls and greater risk of incarceration. Policeonly on-scene response is one key reason why 72% of jailed persons with SMI also have a
co-occurring substance abuse problem.120
Follow-up schemes entrench police in the role of de facto mobile mental crisis workers.
That allows police to continue to order transfers that are often unnecessary, unhelpful for
the patient, and burdensome for multiple government systems. This is in stark contrast to
the alternative of offering both a proper on-scene clinician response and follow-up
services.
Crisis services prevent more costly hospitalizations. Over the past several years
data show that for both children and adults over 80% of those served by crisis
teams were able to avoid hospitalizations. Providing a mental health response also
limits interactions with police.121
2.

Follow-Up Schemes Supporting Police-Only Response—Myth of a Clinician Labor
Shortage

One of the main excuses for avoiding deflection to or co-response with mental health
clinicians is the idea that there is a shortage of such professionals. This excuse is invalid.
Labor market statistics show that there are ample workers for deflection or co-response.
The workers needed to fill this gap in services are master’s level licensed social workers,
namely clinical social workers. These workers are available in greater numbers in higher
population areas – the very places where deflection or co-response are most feasible. In
fact, there are 800 more clinical social workers in all of Minnesota than jobs to employ
them. Section IX below describes the labor market for clinical social workers.
3.

Follow-Up Schemes Supporting Police-Only Response—Betray Early Episode SMI
Sufferers

Those who are exhibiting significant symptoms of mental illness for the first time are
being disregarded in the follow-up schemes that put police between consumers and
providers. Key populations, such as those with first episode of psychosis (FEP), would
benefit greatly from collaborations that create real time on-scene clinician responses.
Inadequacies in the mental health systems can delay access to treatment and increase the
likelihood of contact with police. For them, the police contact is just another obstacle
between them and clinician care. A study in Canada put a number to the problem.

120

Burden of MI Behind Bars. https://www.vera.org/the-human-toll-of-jail/inside-the-massive-jail-thatdoubles-as-chicagos-largest-mental-health-facility/the-burden-of-mental-illness-behind-bars
121
MHLN Blue Book 2018, op. cit.

36

IV. FOUNDATIONS FOR FAILURE

…The same study found that, in large part because of these barriers, over 30% of
people with serious mental illness had contact with the police while making, or
attempting to make, their first contact with the mental health system.122
The problems leading to this police contact are common and exist here in Minnesota.
Individuals experiencing their first psychotic or manic episode are not receiving the
intensive treatment they need to foster recovery. On average a person waits 74
weeks to receive treatment. Our mental health system has relied on a “fail-first”
model of care that essentially requires people experiencing psychosis to be
hospitalized or be committed multiple times before they can access intensive
treatment and supports.123
The contacts with young people in the early stages of mental illness are immensely
important. These contacts are key opportunities to provide early care and reduce
suffering.
"The earlier someone gets into care the better their outcome," says Rachel Loewy,
PhD, associate professor in the department of psychiatry at the University of
California, San Francisco. The symptoms of psychosis often start during the late
teens or early 20s, she says. "These young adults are not only dealing with
symptoms of a mental disorder but also the fact that the changes are happening at a
critical time in their lives when they are developing their identities."124
Well-intentioned officers can sometimes recognize early symptoms of SMI and create
referrals, but that should not represent Plan A. The stakes are too high to tolerate followup schemes that prevent real-time on-scene co-response or deflection to alternative
response by mental health crisis teams.
4.

Follow-Up Schemes Supporting Police-Only Response—Delay Care and Degrade
Effectiveness

On-scene clinician expertise results in a much more useful on-scene patient assessment,
highly effective warm handoffs to provider facilities, and excellent coordination of
follow-up services. It is hard to overstate the advantage of having a clinician do their
mental health assessment on-scene at initial contact. When mental health workers
attempt an assessment hours or days after initial contact, they are not seeing the patient
in their crisis state. Remote and delayed assessments cannot be informed by the state of a
patient’s dwelling and other psychosocial considerations. Being on-scene at initial contact
can mean partnering with family and friends who can offer more accurate information
about the immediate situation and a history of the illness. Being on-scene at initial
contact might help in the evaluation of the effect of medications. The contribution of cooccurring conditions and disorders will be more evident on-scene, in real-time. All this
122

Study in Grey and Blue, op. cit.
MHLN Blue Book 2018, op. cit.
124
Catching Psychosis Early. https://www.apa.org/monitor/2016/10/psychosis
123

37

IV. FOUNDATIONS FOR FAILURE

insight helps well-trained mental health workers apply their expertise better to create
immediate care and more appropriate follow-up services. To forgo co-response or
deflection to a mobile crisis team means less efficient care or even a missed opportunity
for proper care.
5.

Follow-Up Schemes Supporting Police-Only Response—Are Risky

Follow-up schemes paired with a police-only response forsake all of the benefits listed
above, for the old practice of a referral from the officer. Really, this is a procedure that
has long existed for many urban jurisdictions. The premise is that these referrals will be
more effective and that somehow this iteration of the status quo will be better. However,
the risk of police use of force and the potential for arrest, even incarceration, remain with
a police-only initial response. Furthermore, these follow-up schemes do not put an expert
on-scene in real time. Thus, they do nothing to prevent officers from continuing to
default to expensive, traumatic transfers that generally result in no immediate treatment.
Much will depend on whether mental health professionals can reconnect with the person
in crisis after the initial police contact. This is not a certainty and is an unnecessary risk to
the well-being of persons who needed help so badly that a 911 call was made. Follow-up
contact made 1-3 days after the initial crisis might come too late to prevent harm. Persons
who needed help while in crisis are often much less willing to accept help later. These
represent risks and missed opportunities.
6.

Follow-Up Schemes Supporting Police-Only Response—A Business Model Told
Them to Do It

No management model or research paper ever concluded that persons in mental health
crisis can get better on-scene care from a police officer than a mental health professional.
Within public administration, some business models and researchers are promoting
greater investments in upstream prevention via proactive contact with high service
utilizers (see “High Utilizers” in Glossary Section). This is logical and useful. But no
public administrator should proffer a false choice between investments in proactive
contacts and investments that provide appropriate on-scene clinical mental health
responses.
7.

Follow-Up Schemes Supporting Police-Only Response—Maintain a Failed Status
Quo

Follow-up schemes alone maintain the old status quo of police as de facto mobile mental
health crisis workers. This is no longer acceptable. Interestingly, some of the strongest
arguments against the old status quo are being voiced by law enforcement officers
themselves. The following is an excerpt of a 2019 news report by KTAR News in Phoenix.
Jeri Williams, the Phoenix Police Chief, is quoted.
“I know for a fact people call 911 when they’re having the worst day of their life,”
Williams told KTAR News 92.3 FM’s Bruce St. James and Pamela Hughes on
Monday.

38

IV. FOUNDATIONS FOR FAILURE

“There are some times where we should not be responding to these mental health
calls, so why not take that out of the equation,” Williams said, “let the mental
health professionals deal with that, give my officers time to deal with police work.”
“I’m excited about the challenge for us to create a system, not just with the police
department, but with the community, the behavioral health community, other law
enforcement agencies, that’s going to create a response that’s going to be better in
the end for law enforcement and for the community.”
“What this looks like in a tangible sense to me is a mental health professional riding
in the car with one of our two crisis intervention team squads,” Williams said.
“Or, take it a step further, riding in a patrol car with our patrol officers, sitting in
our communication centers, diverting calls from law enforcement that can go
somewhere else.”
“I’m trying to create the dynamic where I’m getting the right calls and the right
people for the right reasons.”125
F. Dedicating Officers to Do Social Work Follow-Up Visits
Sometimes police agencies dedicate one or more law enforcement officers to do work that
mimics the role of an actual social worker and/or mobile mental health professional.126
On-scene collaboration or deflection of calls to mobile crisis response teams should be a
goal, not something to be avoided.
This can evolve into an extreme example of police culture resisting collaboration and
defending its old separate silo territory. Police are trained, authorized, and equipped to
perform a public safety/law enforcement function. Officers can still participate in
community policing and relationship building. But using police officers in follow-up
work as quasi-social workers is wasteful and fraught with conflicts of interest.127 This is
especially true for follow-up work with people who have persistent mental illness and
co-occurring substance abuse disorders. Involving law enforcement in follow-up services
is a means of criminalizing mental illness. Law enforcement can better serve these
populations by improving collaboration with actual social workers and mental health
professionals rather than inserting themselves as substitute mental health workers.
G. LEAD Programs and Mental Illness
LEAD programs create care management and coordination system architecture under a
philosophy that makes law enforcement contact a central and lasting component of care
service delivery. Care management and coordination is discussed in section VIII. We see
125

Could MH Experts Prevent Phoenix OIS? https://ktar.com/story/2542809/could-mental-health-expertsprevent-phoenix-officer-involved-shootings/?show=comments
126
MH Cops Reweave Safety Net. https://www.npr.org/sections/healthshots/2014/08/19/338895262/mental-health-cops-help-reweave-social-safety-net-in-san-antonio
127
Cops Morphing into Social Workers Not the Solution. https://filtermag.org/cops-morphing-into-socialworkers-is-not-a-solution/

39

IV. FOUNDATIONS FOR FAILURE

the need for integration of service delivery to create efficiency and stabilize high utilizers.
That is currently being attempted outside of law enforcement, primarily at the county
government level. Law enforcement can and should support those existing efforts to
provide care management and coordination. This would require law enforcement to
collaborate well within a broader integration effort that does not center on law
enforcement. Unfortunately, the LEAD approach assumes law enforcement operates in a
vacuum and must be leaders in care coordination efforts. This inappropriately expands
the role of police officers— particularly with respect to mental illness. Law enforcement
has a key role to play in cross silo collaboration as facilitators, to get people to the
primary service delivery systems whose personnel are better suited to be primary
contacts.
LEAD (Law Enforcement Assisted Diversion) originated in Seattle. It was meant to divert
substance abusers away from arrest and steer them to treatment. Importantly, mental
illness is often involved because it so often co-occurs with SUD. Some LEAD programs
are also expanding the concept beyond SUD and applying it directly where behaviors are
solely the result of poverty, homelessness, and mental health. Clearly, pre-arrest
diversion of people away from incarceration is a good thing. But LEAD doesn’t just
avoid incarceration; it also promotes a lasting and centralized role for police as
gatekeepers to social services and health services. This is very different from simply
enabling police to handoff vulnerable persons to service providers and case managers.
The good aspects of LEAD programs are those that do not put police into this centralized
role in lieu of other alternative service givers. Pre-arrest diversion and proactive referrals
by police is also commendable, but not unique to LEAD. We applaud all efforts to
improve collaboration and communication between the separate siloed entities: policing
agencies, prosecutor’s offices, and social service providers. Tying persons to services,
including intensive case management, is a worthy goal that can be pursued with or
without LEAD. In fact, many local governments are working to create collaborations,
integration of services, and expand case management to high utilizers without turning
police into de facto social workers. (See section VIII.)
However, the unique characteristic of LEAD programs is that it puts police into a
centralized role in lieu of using other types of personnel in the community. When the
Seattle Police Department initiated their LEAD program, their officers became primary
gatekeepers to services for some people. Proponents of this approach proudly tell stories
of people in parts of Seattle going to police officers to ask for services or putting
themselves in a position to be arrested to gain a police LEAD referral.128 It’s good that
police can provide social services referrals, but it is strange and inappropriate for a
community to utilize police as primary gatekeepers. There are alternatives that should be
explored and funded. The use of community navigators is one such option.129 130
128

Minneapolis City Council LEAD Presentation. https://youtu.be/proXKzWmpC8
PCOC Minutes 3/12/19. http://www2.minneapolismn.gov/meetings/pcoc/WCMSP-217510
130
MPD Community Navigator Program. http://www.minneapolismn.gov/police/about/WCMSP-220186
129

40

IV. FOUNDATIONS FOR FAILURE

LEAD promotes problems analogous to those seen when police are used as de facto
mobile mental health workers. Police are less efficient and knowledgeable than
specialized social workers and other professionals trained to assist SUD sufferers.
Choosing to use police as primary de facto social service gatekeepers also funnels
vulnerable persons through extended contact with policing agencies and prosecutors that
have conflicting obligations. LEAD has been found to suffer from predictable forms of
resistance to system change:
 resistance by rank-and-file officers
 competing demands and expectations
 an inability to measure what matters
 public unresponsiveness
 leadership transition131
The efficacy of LEAD tends to suffer from the fact that only a fraction of officers support
it and the number of persons granted benefits can be a vanishingly small fraction of the
need. Researchers studying the touted LEAD program in Seattle noted that only 40 of
1300 officers participated.132 The then-manager of Seattle’s LEAD program said that at
times there were only 40 people participating in that program despite the sizeable
number of Seattle Police Department contacts.133
Researchers have found that police officer discretion, not expertise in SUD or mental
illness, is a deciding factor in whether officers grant a person a LEAD referral.134 The
worst failure of LEAD programs is that officer discretion tends to prevent benefit to the
target group of frequent fliers. It appears that officers are more reluctant to help persons
who had a longer history of police contact—a trait of the group. Their reluctance to
utilize the LEAD program fit with researchers’ survey data showing 2/3 of the officers
had reservations about the LEAD program and fully half of them held negative opinions
about diversion in general.135
The Dirty Secrets of LEAD Programs – Presentation to Minneapolis City Council
There is an effort to expand LEAD to new cities, including Minneapolis. In 2019, local
law enforcement and prosecutors had a presentation proposing the “LEAD social
services model” to the Minneapolis City Council.136 This presentation provided
additional insight into the operation of LEAD programs. Some of the descriptions
provided by the presenter were:
131

Worden, R. & McLean, S. Discretion and Diversion in Albany’s Lead Program. Crim Justice Policy
Review, 2018, Vol. 29(6-7) 584–610. 10.1177/0887403417723960.
132
Collins, S., Lonczak, H., & Clifasefi, S. (2015). LEAD Program Evaluation: Recidivism Report. Seattle:
University of Washington.
133
Minneapolis City Council PSEM Meeting 11/13/19. op. cit.
134
Worden, R. & McLean, S., op. cit.
135
Ibid.
136
Minneapolis City Council PSEM Meeting 11/13/19. op. cit.

41

IV. FOUNDATIONS FOR FAILURE



“People stay in LEAD forever.” Once enrolled, a person remains in the
records of law enforcement forever. Program advocates insist on this
even for persons who commit no further crimes.



Police comfort level determines what level of illegal substance possession
qualifies a person for participation in LEAD.
This is highly subjective, with decisions made by officers who have no
professional expertise in chemical dependency treatment. Patients are
far better served if treatment experts decide who can enter programs.



Police apply the LEAD program to persons whose behaviors are not criminal.
LEAD programs initially focused on illicit drug users, but today’s
LEAD programs include other types of police contacts due to poverty
and mental illness. Inclusion in LEAD programs depends heavily on
officer discretion.



Social Contact Referrals, which do not involve diversion or criminal conduct,
are designed to be just as important as arrest diversion referrals in the LEAD
program.
This overreach inserts law enforcement into people’s daily lives despite
a lack of criminal conduct. Money and time spent expanding law
enforcement’s reach into the lives of people in crisis would be better
spent on partnering with social services and mental health crisis
responders.



A LEAD referral must be acted on within 30 days to avoid reapplication of
the deferred criminal charges.
People whose criminal conduct stems from mental health crisis deserve
the compassionate aid of government (see “Parens Patriae” in Glossary
Section). That means facilitating deflection to mental health crisis
responders or on-scene co-response. Police referral to the LEAD
program is no substitute for having the right professional on-scene to
offer care and assistance. By promoting this substitution, LEAD
programs normalize the criminalization of homelessness and mental
illness.

The presentation to the Minneapolis City Council was an attempt to sell police as a
primary means of linking vulnerable persons to resources. It also suggested that the
LEAD program was the only means of breaking silos. This is inaccurate in several ways.
There are other ways to provide wraparound services and case management to the high
utilizer population. The fact that other options have not been explored (or funded) does
not necessitate a misapplication of police officers as gatekeepers to social services.

42

IV. FOUNDATIONS FOR FAILURE

LEAD Is an Inappropriate Overreach That Criminalizes Mental Illness
Researchers studying the Albany program concluded that the failings of this model are
reminders of past mistakes in police reform. CIT and LEAD suffer from the same
unfortunate reflex to expand police involvement beyond what is required or appropriate.
The quote below gently reminds us of this old lesson.
Conflicts—internal and external to police—arise over goals and the appropriate
degree of coerciveness in providing services. Community expectations for crime
fighting and order maintenance may, at some point, conflict with the harm
reduction philosophy that underlies LEAD and programs of its ilk. Goetz and
Mitchell (2006) conclude that such programs are “difficult to sustain” (p. 505).
George Santayana said that “those who cannot remember the past are condemned
to repeat it.” We should be careful to draw lessons from experiences with the
implementation of these programs. They have been characterized as “the future of
policing” (Gualtieri, 2016); they are also the past of policing.137
LEAD programs create conflict and waste by over-utilizing police in lieu of other, more
appropriate service providers. This does not represent the future of improved
collaboration and integration our communities want and need.
Leaders in Minneapolis and elsewhere should consider the potential consequences of
expanding law enforcement’s reach into social services delivery. LEAD has the potential
to excuse surveillance of persons, their families, and their friends by police officers acting
as self-appointed social workers.138 This reality already exists in many cities where police
routinely make proactive welfare contacts with persons living with mental illness.139 140
Local city and county leaders cannot ignore unintended consequences when local law
enforcement seeks to initiate a LEAD program that inappropriately expands the reach of
law enforcement in the community.
We call for common sense alternatives that truly reflect community needs and priorities.
Collaboration and service systems integration can occur without LEAD programs and
the conflict they bring. Social service delivery systems can provide wraparound services
and case management. Cities and counties should partner with these programs and work
to get them better funded. When cities and counties want to do more than simple street
outreach, they can utilize social workers instead of police officers to help community
members stay connected to services.

137

Worden, R. & McLean, S., op. cit.
Cops Morphing into Social Workers Not the Solution, op. cit.
139
Maplewood PD and Paramedics Launch MH Team. http://www.startribune.com/maplewood-policeparamedics-launch-mental-health-team/512238992
140
Lakeville Police Team Formed to Follow Up on MH Calls. http://www.startribune.com/lakeville-policeteam-formed-to-follow-up-on-mental-health-calls/307636751/
138

43

IV. FOUNDATIONS FOR FAILURE

It is time for better, more appropriate solutions, rather than reflexively expanding law
enforcement’s role to include the provision of social services.
H. Telepsychology, Where Chosen for Convenience Only
In rural jurisdictions, law enforcement officers can have tremendous logistical obstacles
to collaborating with mental health professionals. It can be common in remote areas to
have no viable options for deflecting persons to alternative services. These are
circumstances where electronic aids are necessary to enable a telepsychology option. This
can put a patient in contact with a provider and/or inform an officer’s decision-making.
However, using electronic aids where not truly necessary, but for the sake of expediency,
encumbers access to mental health professionals and reduces the effectiveness of the care.
The priority is to provide critical care, not to make police responses more convenient for
officers and police administrators.
I. Ambulances and EMTs Instead of Licensed Mobile Mental Health Crisis Workers
Alternatives to a police response are preferred if they are appropriate and adequate.
Using actual mental health clinicians is most appropriate for mental health-related calls.
In some communities there is a reflexive push to use emergency medical technicians
(EMTs) in ambulances as alternatives to a police response. But these are not mental
health professionals; this diverts their expertise, and the ambulance asset, away from
their core function.
This paper focuses on police contacts. It addresses the need for deflection to alternative
response options and the need for real-time, on-scene mental health professional and
police co-response. These are needs born of the reality that police should not be de facto
mobile mental health care workers. Paramedics and EMTs are also not mental health
professionals. Thus, they too should choose deflection to or on-scene collaboration with
mental health workers when their calls involve persons in a mental health crisis. In fact,
collaboration with county mobile mental health crisis teams should already be part of the
standard operating procedure for ambulance services.
In urban areas, the labor market provides an adequate supply of clinical social workers to
enable both deflection and on-scene collaboration (see section VII). It is time for society to
recognize that mental health crises are best addressed with a mental health clinician
response. This will reduce the waste of taxpayer funds and the suffering of persons who
need the right response, at the right place, and at the right time.
J. Using Under-Qualified Workers for Mobile Mental Health Crisis Response
Some communities are exploring co-response options that are cheaper substitutes for
using highly trained mobile mental health workers. This focus simply preserves the
pattern of defaulting to unnecessary revolving door transfers. It is an example of
managing, not solving a problem.

44

IV. FOUNDATIONS FOR FAILURE

1.

CAHOOTS (Crisis Assistance Helping Out On The Streets)

The well-publicized CAHOOTS Program of White Bird Clinic in Eugene, Oregon deploys
mobile teams that historically mostly assisted the sizeable local homeless population.
Their teams are comprised of an EMT and a crisis intervention worker. Much of the
assistance is typical of what outreach teams do— tie persons to services. The teams are
also expected to assist with persons affected by drug use and mental illness. Crisis
intervention workers are expected to perform “mental health assessments” and “crisis
counseling” on their own in the field.141
Postings for crisis intervention workers on the employer’s webpage show the pay is
$15/hour, a college degree is not required, and only two years of related experience is
required.142 This falls far short of the credentials typically required for performing
mobile mental health crisis responder work.143 144
In Minnesota, and in most locales, persons employed to provide “mental health mobile
crisis intervention services” are required to have a Master’s degree and satisfy separate
statutory requirements to perform clinical mental health assessments.145
Communities must consider the importance of providing a true mental health care
response to psychiatric emergencies using highly qualified workers. CAHOOTS does not
provide this. Having highly qualified mental health professionals provide on-scene care
in real time prevents unnecessary transfers, reduces system burdens, and enables better
outcomes. Sending lesser-qualified individuals misses most of the long-term benefits of
avoiding police-only response. In Minnesota, county mobile mental crisis response teams
(e.g. COPE teams in Hennepin County) have the expertise to yield full return on the
investment in an alternative response.146 This is discussed further in sections V and VI.
K. Promises to Collaborate Without Formal Policy and Mechanisms
Time and again, a tragic use of force brings forth public pronouncements of changes,
including collaboration between law enforcement and mental health providers. Too
often, these are empty promises, because they don’t result in concrete policies and
mechanisms ensuring deflection to or co-response with mental health clinicians.

141

Doin’ the Work: Frontline Stories of Social Change, Episode 26.
https://drive.google.com/file/d/1F9yNxZJoG2G4CNwIQmFZtaifwuYMgurC/view
142
White Bird Clinic Crisis Intervention Worker Job Posting. https://whitebirdclinic.org/job-postings/
143
HC Sr Psychiatric Social Worker Job Posting.
https://agency.governmentjobs.com/hennepin/job_bulletin.cfm?jobID=2020787&sharedWindow=0
144
Crisis Clinician Practitioner Job Posting.
https://www.indeed.com/viewjob?jk=da003adc51f7a2da&q=mobile+crisis&l=Ramsey+County,+MN&tk=1e0
p862lbp9p7801&from=web&vjs=3
145
MN Statute 256B.0624, op. cit.
146
Ibid.

45

IV. FOUNDATIONS FOR FAILURE

46

V. FOUNDATIONS FOR SUCCESS

V. FOUNDATIONS FOR SUCCESS
There is no single solution to reducing the use of police as de facto mobile mental health
crisis workers. This section provides general concepts and a review of the limitations that
exist for collaboration in rural areas. Another important consideration for decisionmakers is where to access start-up information and assistance.

A. General Concepts
1.

Multi-Layered Response Schemes That Prioritize Collaboration at First Contact

A multi-layered approach is important for decriminalizing mental illness. The LAPD
created a multi-layered collaborative approach that is a national model.147 148 149 Over the
course of three decades, the LAPD pioneered the first stand-alone Mental Health Unit.
Within that unit they created a co-responder team program (SMART teams), then a
collaborative follow-up team (CAMP teams), and even a triage desk staffed by clinicians.
The Houston PD also has an impressive multi-layered system that has helped many
other agencies to implement their own programs. According to the Council of State
Governments, Justice Center, Houston’s approach includes:
Crisis Intervention Response Team (CIRT) The CIRT, which started in 2008, serves as
Houston’s highest-level response to people in serious mental health crisis. The co-response
program partners a Houston CIT officer with a masters-level licensed mental health
clinician from The Harris Center. CIRT supports officers in the field, responds to CIT calls
for service, is present at SWAT calls, conducts jail assessments, and performs proactive
and follow-up investigations.

147

LAPD Unit Praised. https://www.scpr.org/news/2015/03/09/50245/police-and-the-mentally-ill-lapd-unitpraised-as-m/
148
LAPD Mental Evaluation Unit, September 2016. https://pmhctoolkit.bja.gov/ojpasset/Documents/MEUProgram-Outline-Sept-2016.pdf
149
LA National Model, op. cit.

47

V. FOUNDATIONS FOR SUCCESS

Chronic Consumer Stabilization Initiative (CCSI) This program identifies people who are
in frequent contact with HPD officers and pairs them with a mental health case manager.
Homeless Outreach Team (HOT) The Homeless Outreach Team has worked collaboratively
since 2011 with community organizations to provide services.
Boarding Homes Enforcement Detail (BHED) Houston passed a city ordinance in July
2013 that regulated unlicensed boarding homes, many of which provide housing for people
with mental illnesses.
Crisis Call Diversion Program
Senior Justice Assessment Center
Investigations Unit/Special Projects This unit analyzes every police report pertaining to
mental illness and inputs these incidents into a database.150

Community Navigator programs at the city or county level can add a very valuable
service, remove burdens from more specialized responders, and be a valuable
component in the effort to tie high utilizers to services through integration. Minneapolis
has a nascent program with bachelor’s level social workers offering wraparound
services.151 152
The multi-layered approach is easier to construct in large cities, but the concept can apply
anywhere. Smaller jurisdictions can create similar functionality without following the big
city example with separate distinct teams and programs. It requires a high level of
collaboration with the personnel available in the separate systems. The “Yellow Line
Project” in Blue Earth County, MN, offers an example of a rural effort to create multiple
deflection and diversion opportunities. The Yellow Line Project excels by being
intentional within a framework of close collaboration.153 154
2.

Dispatch Triage

Governments serve their communities best when they respond to requests for service
with the most appropriate resources. When a psychiatric emergency results in a call for
service, the expertise of mobile mental health professionals is the most appropriate
response. This maxim applies whether the call goes directly to a county mobile mental
health crisis team dispatcher or goes to a 911 dispatcher. The public wants and deserves a
mobile mental health care response to a mental health call for service.

150

CSG Law Enforcement MH Learning Site-Houston PD. https://csgjusticecenter.org/wpcontent/uploads/2020/02/Law-Enforcement-Mental-Health-LearningSites_Houston3.26.19_508accessible.pdf
151
PCOC Minutes 3/12/19, op. cit.
152
MPD Community Navigator Program, op. cit.
153
The Yellow Line Project. https://www.yellowlineproject.com/history-of-ylp/
154
Yellow Line Project Jail Project Priorities.
https://static1.squarespace.com/static/59a9b5a96f4ca376db822022/t/59c2c888197aea0c2f8207db/150593
7548753/continuum+of+care.png

48

V. FOUNDATIONS FOR SUCCESS

Dispatch Triage refers to assigning calls to the most appropriate responder. For mental
health-related calls, this could mean a deflection to county mobile mental health crisis
teams or to law enforcement/mental health co-responder teams. In larger cities it might
even enable deflection to specialty teams for domestic disputes or homelessness.
Dispatch Triage must happen within 911 call centers prior to reaching police. The goal should
be to provide real-time response and on-scene expert care—nothing less. This is an
important consideration because some jurisdictions substitute a response by minimally
trained workers for a police response. This betrays the community members whose crises
resulted in calls for help. It is also wasteful. By deflecting to an on-scene clinician
response, dispatch triage creates tremendous benefits and efficiencies.
Missing this opportunity for proper deflection is, frankly, unacceptable for systems that
strive to deliver excellent service with high efficiency. This is the easiest and most
efficient point to break the “separate silos” trap. Dispatch triage should be employed to
prevent unnecessary police contact even in regions where there are separate call systems
(e.g. 211 or crisis hotlines) dedicated to connecting the public to mental health services.
But hard experience shows that deflection to alternative services is highly unlikely unless
there is a formalized mechanism for dispatch triage at the 911 call center level.
Unfortunately, the U.S. 911 system has historically prevented the most appropriate
response to mental health crisis. Our 911 systems do not proceed from the logical starting
point that recognizes a person with mental illness in the category of a person needing
medical assistance. This is analogous to someone who is injured in an automobile
accident. Accident victims get emergency medical responses. In cases where persons
with mental illness present a danger to others, the public safety concern can logically
require a police response. Sadly, the Supreme Court has failed to require police to
respond any differently than they would to a violent criminal.155 But, the great failure of
U.S. 911 systems is their inability to find middle ground when evaluating mental healthrelated calls. Too often the scales have been tilted to treat individual mental healthrelated calls as dangerous despite any and all contraindications. This is especially
problematic for suicide calls, which are often treated as “imminent danger” calls
requiring a police response.
Things can be different in 911 communications centers and in some places outside the
U.S. they already are. In Sweden, they have chosen to decriminalize mental illness by
ending police-only responses for most suicide calls. They have initiated 112 (their 911)
dispatch triage that sorts suicide calls to enable alternative or co-responses where
appropriate.156 In Stockholm, a non-police rapid response team called PAM is dispatched
to calls by their version of a 911 system.157 PAM was created in response to high suicide

155

Reasonable Accommodations, Not Unreasonable Force. http://cdrnys.org/blog/disability-dialogue/thedisability-dialogue-reasonable-accommodations-not-unreasonable-violence/
156
PAM Follow Up. https://www.tandfonline.com/doi/full/10.1080/00207411.2016.1264040
157
Ibid.

49

V. FOUNDATIONS FOR SUCCESS

rates, and 53% of their calls are for severe threat or attempt of suicide.158 (PAM is
discussed in greater depth in section VI.)
Some communities in the U.S. are experimenting with dispatch triage. The proliferation
of co-responder teams has helped. Dispatch triage at 911, with direct call assignment by
dispatchers, is more likely to be used with 3-person co-response teams consisting of a
police officer, clinician, and EMT. In Minnesota, the first locality to implement 911
dispatch triage, Ramsey County, began deflecting calls in 2018.
A Local Success Story
In Ramsey County, MN, there was almost no deflection of calls to mental health
clinicians before the introduction of a dispatch triage system. The supervisor of the
county crisis team reported that before the dispatch triage program, his teams “had about
three assessments per month maybe” that originated from law enforcement. With
dispatch triage, that number rose to more than 30 deflections a month.159
When this deflection occurs, it creates much better public service from all the
collaborating systems.160 161
Limitations will exist when the call for service includes an element of danger to
responders or criminal activity is apparent. Even in those situations, such complications
might not prevent the use of co-response options such as secondary response or policeembedded co-responder teams.
Dispatchers can be trained to better recognize a mental health aspect in an incoming call
for service. The first dispatch triage effort in the State of Minnesota was at the Ramsey
County Emergency Communications Center. At the 2018 Critical Issues Forum by the
Minnesota Chiefs of Police Association, panelists from Ramsey County described their
procedures. Team Supervisor, Brian Theine, described how his local 911 center
determines if they can transfer a call to the county crisis team:
Starting Mar. 1, 2016, the emergency call center began redirecting adult crisis
calls to the Ramsey County Crisis Program. … The telecom person will do an
initial screening for eligibility and assessing to see that the person who needs
assistance is 18, that they are not engaged in an act of suicide – so they haven’t
already ingested a bottle of pills or sitting with a trigger of a gun at their head –
and that the caller believes that the person is not dangerous to the person on the
phone or anyone else in the community, and no crime’s been committed.

158

World’s First MH Ambulance. https://www.dailyscandinavian.com/successful-launch-worlds-first-mentalhealth-ambulance-stockholm/
159
Brian Theine, MPCA Critical Issues Forum. https://youtu.be/nbET9b8p80c
160
Transferring MH Calls. https://www.governing.com/idea-center/Transferring-911-Mental-Health-CallsCould-Reduce-Harm.html
161
Avon and Wiltshire MH Partnership. http://www.awp.nhs.uk/services/community/street-triage-service/

50

V. FOUNDATIONS FOR SUCCESS

...So, we’re set up to respond to an urgent need. Paramedics and police are set up
for imminence. So, dispatch’s job is to decipher where does the call fall. Is it an
urgent call for crisis or is it an imminent call for the police? The dispatch worker
then will talk to the person on the line and see if they are comfortable with being
transferred to my team, and being willing to have counseling, and a potential inperson visit by a mental health professional to their home rather than a police
officer. And, are they safe and comfortable waiting for my team to respond. So, at
that point, dispatch transfers the call to crisis, they announce the caller and their
phone number, and they stay on the line for a short time to make sure that it’s
successfully has transferred. This has also proved helpful – fruitful – for us because
the call is live, it’s being audio-taped, so if something isn’t going well between our
teams we can learn from that. And, it also provides us with a safety thing in case
the call gets dropped; we know who to call and what number to call back on. So
then the assessment ensues, the crisis team decides is this something to offer, like
information referral. Do we go out and see somebody. How do we get that set up?
Sometimes it also slows down the call and we may make a decision to go out into a
joint door knock, with police and crisis together in a non-emergency kind of way.
The whole system has improved because of this. …Once dispatch has transferred
the call, they can go and we can take over…We get to help out people in the
community. We can get them help quickly – right away. And, then police are freed
up to go do police work.162
Abilene, TX, uses conference calling to bring a mental health professional into a 911 call
with the push of a button.
During the three-way call between the person in a mental health crisis, a 911
dispatcher and an Avail clinician, the clinician will “triage them and determine if
it’s something that can be handled over the phone or if they need to dispatch our
Mobile Crisis Outreach Team,” Cole said. Betty Hardwick has at least one team
available around the clock, Cole said.163 Avail is a Texas-based company that
staffs crisis hotlines.
Houston’s Crisis Call Diversion Program was begun in 2015 and handles thousands of
calls. Their program deflects crisis calls to on-phone counseling and possible mobile team
visits.164
In the police community, there is growing recognition of the need for 911-based dispatch
triage. Phoenix Police Chief Jeri Williams described her understanding of the need for
deflection and dispatch triage in a 2019 on-air KTAR interview:

162

Brian Theine, MPCA Critical Issues Forum, op. cit.
Abilene 911 Program. https://www.reporternews.com/story/news/2019/02/01/new-abilene-programaddresses-911-mental-health-call/2747350002/
164
Houston PD Crisis Call Diversion Program. https://perma.cc/XW5L-TCXB
163

51

V. FOUNDATIONS FOR SUCCESS

There are some times where we should not be responding to these mental health
calls, so why not take that out of the equation,” Williams said, “let the mental
health professionals deal with that, give my officers time to deal with police work.
So call 911 but perhaps in that call to 911 we can give you to a service provider, we
can give you to a mental health professional...Why not give you to a crisis line, why
not give you to a suicide prevention line... So we can take those calls but we want
to divert those calls.165
Advocates for those with mental illness are also part of the rising chorus of calls for 911based dispatch triage. NAMI Minnesota’s Executive Director, Sue Abderholden, decried
the lack of 911-based dispatch triage in a 2018 KSTP News report.
"Why would we have a separate mental health number that very few people know
instead of making sure that our current emergency services can connect people to
the right treatment?" she said.
Abderholden says lawmakers allowed 911 to link with mental health crisis response
teams back in 2009. Still, nearly a decade later, few are taking advantage of it.
"We really should have the 911 operators connecting people with mental health
crisis teams instead of just automatically sending out police and ambulances," said
Abderholden.166
Dispatch triage at 911 call centers is key to making effective use of alternative response
options as well as co-response options for mental health crisis calls.
3.

Alternative Responders—911 Mental Health First Responders

Alternative responders are teams of professionals who are qualified to provide mobile
mental health crisis interventions in the community as a substitute for a police response.
These alternative responders help to meet community expectations for quality,
transparency, accountability, and cultural competence and are part of providing a
patient-centered service. The kind of highly skilled personnel needed for this work are
licensed master-level clinical social workers (LICSW). They offer competencies in mental
health care with the social work skills to tie people with the resources they need. LICSWs
make ideal primary responders as well as co-responders. Clinical social workers also
have the credentials and expertise to satisfy the statutory requirements set by Minnesota
for mobile mental crisis response work.167 168 Unlike other mental health professionals,
there is a surplus of clinical social workers in many urban areas and in most of
Minnesota. The labor market for clinical social workers is described in section VII.

165

Could MH Experts Prevent Phoenix OIS?, op. cit.
MH Advocates Want 911 Linked with Crisis Response Teams. https://kstp.com/news/mental-healthadvocates-want-911-linked-with-crisis-response-teams/5105208/
167
MN Statute 256B.0624, op. cit.
168
MN Statute 245.462. https://www.revisor.mn.gov/statutes/cite/245.462/pdf
166

52

V. FOUNDATIONS FOR SUCCESS

4.

Minnesota’s County Crisis Response Teams: Ideal Alternative and Co-Response
Option

Minnesota is blessed to have mobile mental health crisis response teams serving every
county. These teams provide as an ideal foundation for building alternative response and
co-response capacity. Other states should see this resource as an excellent example of
how to build capacity for alternative response and co-response programs of their own.
The teams are staffed with experienced clinical social workers who can provide on-scene
mental health assessment and care. They are also ideally situated to tie individuals to
follow-up services and case management in increasingly integrated county care systems.
There are important benefits to funding these teams at the county level, including the
potential for better response time and efficient coordination with law enforcement.
Transparency and accountability are also significant considerations.
Unlike other states, Minnesota counties have key resources and organizational structure
already in place. The main obstacles are capacity, the lack of 911 dispatch triage, and
inadequate collaboration. More funding is needed to hire workers to handle additional
calls from 911 dispatch triage and for deeper collaboration with law enforcement.
Ramsey County Crisis Teams are Diverting 911 Calls Away from Police
The Ramsey County Mental Health Crisis Response Team already benefits
from 911 dispatch triage and is currently functioning as an alternative
responder for mental health-related 911 calls.169
5.

Co-Response and Mental Health Co-Responder Teams

In situations where police contact cannot be avoided, communities must provide a
working mechanism to enable routine and immediate on-scene co-response by welltrained mental health professionals. This includes the ability to relieve patrol officers
whose contact with someone in crisis was not foreseeable when dispatchers described the
call. This is exactly what the community and consumers want. Research shows coresponse is preferred over a police-only response.170 171
Without a co-response option, many unforeseen or problematic mental health-related
calls will be police-only contacts. The outcomes of these will be a matter of chance and
police discretion instead of a clinician’s expertise.
When the interaction between the police and the person with mental illness is
initiated by the police themselves, police officers have the greatest amount of
discretion. In such situations, there is considerable potential for the disposition to
169

Ramsey County 911 New Approach. https://www.twincities.com/2016/02/29/ramsey-county-911-willsend-mental-health-workers-to-crises/
170
Boscarato, et al., op. cit.
171
Evangelista, et al., op. cit.

53

V. FOUNDATIONS FOR SUCCESS

be influenced by police officers' personal attitudes or beliefs. There may well be no
one—neither citizens nor the police officers' superiors—overseeing whether a
situation is handled in a standardized fashion and in a way that protects both
society and the individual. In these instances, the officers act freely and solve the
problem in whichever way they deem appropriate, on the basis of their particular
attitudes toward, perceptions of, and assumptions about persons with mental
illness.172
The mental health aspect of a call for service might not be understood until the first
officer arrives. In other cases, the nature of the call might require a police officer to be
present to verify and maintain a safe environment. Avoiding a police-only response in
these circumstances requires an extremely rapid and integrated co-response option.
Experience and research have shown that the best way to do this is by creating
police/mental health professional co-responder teams.
COPE Partners with Minneapolis Police in Co-Responder Team Program
In Minneapolis, the county team called Community Outreach for Psychiatric
Emergencies (COPE) currently provides personnel to work within the
Minneapolis Police Department’s Co-Responder Team Program.173 174
Co-Responder Team Basics
Co-responder teams are two-person teams comprised of a dedicated specialty officer,
paired with a mental health professional. These partners respond in the same vehicle
exclusively to mental health-related calls. The teams exist to take the burden of mental
health-related calls off the regular patrol cadre and create better outcomes for persons in
crisis. Co-responder teams are far superior to the outdated model of secondary response,
in which law enforcement officers may call in outside clinicians. As previously discussed,
officers almost always fail to call non-embedded clinicians.
The very first use of this approach was in 1987 in Vancouver. This is the oldest police
mental health crisis response initiative.
A partnership between the Vancouver Police Department and Vancouver Coastal
Health, Car 87 is one of several specialized police vehicles used in the city. For a
given crisis situation, one Vancouver Police constable and a psychiatric nurse will
respond to conduct on-site assessments and make necessary treatment referrals.
The Car 87 team also helps locate and transport individuals at the request of
community mental health services. Car 87 offers the benefits of a law enforcement172

The Police and Mental Health. https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.53.10.1266
Hennepin County Adult MH Crisis Response.
https://www.minnesotahelp.info/Providers/Hennepin_County_Human_Services_and_Public_Health_Depart
ment/Mental_Health_Crisis_Response_Services_Adult/1?returnUrl=%2FSpecialTopics%2FYouth%2F1959
0%3F
174
MPD Co-responder Teams. https://www.minnpost.com/metro/2019/01/how-co-responder-teams-arechanging-the-way-minneapolis-police-deal-with-mental-healthcalls/?fbclid=IwAR1lp9HY0VyAyVH7vq93WbHeMzF4G5E3Ulf2K7E_wYxDsV442oS4LxBMJFw
173

54

V. FOUNDATIONS FOR SUCCESS

mental health response, providing expertise in both maintaining public safety and
administering psychiatric care.175
The Co-Responder Team Model has been in use in the U.S. since 1992, when it was
adopted by the Los Angeles Police Department. Since then it has been refined and
adopted by scores of police departments in the United States, Canada, the United
Kingdom, and Australia. The United States has seen a surge in the effective use of coresponder teams in the past several years. In Minnesota, the Duluth Police Department
studied the Houston PD program and initiated the first such program in the state. Then
Dep. Police Chief Mike Tusken welcomed the innovative approach of their co-responder
program.
Co-responder teams could be asked to respond by 911 dispatchers or on-scene officers
who recognize a mental health issue. In many police departments, the co-responder
teams also monitor police radio traffic and can self-assign to a call. Co-responder teams
can and should respond independently to most calls in which weapons are not involved.
Researchers note that by handling time-consuming mental health-related calls, coresponders are “relieving an otherwise substantial, unnecessary, and inappropriate
burden on law enforcement officers.”176 This benefit to law enforcement is not always
fully appreciated by those who have no experience with this specialized police response
model. However, once implemented, police officers typically recognize the improved
outcomes and reduced burdens on law enforcement. In Boston, embedded co-responder
Mathew Salch observed that evolution firsthand:
We’ve gone from not being accepted when we started, to officers in other Boston
police department districts calling us for help, because they have heard of the work
that we are doing. That feels good.177
Rapid Growth of the Co-Responder Team Model
The Boston experience is typical in several ways. It is common for jurisdictions that
implement co-responder team programs to observe tremendous immediate benefit and
decide to expand their programs within a very short time. The Boston Best Program that
was limited to two police districts at the time of the above quote has since expanded at
the behest of multiple city councilors. The relatively new programs in Duluth and
Minneapolis have both expanded.178 179 Countless other cities have also expanded their
co-responder programs because both the community and police departments valued the
175

Beyond Road Runners. https://www.treatmentadvocacycenter.org/fixing-the-system/features-andnews/4168-research-weekly-beyond-road-runners-insights-from-other-countries
176
Seattle PD CRT.
https://www.researchgate.net/publication/281310578_A_descriptive_evaluation_of_the_Seattle_Police_De
partment's_crisis_response_team_officermental_health_professional_partnership_pilot_program
177
Boston Police Ride Along. https://stepuptogether.org/people/boston-police-ride-along-2
178
MPD Co-Responder Teams, op. cit.
179
Duluth Co-Responder Team Model Recognized. https://cbs3duluth.com/2019/05/22/watch-live-at-130-pm-duluth-st-louis-co-officials-to-recognize-mental-health-unit/

55

V. FOUNDATIONS FOR SUCCESS

improved outcomes.180 181 182 183 184 185 Multi-jurisdictional programs are part of this
explosive growth. These programs are partnerships of two or more communities to
create a co-responder team program that serves areas that could not sustain their own
independent programs. This allows suburbs to benefit from the co-responder team model
as a partnership that leverages economies of scale. The largest example of this is the
PERT Program that provides co-responder team service to all of San Diego County.186 187
188
A smaller example is the eleven-city Johnson County, Kansas program.189
Co-Responder Expertise Brings Highly Effective On-Scene Care and Advocacy
Police-embedded co-responder programs are important because they provide great
benefit to the vulnerable persons in crisis. Community-based clinician care has been
shown in research and experience to promote de-escalation, prevent unnecessary
transfers, and help prevent patient entanglements in the criminal justice system.190
Avoiding entanglements with the criminal justice system is a key benefit. Such
entanglements can have severe consequences for persons struggling to maintain a home
and employment. Law enforcement consistently describes how the clinician elicits more
cooperation from the patient, thus reducing the potential for use of force.191 192
In Denver, this ability to gain cooperation and de-escalate situations helped the coresponders gain acceptance from patrol officers.
Snow says that at first, there was concern that officers might not accept clinicians
riding in their cars. But that concerned quickly disappeared after officers saw how

180

Boston MH Clinicians to Attend to 911 Calls. https://www.bostonherald.com/2017/02/15/city-eyesstaffing-mental-health-clinicians-to-attend-to-911-calls/
181
St Paul PD Expanding MH Unit. https://www.mprnews.org/story/2018/12/24/st-paul-police-already-wantto-expand-new-mental-healthunit?fbclid=IwAR0doyxcYdMdecy6roJ_x39NYaJZAMXOfGnQ7wWaokM3Yuv2zYjQ5-Yl6oM
182
County Votes to Expand Mental Evaluation Teams. https://www.printfriendly.com/p/g/gkRxzr
183
Johnson County Hiring More MH Co-responders. https://youtu.be/VlW9r0V4YqE
184
Baltimore Police Add Crisis Response Team. https://www.baltimoresun.com/maryland/baltimore-city/bshs-police-crisis-response-20170727-story.html
185
Grant to Help Tulsa’s CRT. https://www.tulsaworld.com/news/crimewatch/grant-to-help-tulsa-scommunity-response-team-expand-beyond/article_0f183e3e-5070-53df-a452ca014a425f64.html?fbclid=IwAR05DFpkXKmOZCb7vZdTHhEsZVtVsETjRq1g7CVaTLZQ7AKUTziSCAbw1
uo
186
San Diego PERT. https://popcenter.asu.edu/sites/default/files/library/awards/goldstein/2005/05-12.pdf
187
Escondido PERT, op. cit.
188
San Diego Blueprint for Mental Health Reform, op. cit.
189
Eleven Johnson County Cities to Partner, op. cit.
190
Evangelista, et al., op. cit.
191
CMPD Co-responders. https://www.wsoctv.com/news/local/cmpd-pairing-officers-with-social-workers-tohelp-de-escalate-mental-health-calls/908753927/
192
Evangelista, et al., op. cit.

56

V. FOUNDATIONS FOR SUCCESS

effective clinicians were in de-escalating potentially volatile situations. "Then
officers started competing to have clinicians," says Snow.193
Replacing a police-only contact with co-response can save lives and reduce trauma. A use
of force can de-stabilize a patient and affect them for days or weeks.
Many victims of police violence often experience PTSD, which manifests as severe
agoraphobia and paralyzing panic attacks. This creates a downward spiral of
isolation, depression, and even suicide.194
Without co-response, officers typically default to a transfer to a brick and mortar facility
where a mental health professional can make an assessment. These transfers are often
unnecessary, but officers, lacking mental health expertise, naturally choose the action
that will indemnify them and their agency. Researchers found that 80% of police-initiated
transfers in a Minnesota jurisdiction resulted in no care.195 This has always been a key
inefficiency of the police-only response. It creates a large and unnecessary burden on
hospital emergency rooms and other facilities. It adds trauma and possibly an ambulance
bill to the patient’s experience.196 197 On the west side of the continent the same
dysfunction was described in Orange County, CA, where officers wait for hospitals
personnel to triage patients being dropped off:
Unfortunately, Orange County relies on an obsolete, inefficient triage system that
handicaps the police officer and results in an inordinate loss of time and resources.
Moreover, the County jails and emergency rooms are the worst places in which to
treat the severely and dangerously mentally ill.
The County’s shortcomings with regard to mobile response teams and in-the-field
medical clearances of the severely mentally ill, and have caused long delays in
evaluating and treating the mentally ill, many wasted hours of valuable police time
spent in emergency rooms and while driving the mentally ill to and from
emergency treatment facilities. The County’s lack of vision and leadership have
resulted in a disjointed, dysfunctional system that contributes to the revolving
door.198
Co-response eliminates wasteful inefficiency and harm caused when police act as
gatekeepers. When co-responder teams were introduced in multiple jurisdictions in the
United Kingdom, the result was 50% or greater reductions in transfers.199 200 201 In one
193

DPD Co-responder Unit. https://www.westword.com/news/part-of-caring-4-denver-money-would-go-toco-responder-unit-10935094
194
Officers with PTSD, op. cit.
195
New Paradigm, Not New Building, op. cit.
196
New Paradigm, Not New Building, op. cit.
197
Cost of MH Crisis in ED. https://www.healthcarebusinesstoday.com/true-cost-mental-health-crisisemergency-department/
198
Ml Revolving Door, op. cit.
199
Street Triage and Detentions. https://bmjopen.bmj.com/content/bmjopen/6/11/e011837.full.pdf
200
Nottinghamshire Street Triage. https://www.england.nhs.uk/mental-health/case-studies/notts/
201
Street Triage to Help the Vulnerable. https://www.bbc.com/news/health-32739451

57

V. FOUNDATIONS FOR SUCCESS

case the reduction was by 90%.202 A Boston researcher documented her observations in
that city:
What clearly came across in the co-responder data and the officer interviews is that
there are families who rely on police to provide a type of respite when their loved
ones are in crisis. There are residents of Boston who rely on 911 and the police to
address immediate problems, such as suicidal ideation, that require a quick
emergency response. Traditionally, the city has filled this need through ambulance
transports and emergency department evaluations, but this is not a sustainable
solution both in terms of cost and outcome. It creates a revolving door of crisis
services without addressing the long-term needs of these families and frustrates an
already-overburdened public safety system.203
In Dallas a co-responder team program and 911 dispatch triage created noticeable results
after only three months of operation.
B.J. Wagner, senior director at the Meadows, said since the program kicked off Jan.
29, ambulance calls for mental services in southern Dallas have decreased by 23
percent [emphasis added]. When mental health emergency calls come in, clinicians
and specialists use their expertise to talk a person down and free up Dallas’ 42
ambulances to respond to other calls.
…
Wagner added that of the 709 mental health emergency calls fielded since January,
just 3 percent ended in arrest. In the first three months of the program, the
clinician's diversion of calls saved the police force about two weeks of salaried work
[emphasis added]. “We want public safety to be our first priority, not law
enforcement,” Assistant Chief David Pughes said Friday. “The police officer is just
there to make sure the paramedic and clinician are safe.”204
Having the Clinician On-Scene Immediately Is Powerful
Police co-responder teams create an immediate community-based care option that can
turn a police response into a healthcare response. Being on-scene enables optimal service
that begins with a more accurate assessment and immediate care. The clinician can
provide counseling or evaluate co-occurring substance abuse issues.
Co-responding clinicians are well positioned to partner with family and friends to create
a plan for follow-up care. This follow-up care might include wraparound services or case
management. It all starts with an immediate on-scene clinician response to a psychiatric
emergency. When a transfer to a brick and mortar care facility is deemed necessary, the
202

Operation Emblem. https://rcni.com/newsroom/nurse-awards/caring-approach-street-triage-nursespeople-mental-health-crisis-26411
203
Boston Experience with Co-Responder Model. https://doi.org/10.1080/15564886.2018.1514340
204
Senator Praises Program. https://www.dallasnews.com/news/2018/07/28/sen-john-cornyn-praisesdallas-police-mental-health-crisis-response-program/

58

V. FOUNDATIONS FOR SUCCESS

clinician’s expertise creates a much better handoff into the care of other mental health
workers.205
If there is a transfer, the professional on-scene assessment and clinician-to-clinician
communication is immensely important for immediate care and coordinating follow-up
work.
Co-Responder Teams and Care Management
These initial contacts are extremely important opportunities to pull individuals into the
care continuum. Many police-only contacts involve persons who are “off the radar” of
care systems or are experiencing their first episodes. One study determined 30% of
mental health contacts were early onset consumers who were not yet tied to services.206
Stabilizing early onset individuals can prevent many from becoming “high utilizers” of
social services and additional police contacts. These contacts are important windows of
opportunity to help people. Very often police officers lack the expertise to identify an
individual’s true need for care. Researchers in Seattle noted that a co-responder team
program there was creating better dispositions due to the insight of the on-scene
clinicians.
The current findings show the ways in which the SPD CRT OFC/MHP team was
able to provide nuanced intervention and case disposition that meaningfully
addressed issues presented by frequent fliers. These individuals tend to get caught
in a never-ending cycle as both victims and offenders. Without necessary resources,
law enforcement officers have difficulty ascertaining the nature of the situation of
individuals they come in contact with who are experiencing such severe and
complex problems. Individuals with chronic and complex needs, disability, and
disadvantage utilize an enormous amount of police and emergency resources. They
often become targets of the police because of their unusual behavior and interaction
with police tends to make them anxious which can exacerbate their problems,
resistance, and contacts with police. Units such as the SPD CRT that pair law
enforcement and mental health professionals provide the expertise to reduce future
contacts with police and utilization of emergency and police resources by taking
steps to break the cycle through appropriate case disposition that addresses the
multiple and complex needs of these individuals.207
The quote from the researcher in Seattle shows why failing to ensure immediate on-scene
co-response is risky. When a call for help doesn’t result in on-scene co-response, a
window of opportunity to intercede can be lost for an unknown period of time. A followup worker returning through a referral by police might find a patient who is less
cooperative with caregivers. An inadequate initial on-scene response might leave a
vulnerable person in a decompensated state for days before follow-up is even attempted.
205

Evangelista, et al., op. cit.
Study in Blue and Grey, op. cit.
207
Seattle PD CRT, op. cit.
206

59

V. FOUNDATIONS FOR SUCCESS

The right response, at the right place, and at the right time can reduce suffering and even
prevent tragedies.
Co-response means de-criminalizing mental illness. This is common sense that also
reduces waste of taxpayer funds. Most importantly, this is an approach that recognizes
the needs of vulnerable citizens. Martin County Florida Sheriff, William Snyder,
successfully lobbied his state legislature for the funds to initiate a co-responder program.
In 2017, he explained why he thought this was important:
Law Enforcement officers responding to calls for service involving citizens with
mental illness and/or substance abuse challenges are fraught with dangers to both
citizen and officer. I intend to hire Master's Level Clinical Professionals licensed in
mental illness and substance abuse intervention, who will respond alongside
deputies to assist with these difficult and complex circumstances.
It is my fervent hope that this pilot program alleviates some suffering for the most
fragile among us. A compassionate community should do no less.208
Co-Responder Teams Prevent Police-Only Contacts
Support for co-responder teams to prevent police-only response is growing. In Boston, a
police-embedded co-responder team program (Boston BEST program) proved its merit to
city leaders, police officers, and the broader community. City council leaders demanded
full funding and expansion of the program.209 This is only one example of how coresponder team use has exploded across the nation in the past several years. One clear
reason is that co-responder teams put a caregiver and advocate on-scene where there
would otherwise only be police officers. That creates positive consequences.
Mayor Usha Reddi said she can “almost guarantee” that hiring the two coresponders is the best investment that the city and county has made.
“They’re literally saving lives,” she said. “Not only are they saving lives, they’re
doing a lot of follow-ups.”210
Other impressive statements of approval come from independent citizen groups focused
on police reform. The community members on the 2016 Chicago Police Accountability
Task Force issued a report with reform recommendations that included implementation
of co-responder teams.

208

Martin County Sheriff’s Office MH Co-Responder Program.
https://www.facebook.com/MartinCountySheriffsOffice/photos/a.316726388337911/1565414696802401/?ty
pe=3&theater
209
Boston MH Clinicians to Attend 911 Calls, op. cit.
210
RCPD Happy with Co-Responders. https://themercury.com/news/city/rcpd-happy-with-mental-health-coresponders/article_d1b9ee25-f94f-59d4-9843-0c781d64b2cd.html?fbclid=IwAR12GncQNvGul34pueoQycFt4aNNxCH9E0TEaLGWSL0ARrcs49-3EtahFU

60

V. FOUNDATIONS FOR SUCCESS

Recommendations: The City should create a crisis response system to support
multi-layer co-responder units where behavioral health providers are working with
OEMC and CPD to link individuals with mental health issues to treatment, 24
hours a day. While providing CIT training to police officers is a key tool for deescalating responses to mental health crises, many jurisdictions recognize the value
of also going beyond traditional police functions to more directly address the
problem of mental illness. The President’s Task Force on 21st Century Policing
recommended that law enforcement agencies “engage in multidisciplinary,
community team approaches for planning, implementing, and responding to crisis
situations with complex causal factors.” The co-responder model is one such
approach. The model’s primary component is intensive collaboration with mental
health professionals for responding to crises and persons with mental health issues
who repeatedly come to the attention of police. Police may respond in tandem with
mental health professionals, allowing them to maximize their respective skills and
better share information. Instead of simply arresting a person experiencing a
mental health crisis, these clinicians help assess whether an alternative intervention
(e.g., connecting with a social worker, getting treatment) would be more
appropriate. After an incident, a clinician may follow up with the person who
experienced a crisis. The crisis response system includes a crisis line that is staffed
by clinicians and is well-connected to other systems (like OEMC) that can respond
to mental health emergencies. Intensive training and development of this multilayer co-responder model is necessary and relies heavily on the City and its
Department of Public Health. The crisis response system should also include mobile
crisis workers that can respond and provide assessments. These clinicians may also
respond at the request of police officers, and request police assistance when needed.
The Los Angeles Police Department’s crisis response system includes co-response
teams and has become nationally recognized as a best practice.211
Black Lives Matter also advocated for the use of co-responder teams in their original
Campaign Zero plan. That draft called for reducing police use of force by using “a multidisciplinary co-responder team that includes mental health professionals, social workers,
and crisis counselors as well as specially trained police officers.”212
6.

Statutes, Medical Assistance, and Insurance Requirements

State statutes, Medical Assistance (i.e. Medicaid) rules, and private insurance rules are
important considerations for both deflection to and co-response with mental health crisis
teams. These statues and rules often create elevated requirements for worker education
and training, supervision, government oversight, and documentation of mobile crisis
care. These requirements generally exist to ensure a higher quality of mobile crisis care
for vulnerable people. However, they often conflict with the priorities of law enforcement
211

Chicago PATF Final Report, p. 124. https://chicagopatf.org/wpcontent/uploads/2016/04/PATF_Final_Report_4_13_16-1.pdf
212
Campaign Zero. https://www.joincampaignzero.org/solutions#solutionsoverview

61

V. FOUNDATIONS FOR SUCCESS

or local government, entities that typically drive reform. Creating a cheaper alternative to
using an expensive ambulance for transfers is relatively simple. But the consumer and
taxpayer might be better served by deflection and co-response options that create higherquality community-based care that qualifies for reimbursement by insurers. In fact, this is
key to the success of the Yellow Line Project in Blue Earth County, Minnesota. To justify
its community-based care reforms, the Yellow Line Project leverages both the expansion
of Medicaid coverage under the Affordable Care Act and avoidance of hospital expenses.
Effective reforms target people who are high utilizers of services with cross-system
solutions that go beyond just creating a cheaper ride to the emergency room.213 214
In Minnesota, statutes require those providing mobile mental health crisis care to be
highly educated, for example state licensed clinical social workers (LICSW).215
Further requirements include appropriate documentation, proper supervision, and
regulatory oversight by the county health department. Thus, in Minnesota, it is typical to
see master’s-level LICSWs with years of experience performing mobile crisis work. The
State of Minnesota clearly defines worker roles, employer roles, the work being done,
and the meaning of a “mobile crisis intervention team.”216 217
Only one team member must be on-site. So, mental health practitioners with the ability to
readily contact a partner can satisfy the definition of a mobile crisis intervention team
when performing co-responder field work with a police partner.218 Some alternative
response options used in other states are not acceptable under Minnesota statutes which
prescribe higher levels of supervision and training.
B. Considerations for Rural Areas
Practical limitations exist for collaborations between police and mental health
professionals in rural areas. Logistics and scarcity of resources affect most efforts. Still,
there are options for promoting collaboration and avoiding the “separate silos”
paradigm.
1.

Dispatch Triage and Alternative Response

Dispatch triage can and should be attempted in rural areas. The benefits of collaborating
are only increased where the logistics of responding to calls is more difficult.
2.

Rural Co-Response

In rural areas, we recognize that lower call load, logistics, and resource limitations can
prevent the use of standing co-responder teams. It is useful to have a formalized
agreement for police and mental health professionals to co-respond on some calls. It is
213

Yellow Line Project, op. cit.
Yellow Line Project Jail Project Priorities, op. cit.
215
MN Statute 256B.0624, op. cit.
216
Ibid.
217
MN Statute 245.462, op. cit.
218
MN Statute 256B.0624, op. cit.
214

62

V. FOUNDATIONS FOR SUCCESS

also useful to consider co-location and, if necessary, the use of technology to facilitate
collaboration.
3.

Co-Location

Co-location refers to having non-police mental crisis response teams responding from the
same building that houses the 911 call center and/or a policing agency. It is especially
useful in rural communities where low call volumes and logistics might otherwise
promote a separate silo paradigm. Co-location can enable deflection and make coresponse more convenient. When law enforcement officers serve large areas, they cannot
afford to respond to calls where they are not necessarily needed. Co-location can help
identify opportunities for deflection to mental health clinicians at dispatch. It also allows
law enforcement and mental health professionals to routinely consult and train together.
Locally, one can see examples of co-location in Washington County and Scott County.219
220
Co-location enables more collaboration generally, but should definitely be leveraged
to increase deflection of calls and co-response.
4.

Telepsychology for Rural Collaboration

Jurisdictions with low population density are increasingly utilizing telepsychology (a.k.a.
telemental health).
Key benefits to telemental health include savings in time, money and travel
(Khalifa et al., 2008). These benefits may be particularly felt in rural or remote
locations where the time and financial costs associated with patient transportation
to facilities are typically higher than in urban areas; this was borne out in an
Australian study which piloted an effective service to provide 24 hour access to
mental health specialists via video-link (Saurman et al., 2011).221
While in-person care by a licensed clinical social worker is more appropriate for 911 calls
involving persons in mental health crisis, telepsychology can help where the alternative
is a police-only response. The danger is that this tool will be abused as a rationale for
unnecessarily avoiding deflection and co-response options. Telepsychology has a history
in basic counseling services but not in mobile mental health crisis response. Communities
should carefully evaluate how telepsychology will be applied in any local initiative.

219

Washington County Crisis Response Unit. https://kstp.com/medical/new-crisis-response-unit-inwashington-county-helps-answer-mental-health-crisis-calls/5249677/
220
Scott County Mental Health Crisis Response.
https://www.swnewsmedia.com/shakopee_valley_news/county-mental-health-change-exposes-largeneed/article_7133a52c-b45a-5bfd-9a36-c1770fbc1bd8.html
221
MH Interventions: What Works?
https://www.gov.scot/binaries/content/documents/govscot/publications/research-andanalysis/2018/08/works-collaborative-police-health-interventions-mental-healthdistress/documents/00537517-pdf/00537517-pdf/govscot%3Adocument/00537517.pdf

63

V. FOUNDATIONS FOR SUCCESS

Not all clients or interventions are appropriate for teletherapy services. It is
important that you identify criteria for clients who are appropriate for this kind of
intervention and carefully screen clients to ensure they meet these criteria. Clients
who are high risk or who need extensive support between sessions are not likely to
be good candidates for teletherapy.222
The American Psychological Association has developed its Guidelines for the
Practice of Telepsychology.

Guideline 7. Psychologists are encouraged to consider the unique issues
that may arise with test instruments and assessment approaches
designed for in-person implementation when providing telepsychology
services.223
Although some studies have shown that telepsychology has similar benefits to person-toperson contact for therapy, those studies do not apply to 911 psychiatric calls. 224
Clearly, the technology can be very useful for basic consultation and coordination of
services – a triage desk function. This is certainly better than having police default to a
transfer to the nearest hospital emergency room.
Thus, the decision to use telepsychology should not rest on expediency and cost savings,
but rather be based on creating the best possible care under the circumstances. It should
never be abused for the purpose of avoiding on-scene co-response or deflection to
alternative responders when those options are appropriate.
C. Start-Up Resources for Evidence-Based Approaches
Implementing alternative responses and co-responses can be daunting. Fortunately, there
are well-established resources for information-gathering and start-up planning. Using
these resources saves time and money by helping communities apply proven practices
and models.
Planners should seek technical assistance from objective expert sources like those listed
below. This is key to steering project designs toward evidence-based approaches. When
decision-makers create initiatives that are based on existing models, their communities
can have more confidence in the outcomes.
Planners must also bring together stakeholders from the community, issue advocates,
and professionals in partnership to ensure that plans reflect local needs and values. These

222

Managing Risks of Telepsychology. https://nationalpsychologist.com/2018/08/managing-risks-oftelepsychology/104807.html
223
Guidelines for the Practice of Telepsychology. https://www.apa.org/pubs/journals/features/ampa0035001.pdf
224
Does Telemental Health Alter the Experience? https://psycnet.apa.org/record/2008-00950-018

64

V. FOUNDATIONS FOR SUCCESS

partnerships can create the political momentum needed to overcome resistance and
enable bold reform.
The entities listed below can assist in creating patient-centered programs for alternative
response, co-response and 911 dispatch triage. They provide technical assistance in the
design, planning, and start-up of collaborative projects that reduce police-only contacts.
1. Advocates Inc. of Massachusetts – Technical Assistance Center
Advocates Incorporated has been working with local law enforcement agencies since
2003 to create collaborative initiatives. This is a mental health services organization
applying clinical expertise to develop highly patient-centered collaborations with law
enforcement. They have a strong focus on creating alternative responses and multijurisdictional programs. They also have much experience with on-scene collaborative coresponse teams based at police departments for rapid response. Advocates Inc. excels at
assisting with program replication.225 226
2. Law Enforcement Learning Sites
The United States Department of Labor, Bureau of Justice Assistance (BJA) created
several Criminal Justice Mental Health Law Enforcement Learning Sites.227 At these
sites, communities can study the operation of active criminal justice diversion programs.
They offer direct assistance in the planning and implementation of reform initiatives at
other police departments. Police administrators and supervisors often travel to learning
centers to examine collaborative practices in actual use.
Arlington (MA) Police Department
The Arlington Police Department is a BJA designated learning site serving a
suburban, medium-sized jurisdiction. They have several points for
diversion, including a police-based mental health co-responder team
option.228
Houston Police Department
Houston’s police department has a long history of collaborating with the
mental health provider system. This large agency has a fully developed
multi-level structure to improve outcomes for persons with mental illness.
The HPD has assisted many other agencies including the Duluth Police
Dept. Typically, HPD hosts visiting officers, but HPD has actually sent their
own police supervisors to other cities to assist start-ups.
225

Advocates Jail Diversion Program Tool Kit. https://mn.gov/dhs/assets/czech-advocates-jds-manual12_tcm1053-256994.pdf
226
Advocates Jail Diversion Program Impacts. https://www.advocates.org/services/jail-diversion/jaildiversion-program-impact-outcomes
227
CSG Law Enforcement MH Learning Sites. https://csgjusticecenter.org/projects/police-mental-healthcollaboration-pmhc/law-enforcement-mental-health-learning-sites/
228
CSG Law Enforcement MH Learning Site-Arlington PD. https://csgjusticecenter.org/projects/policemental-health-collaboration-pmhc/law-enforcement-mental-health-learning-sites/arlington-policedepartment/

65

V. FOUNDATIONS FOR SUCCESS

Houston’s mental health co-responder team program is called Crisis
Intervention Response Teams (CIRT).229 HPD’s form of dispatch triage
through the Crisis Call Diversion Program began in 2015.230
Los Angeles Police Department
For over 30 years, the LAPD has been at the vanguard of innovation in how
police handle contacts with persons living with mental illness. It is a busy
BJA learning site. It is the agency that created the first mental health coresponder team program (called SMART) in the U.S.231 232 233 234

229

CSG Law Enforcement MH Learning Site-Houston PD, op. cit.
Harris County Crisis Call Diversion Program.
https://www.houstontx.gov/council/committees/pshs/20151119/911diversion.pdf
231
LAPD Unit Praised, op. cit.
232
LAPD Mental Evaluation Unit September 2016, op. cit.
233
LAPD Mental Evaluation Unit, op. cit.
234
In LA a National Model, op. cit.
230

66

VI. SPECIFIC APPROACHES FOR SUCCESS

VI. SPECIFIC APPROACHES FOR SUCCESS
Community members and decision-makers should challenge themselves to look beyond
separate silos approaches. This section briefly summarizes some of the approaches for
creating deeper law enforcement/mental health professional collaborations and
deflections. This survey of approaches is intended to encourage the reader to further
explore the means of enabling deflection to or co-response with mental health crisis
teams in lieu of police-only contact. Whenever possible, communities should be provided
with both alternative response options and co-response services.
A. Deflection and Prevention Before the Call to 911
While we recognize the importance of investment and reform in this area, the scope of
this paper does not include these efforts.
This paper focuses on contacts made in the window from 911 call intake to the arrival of
a police officer on scene. This scope does not cover the necessary and commendable
efforts to prevent the use of the 911 systems for mental health crises. Those efforts are
extremely important, and this discussion is not an endorsement for using the 911 system.
B. Dispatch Triage—Examples
Dispatch triage is described above and is in use in many places with little fanfare or
public attention. Dispatch triage is key to preventing police only response through better
use of alternative response and co-response options. This practice must be conducted
within 911 call centers, rather than downstream at police dispatch. There will be
significantly less deflection of calls to alternative responders if triage decision-making is
pushed downstream to police dispatchers and police administrators. The merits of
dispatch triage are described in section V. What follows are a few examples of dispatch
triage in practice.
1.

Ramsey County Deflection to County Crisis Response Team

Since starting this practice in 2017, the Ramsey County Emergency Communications
Center has generated nearly ten times more deflections to alternative services than before
the practice started.235 236 The system effectively deflects mental health-related calls to
Ramsey County’s mobile mental health crisis teams. As described in section V, 911
dispatchers can now immediately involve dispatchers for the county mobile crisis
response team on calls involving mental illness. The crisis team dispatchers help
determine if their teams can respond alone or with police backup. This is the only
dispatch triage effort in Minnesota and is a national leader because it deflects calls at the
highest possible level (Sequential Intercept Model, Level 0 diversion).

235
236

Ramsey County 911 New Approach, op. cit.
Brian Theine, MPCA Critical Issues Forum, op. cit.

67

VI. SPECIFIC APPROACHES FOR SUCCESS

2.

Abilene (TX) Deflection to Crisis Response Teams

Here the 911 dispatchers can create a 3-way conference connection with crisis response
team dispatchers to enable a non-police response for mental health-related calls for
service. In this area, the Betty Hardwick Center can respond with a Mobile Crisis
Outreach Team of clinicians if no police involvement is necessary.237 Alternatively, they
can opt for a brand new co-response option using new 3-person crisis response teams
comprised of an officer, clinician, and EMT.238 239
3.

Harris County 911 Crisis Call Diversion Program

The goal of this program is to have dispatchers identify and refer all qualifying and
eligible non-emergency mental health-related calls for immediate connection to a Harris
County Public Mental Health System phone counselor. To do this, mental health
counselors are physically located at the Houston 911 call center. These bachelor-level
mental health workers can provide counseling on the phone, initiate a non-police care
response, or verify that a co-response is appropriate. The Houston Police Department
CIRT (Crisis Intervention Response Team) program includes co-responding mental
health workers for such a situation. The CIRT program has in-person co-response and a
virtual co-response with clinicians consulting via iPads.240 241 It should be noted that we
do not believe telepsychology is an adequate response for more serious mental crisis
calls. This call diversion effort fits within a mature multilayered response scheme that
has other specialty services. Other services can be summoned from the Chronic
Consumer Stabilizing Initiative (CCSI) and the local Homeless Outreach Team (HOT). In
Harris County they have deflected tens of thousands of calls away from a police
response.242
4.

Mental Health Nurses in U.K. Emergency Call Centers

The U.K.’s national Street Triage effort has transformed crisis response in that country to
prevent police-only responses and an urgent need to reduce Section 136 mental health
holds by police.243 244 245 Unlike the U.S., their evolution to a standard for deflection away
from police-only response occurred relatively rapidly, benefited from high-quality ongoing academic study, and has seen universal support from law enforcement. In some
237

Abilene 911 Program, op. cit.
Behavioral Advisory Team. https://ktxs.com/news/local/behavioral-advisory-team-to-change-howmental-health-emergencies-are-handled
239
Abilene 911 Program, op. cit.
240
Harris Center CIRT. https://www.theharriscenter.org/Portals/0/CIRT.pdf
241
Harris County iPads. https://www.houstonpublicmedia.org/articles/news/indepth/2018/07/26/297294/ipads-could-change-how-harris-county-deputies-assess-mental-health-crises/
242
Harris County Crisis Call Diversion, op. cit.
243
Street Triage Services in England.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465222/pdf/S2056469418000621a.pdf
244
Street Triage Evaluation.
https://www.ucl.ac.uk/pals/sites/pals/files/street_triage_evaluation_final_report.pdf
245
Street Triage and Detentions, op. cit.
238

68

VI. SPECIFIC APPROACHES FOR SUCCESS

parts of the U.K., mental health nurses are embedded in emergency communications
centers and work closely with law enforcement officers.246 247 In the U.K., the Street
Triage model has utilized both two-person officer/clinician teams, and three-person
teams with a dedicated officer, mental health professional, and EMT responding in a
special van.248 249
5.

Dallas Deflects at 911 to RIGHT Teams to Avoid Police Response

The Dallas RIGHT Teams program is noteworthy because it has deflection at the highest
level of 911 call intake and utilizes personnel capable of responding to true psychiatric
emergencies. A clinician is embedded in 911 call centers to manage the response to
mental health-related calls.250 RIGHT teams then respond to these calls instead of police
and ambulances. Like the U.K. Street Triage model, this program has 3-person teams
comprised of a dedicated officer, mental health professional, and an EMT.251
6.

Other Examples of Dispatch Triage at 911 Emergency Call Centers

Other examples exist in the U.S. and internationally with wide variation in what calls are
eligible for deflection away from police-only response and what kind of personnel are
used in the alternative response. We support programs that utilize highly qualified
personnel capable of handling psychiatric emergencies. This is because supplanting a
police-only response is not the only consideration. The alternative response should truly
address the needs of the person in mental health crisis.
Existing co-responder teams across the nation are sometimes empowered to respond to
mental health-related 911 calls in lieu of a police-only response. Sometimes this is done
by direct assignment from 911 dispatchers. In some cases, co-responder teams monitor
police dispatch and self-assign to calls that have a mental health component.252
C. Alternative Responders—911 Mental Health First Responders
Communities considering alternative response models must advocate for approaches
designed to provide high quality mental health services and guard against schemes that
serve only to reduce budgetary stress on ambulance services, emergency rooms, and
policing agencies. These stressors are often the reason the status quo breaks down to
enable some 911 calls to be deflected to alternative responders. However, there are
consequences for adopting the “bargain plan” by substituting outreach workers or other
poorly qualified individuals for licensed clinical social workers. If people in mental

246

Avon and Wiltshire MH Partnership, op. cit.
Devon Street Triage. https://youtu.be/q2La-Hq3xB0
248
Nottinghamshire Street Triage, op. cit.
249
Nottinghamshire Street Triage Model. https://youtu.be/J3sJ0xMVEzQ
250
Program Pairs Counselors with Cops. https://www.dallasnews.com/news/2018/01/24/program-pairscounselors-with-cops-to-better-handle-mental-health-calls-in-southern-dallas/
251
Senator Praises Dallas Program, op. cit.
252
Baltimore County Crisis Response. https://www.thesantegroup.org/baltimore-county-crisis-services
247

69

VI. SPECIFIC APPROACHES FOR SUCCESS

health crisis are not given the on-scene assessment and services they need, they can fall
through the cracks and become “frequent flyers.”
1.

Ramsey County Mental Crisis Response Teams

The number of calls deflected from police-only response increased tenfold with the
initiation of dispatch triage at the local 911 call center in 2018. See section V for a detailed
description of the collaborative procedure used by 911 dispatchers to hand off calls to the
county team. Ramsey County has the first true application of dispatch triage in
Minnesota, despite the state’s well-developed system of county mobile mental crisis
response teams.
In terms of quality, Minnesota mobile crisis response teams are unmatched. They are a
tremendous asset and the ideal foundation for adding new dedicated 911 mental health
first responder capacity. Ramsey County has proven this. The list of advantages is worth
repeating:


High prevalence of master’s-level, licensed clinical social workers (LICSW)
with years of education and experience in mental health care, who are capable
of professional on-scene assessments.



A team of county mental health personnel whose care and care coordination
are aided by having access to public health records.



Personnel whose credentials enable them to seek certification as Rule 25
Assessors. This means they can help indigent persons with co-occurring
substance abuse disorders get access to publicly-funded treatment services.



Better care coordination, case management, and integration. The skilled clinical
social workers operating within the county health department are well placed
to coordinate follow-up care, wraparound services, and case management.

Many of the benefits are a direct result of using licensed clinical social workers (LICSW)
on the county crisis response teams. These professionals offer competencies in mental
health care combined with the social work skills needed for persons who are high
utilizers of services. A licensed clinical social worker is a professional who has earned a
master’s degree, spent 4000 hours in supervised clinical settings, and passed a
challenging state licensing exam.253
To invest in this optimal approach, communities must invest in dedicated mental health
crisis response teams to handle the increased workload resulting from calls deflected
away from police. In Minnesota, the safest investment would be beefing up the existing
county crisis response team infrastructure to meet the need.

253

MN LICSW Licensing Requirements, op. cit.

70

VI. SPECIFIC APPROACHES FOR SUCCESS

2.

Psychiatric Emergency Response Team (PAM)—Stockholm

In 2015, Sweden’s care services introduced a response unit that might be a preview of
what Minnesota could create by expanding its county mental health crisis team system.
The Stolkholm-based Psychiatric Emergency Response Team (in Swedish: Psykiatrisk
Akut Mobilitet [PAM]) is the world’s first psychiatric ambulance service.254 The unit is
tasked with “responding to emergency calls regarding persons in severe mental health or
behavioral distress, with suicide prevention as the main priority.”255
“We help people who are suicidal and people who suffer from severe mental
illness,” says mental health nurse Anki Björnsdotter. And adds, “It can be someone
who is manic and not aware of their own mental state, such as a person who needs
to go to a hospital without realizing they need to. Also, people who are psychotic
and people suffering from schizophrenia who haven’t taken their medicine and are
in distress.”256

254

World’s First MH Ambulance, op. cit.
PAM Follow Up, op. cit.
256
World’s First MH Ambulance, op. cit.
255

71

VI. SPECIFIC APPROACHES FOR SUCCESS

Photos from PAM Follow Up.
https://www.tandfonline.com/doi/full/10.1080/00207411.2016.1264040

The PAM teams consist of two psychiatric nurses and a paramedic.257 The paramedic is
available to determine if there are any medical conditions contributing to the situation.
They get direct call assignment from the Emergency Call Center (ECC) in Stockholm
County.258 Each call gets assigned a priority level by the dispatcher to indicate the level of
crisis. The highest level is assigned Priority 1. Because this indicates there is a suicide
attempt or serious threat, the vehicle must respond rapidly with the blue lights of their
specialty ambulance on. The response times are very good. Priority 1 calls have an
average response time of only 15 minutes. Priority 2 calls have medium risk of self-harm
and the Priority 3 calls usually only require a transport to services.259
PAM was designed to respond to true psychiatric emergencies and those are the bulk of
its contacts. In their first year 51% of the calls were Priority 1 calls and 46% were Priority
2 calls.260
It takes highly qualified mental health professionals to successfully (and ethically) serve
persons in this level of crisis. The PAM psychiatric nurses have experience, specialized
training, and hold master’s degrees.261 Their qualifications and experience would satisfy
Minnesota standards for workers performing “mental health mobile crisis intervention
257

Sweden Dedicated MH Ambulance. https://vt.co/news/world/sweden-unveiled-amazing-dedicatedmental-health-ambulance/
258
PAM Follow Up, op. cit.
259
PAM Follow Up, op. cit.
260
PAM Follow Up, op. cit.
261
Patient Experiences with PAM. https://onlinelibrary.wiley.com/doi/pdf/10.1111/hex.13024

72

VI. SPECIFIC APPROACHES FOR SUCCESS

services.”262 These mental health professionals are part of the larger care system and
have access to patient medical records using a computer with mobile records access.
The specialty ambulance is designed as a space for counseling with a comfortable, clean
space and four rotatable chairs.
During missions, the staff can wirelessly access the patient’s journal through this
identification number. All the public hospitals in Stockholm County share the same
system for medical records. This enables the staff to receive medical background
before seeing the patient.
Assessment often takes place in the PAM vehicle. The staff can ask for a voluntary
alcohol breath test when it seems relevant. … A patient in need of further
assessment and inpatient care will be transported by PAM and admitted to the
appropriate emergency department (psychiatric, somatic, or substance use ED). In
Stockholm County, PED is separated from substance abuse ED, the latter
traditionally handling drug induced psychosis and acute alcohol-related medical
conditions like abstinence and alcohol induced delirium.263
The psychiatric nurses frequently collaborate with others. They can communicate with
psychiatrists in the psychiatric emergency room and sometimes request police assistance
with persons who are agitated.264
Researchers found that service delivery is very patient centered.
…the PAM team created good conditions for the patients to participate in the care
by being empathic, communicating in a calming way, and working to gain trust
and understanding in the situation that had caused the psychiatric emergency. The
PAM also invited the patients' next of kin, when present, to participate in the care.
Altogether, the caring delivered by the PAM team resulted in outcomes that were
attuned with the patients' needs and wants.265
3.

CAHOOTS Teams—Eugene, Oregon

The well-publicized CAHOOTS Program of White Bird Clinic in Eugene, Oregon has
mobile teams comprised of an EMT and a crisis intervention worker. The sizeable local
homeless population makes up most, but not all the contacts.266

262

MN Statute 256B.0624, op. cit.
PAM Follow Up, op. cit.
264
PAM Follow Up, op. cit.
265
Patient Experiences with PAM, op. cit.
266
Helping People in Crisis. https://www.registerguard.com/rg/opinion/36272835-78/helping-people-incrisis.html.csp
263

73

VI. SPECIFIC APPROACHES FOR SUCCESS

The relatively large homeless populations in the area have much to do with the creation
and growth of CAHOOTS. Oregon has the second-highest rate of unsheltered
homelessness in the county, at 61.7%. Eugene leads the nation in the number of homeless
people per capita.267 The Eugene-Springfield area has the second-largest concentration of
unsheltered homeless persons, by rate and raw numbers, among its category of urban
area. The local concentration for Eugene/Springfield/Lane County is so great that Lane
County, with 8.9% of the state population, has 18.4% of the state total unsheltered
homeless population.268
The homeless population is also highly concentrated in the downtown area of Eugene. In
2016 the Eugene Police Department began a “hotspot enforcement” effort in response to
aggressive panhandling, open drug use (including methamphetamine), and fights. The
department also began a Community Outreach Team effort in partnership with both
White Bird Clinic and Lane County Behavioral Health.
The recent “hot spot” enforcement and the outreach team, which started in April
and was only publicly announced recently, are separate initiatives of the police
department.

267

Eugene Makes National Headlines. https://www.kezi.com/content/news/Eugene-makes-nationalheadlines-for-homeless-crisis-509933051.html
268
HUD 2018 Report to Congress. https://files.hudexchange.info/resources/documents/2018-AHAR-Part1.pdf

74

VI. SPECIFIC APPROACHES FOR SUCCESS

For about five hours every Thursday, the team looks for and talks with downtown’s
most chronic offenders, those individuals whom the police department makes the
most contacts with.269
The Eugene Police Department was experiencing huge increases in welfare checks, such
as an increase of 55.8% in 2016.270 This was happening in a state that was ranked very
low in social services and mental health services delivery.
A U.S. Department of Justice investigation in 2014 found Oregon institutionalized
too many people with mental illness, the department alleged. The state needed to
pivot to more cost-effective community-based approaches.
Chris Bouneff, director of the Oregon chapter of the National Alliance on Mental
Illness, puts it more bluntly. Too much goes to prisons and psych wards, not
enough to clinics and housing.
“There isn’t a jail in this state that isn’t overwhelmed by mental health issues,”
Bouneff says. “That’s because we’ve failed on the healthcare side.”271
Then in 2017, a consultant hired by the city reported that the large, highly concentrated
downtown homeless population has put the neighborhood in crisis and is the worst
homelessness situation that the New York-based firm had ever seen. The consultant also
reported that many local residents felt intimidated and unsafe when walking
downtown.272 273
The consultant’s report was followed a few months later by an article in the Eugene
Weekly spotlighting the effects of the police “hotspot enforcement.” Their analysis of
public records revealed that police were issuing many citations for trespassing, illegal
camping, and parking violations. The data showed that 25% of non-traffic violations and
35% of court cases involved homeless persons.274 The Eugene Police responded by
further expanding their existing partnership with White Bird Clinic’s CAHOOTS
program. CAHOOTS teams began to be “dispatched in Eugene through the nonemergency police call center.”275
Thus, the CAHOOTS program joined a relatively short list of programs that benefited
from high-level dispatch triage. The CAHOOTS program has been growing and
269

Eugene Worst Homelessness. https://www.bendbulletin.com/nation/eugene-police-chief-says-homelessproblem-worst-he-s-seen/article_f9a1dc5f-1fb3-5ad9-a7c7-02194ee0a360.html
270
Eugene Police Service STATS 2016. https://www.eugene-or.gov/archivecenter/viewfile/item/4801
271
Mental Math. https://www.oregonbusiness.com/article/health-care/item/18330-mental-health
272
Downtown Eugene in Crisis. https://www.seattletimes.com/seattle-news/downtown-eugene-in-crisisconsultant-says/
273
Lane County Shelter Feasibility Study.
https://lanecounty.org/UserFiles/Servers/Server_3585797/File/HSD/Lane%20County%20Final%20Report_
1.14.19.pdf
274
Criminalizing Homelessness. https://www.eugeneweekly.com/2017/06/01/criminalizing-homelessness/
275
CAHOOTS FAQ. https://whitebirdclinic.org/cahoots-faq/

75

VI. SPECIFIC APPROACHES FOR SUCCESS

expanding with an offshoot in neighboring Springfield and program replication in other
West Coast cities struggling with large homeless populations. Much of this growth can
be attributed to news coverage by the Wall Street Journal and CBS News. The approach
is generally sold on its merits as a very low-cost operation that helps avoid the use of
expensive ambulance services and the costs of police response.
Some avid allies of this program have had to refute the veracity of estimated cost savings
of the CAHOOTS program.276 With CAHOOTS, the emphasis on cost savings has mostly
obscured any consideration of whether the program is an adequate or appropriate
alternative response for complicated calls involving psychiatric emergencies. The
marketing appears to be getting ahead of larger questions about how to replace police
response with an appropriate mental health crisis response.
CAHOOTS teams provide multiple levels of service. Some of their services are typical of
what outreach teams would do. However, the teams are also expected to care for persons
affected by drug use and mental illness. The crisis intervention worker on a CAHOOTS
team is expected to perform “mental health assessments” and “crisis counseling” on their
own in the field.277 However, a posting for this job on the employer’s webpage shows the
pay is $15/hour, a college degree is not required, and only two years of related
experience is required.278 In essence, CAHOOTS workers have qualifications for a wellrun street outreach program but are not qualified mental health professionals. 279 280
In Minnesota and most locales, persons employed to provide “mental health mobile crisis
intervention services” are required to have a master’s degree in a behavioral science and
satisfy separate statutory requirements to perform clinical mental health assessments. 281
282 283

Why CAHOOTS is Not the Solution for Mental Health Crises
Communities must prioritize a true mental health care response to psychiatric
emergencies using highly qualified professionals over instincts to provide the cheapest
possible service. CAHOOTS is that cheapest possible service–not the right person, at the
right place, and at the right time to deal with true psychiatric emergencies. This goal is as
important as simply preventing police-only contacts.

276

Eugene Budget Committee Meeting 5/23/18. https://youtu.be/wYCcYwVT6bw
CAHOOTS Crisis Intervention Job Description. https://whitebirdclinic.org/job-postings/
278
Ibid.
279
CAHOOTS Worker Audio Interviews. https://youtu.be/kbhpjGTybK4
280
Street Outreach Worker Job Posting.
https://www.indeed.com/viewjob?jk=73f67fc06a73335e&tk=1e0p80r3vp9p7800&from=serp&vjs=3
281
MN Statute 256B.0624, op. cit.
282
Crisis Clinician/Practitioner Job Posting.
https://www.indeed.com/viewjob?jk=da003adc51f7a2da&q=mobile+crisis&l=Ramsey+County,+MN&tk=1e0
p862lbp9p7801&from=web&vjs=3
283
Senior Psychiatric Social Worker Job Posting.
https://www.indeed.com/viewjob?jk=731a72b7b6411d7d&tk=1e0p83antp9p7800&from=serp&vjs=3
277

76

VI. SPECIFIC APPROACHES FOR SUCCESS

Having highly qualified mental health professionals respond in real time with on-scene
care prevents unnecessary transfers, reduces system burdens, and enables better
outcomes. Response by lesser- qualified individuals misses most of the long-term
benefits of avoiding police-only response. Using CAHOOTS-style programs to respond
to mental health crises puts the disposition of patients in the hands of persons who are
only marginally more qualified to understand mental illness than well-trained police
officers. Patients will not benefit from the improved outcomes that researchers have
shown to be the result of placing highly qualified clinicians on-scene. Furthermore,
services by underqualified non-professionals are not reimbursable by Medicaid and other
payers.
In Minnesota, the county mobile mental crisis response teams (e.g. COPE teams in
Hennepin County) have the necessary expertise to maximize the return on investment in
an alternative response.284 That return on investment can be measured in tax dollars and,
more importantly, in improved outcomes for patients. In contrast, the CAHOOTS
approach has not been studied by academic researchers to validate cost savings or
outcomes for patients.
Despite its limitations in responding to mental health crises, CAHOOTS-style programs
offer some value as part of a multi-layered response system to link people to resources in
the community. But such programs cannot replace an appropriate, qualified mental
health crisis response.

284

MN Statute 256B.0624, op. cit.

77

VI. SPECIFIC APPROACHES FOR SUCCESS

78

COMPARING POTENTIAL 911 MENTAL HEALTH FIRST RESPONDERS
RAMSEY COUNTY MOBILE
RESPONSE TEAMS

COPE
Teams
(Hennepin Co)

PAM
Teams
(Sweden)

RIGHT Teams
Program
(Dallas)

CAHOOTS
Teams
(Eugene, OR)

Public Entity
Alternative to Police
Response

Public Entity
Alternative to Police
Response

Public Entity
Alternative to Police
Response

Police/EMT/MH Professional
Team
(type of co-response)

Private Entity
Alternative to Police
Response

Dispatched by 911 to
Deflect from PD Contact

YES
Dispatch Triage At 911
Communications Center

NO
Local Resistance to Dispatch
Triage

YES

YES

NO
Calls referred via “police nonemergency dispatcher”

Mental Health Workers
Can Do Assessments and
On-Scene Care

YES
Master’s-level clinicians with
state licenses. Satisfy MN
statutory requirements.

YES
Master’s-level clinicians with
state licenses. Satisfy MN
statutory requirements.

YES
Master’s-level psychiatric
nurses

YES

Not by MN standards. Most
workers have little relevant
education and training.

Rapid Response
Alternative to Police
For Non-Criminal Contacts

Unknown
Funding for a dedicated team
serving 911 calls would be
advised.

Requires new dedicated
teams to ensure availability &
response time

YES
Ave. 15 min. response time to
Priority 1 calls.

YES

YES
“A mobile social service.”

Can Handle Psychiatric
Emergencies Including
Suicides

YES
Highly qualified employed
licensed master’s-level clinical
social workers. Qualifications
meet MN statutory
requirements.

YES
Highly qualified employed
licensed master’s-level clinical
social workers. Qualifications
meet MN statutory
requirements.

YES
Highly qualified psychiatric
nurses – would meet MN
statutory requirements

YES

Not by MN standards.
Most workers do not have
the education and training.
Most Common Calls:
1) Public Assistance (66.3%)
2) Transport to Services
(34.8%)
3) Welfare Checks (32.5%)

YES
Workers are experienced
mobile crisis workers and
clinical social workers within
the county system. Have
expertise to certify for Rule
25 Chemical Dependency
Assessments.

YES
Workers are experienced
mobile crisis workers and
clinical social workers within
the county system. Have
expertise to certify for Rule
25 Chemical Dependency
Assessments.

Unknown

Unknown

Not by MN standards.
Most CAHOOTS workers have
minimal formal training and
relevant education.

Private or Public Entity

Expertise for Co-Occurring
SUD and Getting Rule 25
Chemical Dependency
Assessment.

VI. SPECIFIC APPROACHES FOR SUCCESS

79

YES
County-employed licensed
master’s-level clinical social
workers. Part of existing care
integration efforts in an
established care system.

YES
County-employed licensed
master’s-level clinical social
workers. Part of any existing
care integration efforts.

YES
Mobile com-link access to
healthcare records and also
allows live consults with
psychiatrists.
Records are often reviewed
before reaching a patient.

YES

Local system almost nonexistent prior to 2018. White
Bird Clinic won county
funding as the only bidder to
provide contract social
services for Lane County.
White Bird Clinic offers
medical and dental services in
addition to CAHOOTS.

NO

NO, but new dedicated teams
could

YES
Paramedic

YES

YES. Most have only basic
EMT-B level skills.

Coordinating Wraparound
Services and Case
Management

YES
Experienced and capable.
County-employed licensed
master’s-level clinical social
workers.
County employer also has
established tier of workers
who assist with wrap around
services and do case
management.

YES
Experienced and capable.
County-employed licensed
master’s-level clinical social
workers.
County employer also has
established tier of workers
who assist with wrap around
services and do case
management.

NO

Unknown

YES
Workers generally have
experience with outreach
work and good knowledge of
how to tie persons to
services. Some case
management is done through
White Bird Clinic.

Spends Time Needed Per
Call to Create True
Community-Based Care
for Mental Health Crisis

YES

YES

YES
Calls typically take more than
1 hour and teams average 3.4
calls per day.
Expertise prevented
unnecessary transfers; 78% of
patients transferred were
admitted for inpatient
psychiatric care.
Local psychiatric ER reported
significant drop in visits after
PAM.

YES
Has created a 23% drop in
ambulance transfers.

“The two-person teams that
staff each van respond to an
average of about 15 to 16
calls in a 12-hour shift in
Eugene, although it can be as
many as 25 calls per shift”

YES

YES
The model is very wellresearched in the UK where it
is in common use.

Part of Larger Care System
(incl. access to records)

EMT is Part of the
Response Team

Reviewed by Independent
and Academic
Researchers

YES

YES

Counseling provided in 15%
of calls.

NO
Only data is the contract
private operator’s estimates
of cost savings for local
government. Accuracy has
been refuted by program
allies.

VI. SPECIFIC APPROACHES FOR SUCCESS

80

1. Program Pairs Counselors with Cops Dallas. https://www.dallasnews.com/news/2018/01/24/program-pairs-counselors-with-cops-to-better-handle-mental-health-calls-in-southern-dallas/
2. CAHOOTS FAQ. https://whitebirdclinic.org/cahoots-faq/
3. Senior Psychiatric Social Worker Job Posting. https://agency.governmentjobs.com/hennepin/job_bulletin.cfm?jobID=2020787&sharedWindow=0
4. CAHOOTS Crisis Intervention Worker Job Posting. https://web.archive.org/web/20161111172544/http://whitebirdclinic.org/job/cahoots-crisis-intervention-worker
5. Mobile Crisis Intervention - Brenton Gicker and Chelsea Swift. https://dointhework.podbean.com/e/mobile-crisis-intervention-brenton-gicker-and-chelseaswift/?fbclid=IwAR25J66GT1sdeLn79M1HMe_6CBiNkLHSNxJY5nTDOnJfhg69EoWedjh1ses
6. First-year follow-up of the Psychiatric Emergency Response Team (PAM) in Stockholm County, Sweden: A descriptive study.
https://www.tandfonline.com/doi/full/10.1080/00207411.2016.1264040
7. Crisis Assistance Helping Out on the Streets. http://www.mentalhealthportland.org/wp-content/uploads/2019/05/2018CAHOOTSBROCHURE.pdf
8. Lane County Mental Health Services Agenda. https://www.lanecounty.org/UserFiles/Servers/Server_3585797/File/Government/BCC/2019/2019_AGENDAS/070919agenda/T.5.C.2.pdf
9. CAHOOTS Medic Job Posting. https://web.archive.org/web/20160915221941/http://whitebirdclinic.org/job/cahoots-medic/
10. Helping People in Crisis. https://www.registerguard.com/rg/opinion/36272835-78/helping-people-in-crisis.html.csp
11. Rule 25 Assessments. https://www.northstarbehavioralhealthmn.com/what-is-a-rule-25-assessment
12. Mental Health Legislative Network Blue Book 2018. https://mentalhealthmn.org/wp-content/uploads/2017/05/2018-MHLN-Blue-Book.pdf
13. Eugene Budget Committee Meeting May 23, 2018 (at 03:12:00). https://www.youtube.com/watch?v=FM3PpOP9Np0

VI. SPECIFIC APPROACHES FOR SUCCESS

D. Post-Booking Diversion
The scope of this paper is limited to field contacts with persons living with mental illness.
However, this is a promising area of exploration.
E. Co-Location
Co-location—placing members of mental health crisis response teams in the same
physical space as law enforcement officers—is especially useful in rural jurisdictions. Colocation was adopted in Scott County to overcome the immense difficulties in
collaborating with existing crisis response teams that served two counties and were
based on the opposite side of the Minnesota River.285 Washington County, Minnesota has
also co-located their county mobile mental crisis responders with law enforcement.286
F. Co-Response Options
When police contact cannot be avoided, co-response with mental health workers offers a
stark improvement over a police-only response. Co-response puts a mental health
worker on-scene to advocate and care for a vulnerable person. Co-response has long been
an option in places which have county mobile mental health crisis response teams. But
routine co-response will not occur organically. This elevated level of collaboration is best
promoted through dispatch triage at the 911 call centers.
1.

New to the U.S.: Three-Person Officer/Clinician/EMT Co-Response Teams

When 911 emergency call centers deflect calls to a co-response option in the U.S., the
odds are that it will be a new three-person officer/clinician/EMT team. This approach
also seems more likely to get direct call assignments from 911 call centers than the
traditional police officer and clinician teams. Although new to the U.S., this approach is a
national model in the U.K. (a.k.a. Street Triage). The U.K. experience was very positive,
as described in section VI.
2.

LAPD and Houston: Very Large City Programs

The Los Angeles Police Department was a vanguard agency for co-response in the early
1990s. Their work refined the model and showed how it fit into a larger multi-level
response serving persons having mental illness. The LAPD and Houston PD are two of
the very largest programs and routinely offer other police agencies start-up assistance.287
3.

St. Paul, Gainesville, and Other Mid-Sized Programs

St. Paul police created a program that incorporates many of the lessons from the LAPD
model. They separated the co-responder teams from the patrol function by creating a

285

Scott County MH Change, op. cit.
Washington County Crisis Response Unit, op. cit.
287
LAPD Mental Evaluation Unit September 2016, op. cit.
286

81

VI. SPECIFIC APPROACHES FOR SUCCESS

Mental Health Unit.288 Like most programs, their teams have highly qualified mental
health workers supervised by a mental health provider. In Minnesota, state statutes
require that those performing mobile crisis work satisfy strict qualifications for
education, experience, and supervision.289 The St. Paul program uses master’s-level, state
licensed clinical social workers (LCSW) who can be certified to perform Rule 25
assessments.290 These clinical assessments determine appropriate chemical dependency
treatment and ensure that indigent people qualify for public funding of the treatment.291
292
This is only one example of how well-qualified workers can create better, lasting
outcomes.
Gainesville and other cities have also partnered with local mental health service
providers to create co-responder teams.293 294 295 296 297 The use of co-responders is also
common in Colorado.298
4.

Multi-Jurisdictional Programs Enable Suburbs and Smaller Cities to Share Teams

Multi-jurisdictional programs bring economies of scale and staffing flexibility to smaller
jurisdictions that would otherwise be unable to support a standing co-responder team
service. Suburbs of bigger cities are especially suited to this approach. One example is
found in Johnson County, KS. This partnership brings together 11 cities and the sheriff’s
office to serve almost the entire county.299 The county provides and supervises the
Licensed Mental Health Professionals (LMHP) and provides additional services like case
management. Partnerships like these are created by having individual jurisdictions sign
onto a common Memorandum of Understanding which lists participant responsibilities
and monetary contribution to the program. The Johnson County program memorandum
can be found and reviewed online.300

288

Embedded Social Worker SPPD. https://www.twincities.com/2018/08/01/embedded-social-workerworking-with-st-paul-police-mental-health-unit-with-a-second-starting-soon/
289
MN Board of Social Work LICSW Requirements, op. cit.
290
MN Rule 9530.6615, op. cit.
291
HC Sr Psychiatric Social Worker Job Posting, op. cit.
292
Rule 25 Assessments. https://www.northstarbehavioralhealthmn.com/what-is-a-rule-25-assessment
293
Gainesville MH Co-Responder Team. https://www.wuft.org/news/2019/04/26/gainesvilles-mental-healthco-responder-team-diverts-arrests-and-saves-taxpayers-money/
294
Civilized Approach to MI Duluth. https://blogs.mprnews.org/newscut/2019/05/a-civilized-approach-tomental-illness-pays-off-in-duluth/
295
Overland Park PD Co-Responder Program, op. cit.
296
Sending Social Workers to Answer 911 Calls. https://www.economist.com/unitedstates/2019/05/11/why-american-departments-are-sending-social-workers-to-answer-911-calls
297
Program Pairs CMPD and MH Experts.
https://www.charlotteobserver.com/news/local/crime/article224956705.html
298
Colorado Co-Responder Program. https://www.colorado.gov/pacific/cdhs/co-responder-programs
299
Co-Responder National Conference. https://shawneemissionpost.com/2020/03/12/mental-healthprofessionals-discuss-client-confidentiality-uniform-choice-funding-issues-at-first-national-co-responderconference-88360/
300
Johnson County MOU (p. 11).
https://drive.google.com/drive/folders/0B28l5JpCZgBfYTVMWnJLckRHT1U

82

VI. SPECIFIC APPROACHES FOR SUCCESS

The largest multi-jurisdictional co-responder program is undoubtedly the Psychiatric
Emergency Response Team (PERT) that serves all of San Diego County. This program
has operated for 23 years without any harm befalling a co-responding clinician. It has
also grown rapidly in size over the last several years and currently employs 70
clinicians.301 302
Massachusetts has many jurisdictions with co-responder programs including multijurisdictional efforts. Many of these programs were assisted by the provider, Advocates
Inc., which has helped police departments implement co-responder programs in
Massachusetts since 2003.303
5.

Co-Response with Officers, EMTs, and Mental Health Workers

There is growing use of three-person responses utilizing a police officer, emergency
medical technician, and mental health worker. These teams are more likely to get direct
call assignments from 911 centers because they can handle a wide variety of calls. They
can reduce burdens on ambulance services, police, and hospital emergency rooms. By
adding an EMT to the mix, the response can include an evaluation for medical issues. By
using EMTs and special vehicles, the teams can transfer individuals.
This approach became part of the national model in the U.K. following pilot trials in
2011.304 305 306 The U.K .programs are broadly grouped under the term “street triage.”
They quickly proved that having mental health workers on-scene prevented a huge
number of unnecessary transfers to U.K. care facilities. Transfers were often reduced by
50% or more.307
The Dallas RIGHT Team program began in 2018 and quickly impressed. Like its U.K.
cousin, this program was able to utilize on-scene clinician expertise to drastically cut
transfers by ambulances.308 Dallas reported a 23% reduction in the use of ambulance
transfers within the first three months of the RIGHT Teams program even though the
teams only served a fraction of the city.309
These three U.S. cities are known to use the three-person co-response model:
 Dallas RIGHT Teams
 Abilene (TX) Crisis Response Teams
 Tulsa Crisis Response Teams
301

Escondito PERT, op. cit.
San Diego Blueprint for MH Reform, op. cit.
303
Abbott Presents Research on Jail Diversion. https://www.advocates.org/news/sarah-abbott-presentsresearch-about-jail-diversion-program
304
Street Triage Services in England, op. cit.
305
Street Triage Evaluation, op. cit.
306
Street Triage and Detentions, op. cit.
307
Avon and Wiltshire MH Partnership, op. cit.
308
Houston PD Crisis Call Diversion Program, op. cit.
309
Senator Praises Dallas MH Crisis Response Program, op. cit.
302

83

VI. SPECIFIC APPROACHES FOR SUCCESS

6.

A-PACER in Victoria, AU

This is a co-response initiative that has been very well studied by researchers. The
researchers provided tremendous value to their work by including data about the
immediate outcomes for patients and their own perceptions of the collaborative
response. In comparison, researchers in the U.S. have spent much time evaluating police
officer perceptions of initiatives and relatively little time assessing patient outcomes and
perceptions of value. The Australian researchers found that having clinicians respond in
tandem with police was much preferred over a police-only response.310 Consumers also
noticed that there was much more cooperation and healthy teamwork between the
clinicians and officers when they responded together versus separately.311 When
clinicians were allowed to co-respond, researchers found that they were able to create
much more effective warm handoffs of patients to care facilities.312 Some patients noted
how the clinicians were effective in de-escalating situations and helping promote
cooperation with police.313
7.

Co-Response by Non-Embedded Clinicians (a.k.a. Separate Response)

This type of response has always been available and exists without formalized
agreements. The on-scene collaboration can result when either policing agencies or the
local provider of mobile mental health crisis services determines they need the other
entity to co-respond. This is the old status quo that has mostly failed. It is often the only
option in rural locations.
However, even when available, this option has been severely underutilized by law
enforcement.314 Even in urban areas, law enforcement has historically viewed nonembedded clinician teams as poor co-response partners due to inadequate availability
and unacceptably long response times.315 Adequate availability and response time can be
engineered with the creation of mobile crisis response teams dedicated to filling a coresponse role with police in high-density areas. Section IV has more information on the
separate response form of co-response.

310

Consumer Experience of CR Services, op. cit.
Ibid.
312
Ibid.
313
Ibid.
314
Omaha Police Have Options, op. cit.
315
Police Perspectives, op. cit.
311

84

VII. THE LABOR MARKET FOR KEY MENTAL HEALTH PROFESSIONALS

85

VII. THE LABOR MARKET FOR KEY MENTAL HEALTH PROFESSIONALS
The highly skilled workers needed to staff alternative responses are in greater supply
than other types of mental health workers. It is common knowledge that there are
shortages in some kinds of mental health workers (e.g. psychiatrists), especially in rural
areas. However, many communities currently have a surplus of the types of workers
needed to create alternative responses or co-response teams for mental health-related
calls. The primary type of worker needed for on-scene responses are licensed clinical
social workers (LICSW).
The U.S. Department of Health and Human Services, Health Resources and Services
Administration (HRSA) workforce study released in 2018 has provided state-by-state
statistics per worker type.316
HRSA data shows that, in 2016, Minnesota had 800 more such workers than jobs to
employ them. Interestingly, the study indicated that the future supply of licensed clinical
social workers would keep up with or exceed demands in almost all states through 2030.
This supply of workers can be further deepened and improved with programs that
provide tuition assistance and opportunities to gain early career experience.
The labor supply is available if communities are willing to fund alternatives to a policeonly response to mental health-related calls.

316

Behavioral Health Occupation Projections.
https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/state-level-estimates-report-2018.pdf

VII. THE LABOR MARKET FOR KEY MENTAL HEALTH PROFESSIONALS

Source: https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/state-level-estimates-report-2018.pdf

86

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

87

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED FOR QUALITY MOBILE
RESPONSE
A. Co-Occurring Conditions and Factors
People experiencing mental illness often have co-occurring conditions and socioeconomic
factors. Substance use disorder is a commonly discussed example and is typically termed
a “co-occurring disorder.”317 However, when considering the topic of law enforcement
contacts, it is important to recognize a wider spectrum of co-occurring conditions and
factors. Other examples are homelessness, autism, chronic medical diseases (e.g.
hypertension, diabetes, or asthma), domestic abuse, poverty, and unemployment.
Broader co-occurring psychosocial factors might include age and subculture.
All this added complexity can challenge emergency responders. When police respond to
persons with a complex palette of needs, there is a much greater risk of harmful
outcomes for the vulnerable community members and society as a whole. However, it is
imperative that any alternative response schemes employ professionals capable of
addressing the complex demands of co-occurring conditions and factors.
Local governments are rapidly embracing the reality that they must do a better job of
serving persons who are “high utilizers” of healthcare and behavioral health services:
High utilizers are typically vulnerable populations with complex social
components, high behavioral health needs, and multiple chronic conditions. The top
5% of individual utilizers account for about 50% of overall health care
expenditures. Due to their complicated medical needs, these patients tend to heavily
rely on ED facilities and are difficult to engage in ongoing care with primary care
providers. ED use is more expensive to the health care system than going to a
primary care physician.318
Decision-makers can create dollar savings by focusing on correcting the “disjointed
system that perpetuates inefficiencies, such as overreliance on emergency departments
(EDs).”319 Yet, one under-appreciated contribution to the overall inefficiency is the use of
police as de facto mobile mental healthcare workers. The same high utilizers in other
systems are well-known as “mental health frequent fliers” to law enforcement.320 321
When the problem of co-occurring conditions was studied by state mental health and
substance abuse directors and the National Council for Community Behavioral

317

Co-Occurring Disorders. https://www.psychologytoday.com/us/conditions/co-occurring-disorders
Targeting High Utilizers. https://ldi.upenn.edu/sumr-blog/targeting-high-utilizers-health-care
319
Ibid.
320
Integrating Public Health and Public Safety Data. https://www.policeone.com/crime/articles/researchanalysis-why-integration-of-public-health-and-public-safety-data-makes-sense-gUVAkLS5kWUVrfXD/
321
LAPD ME Unit Named Learning Site. http://www.lapdonline.org/newsroom/news_view/46481
318

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

88

Healthcare (NCCBH), the conclusion was that separate silos thinking and planning was
thwarting effective care.
Increased integration of behavioral health and healthcare services is a priority at the
national, state, local and person levels. Good public policy will work to sustain,
support and require integration of services between the two “safety net” systems of
CHCs [community health centers] and SMHA [state mental health agency]
providers with integration ranging from coordination of care to full integration of
medical and behavioral services.322 323
The NCCBH recommendation for integration of behavioral health and healthcare
services has been embraced nationally. It is recognition of the need for improvement by
breaking down silos.
Between now and 2020, the system of funding and management that we have worked
under for years will be transformed. Rather than treat substance use disorders and
mental illness as separate conditions, with separate providers and funding sources,
the trend is to offer comprehensive care that encompasses both conditions, as well as
physical healthcare. This will provide our clients with more effective, integrated care.
But it also means that every aspect of how we deliver services, and how we are
funded, will change.324
Yet, this high stakes integration trend has not overcome the silo around law enforcement,
a sector that has many critical contacts with persons in crisis and/or poorly tied to
services. Catherine R. Counts, a researcher at the University of Washington, spelled out
the problem with pursuing integration without including law enforcement:
Until silos around the healthcare and criminal justice systems are broken, it will be
impossible to fully understand the driving forces behind individuals frequenting
both systems.325
B. Care Integration Versus the Law Enforcement Silo
The integration of system services to serve those with co-occurring conditions and factors
has been enabled by the Medicaid expansion available through the Affordable Care Act

322

Integrating Behavioral Health and Primary Care.
https://www.integration.samhsa.gov/workforce/Final_Technical_Report_on_Primary_Care__Behavioral_Health_Integration.final.pdf
323
Rule 25 Assessments, op. cit.
324
Building Hope One By One. https://www.glmhc.org/wpcontent/uploads/2016/11/Greater_Lakes_Connections_2016.pdf
325
Integrating Public Health and Public Safety Data, op. cit.

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

89

(ACA) of 2010.326 The ACA created insurance coverage for large numbers of poor people,
including many high utilizers.327 The bar graph below illustrates this effect in Minnesota.
Increase In MA/Medicaid Coverage In Minnesota328

The influx of Medicaid expansion funds creates a tremendous opportunity to fund
integrated programs aimed at stabilizing the lives of these high utilizers.329
County-level administrators are busy quantifying their high utilizer challenges and
studying integration options.330 331 332 Administrators are also steering these changes with

326

Moving Beyond Parity. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359059/pdf/nihms375613.pdf
Effects of Medicaid Expansion. http://files.kff.org/attachment/Report-The-Effects-of-Medicaid-Expansionunder-the-ACA-Updated-Findings-from-a-Literature-Review.pdf
328
Reforming Mental Health in Minnesota.
https://static1.squarespace.com/static/5a32b14bccc5c5b7c9b19622/t/5a9c44e4e2c48369e043cfec/152019
0697410/Overview-Mental-Health-Prese.pdf
329
CHCS High Utilizer Report. https://www.chcs.org/media/HighUtilizerReport_102413_Final3.pdf
330
Integrated Care Affects Health Care Use. https://twin-cities.umn.edu/study-shows-integrated-careaffects-health-care-use-among-vulnerable-adults
331
Care Delivery for New Medicaid Beneficiaries. https://www.commonwealthfund.org/publications/casestudy/2016/oct/hennepin-health-care-delivery-paradigm-new-medicaid-beneficiaries
332
Cross-Sector Service Use.
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0991?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.
88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=hlthaff
327

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

90

a host of new public sector business models like the Harvard University Human Services
Value Curve.333
Locally, a Hennepin County research study of more than 70,000 new Medicaid enrollees
confirmed that high utilizers of services also had a great deal of contact with the criminal
justice system.
High healthcare utilizers, approximately 7 percent of our sample, were
disproportionately American Indian, younger, and significantly more likely than
other expansion enrollees to have mental health (88.1 percent versus 48.0 percent)
or substance use diagnoses (79.2 percent versus 29.6 percent). Total cross-sector
public spending was nearly four times higher for high health care users ($25,337
versus $6,786), and their non–health care expenses were 2.4 times higher ($7,476
versus $3,108). High levels of cross-sector service use suggest that there are
opportunities for collaboration that may result in cost savings across sectors.
…Almost eight out of ten Medicaid expansion high utilizers had an interaction
with the criminal justice sector during the study period (70.6 percent versus 35.9
percent of other enrollees).
…Overall, Medicaid expansion high utilizers accounted for 8.1 percent of all jail
days in Hennepin County during the study period.
…Criminal justice involvement includes non-traffic, non-petty misdemeanor
offenses.
…Over three quarters of high utilizers were diagnosed at least once with either
mental illness (88.1 percent), a substance abuse disorder (72.2 percent), or both
(74.5 percent versus 22.9 percent of other enrollees).334
We currently have the most favorable environment to date for finally addressing the
inefficiencies and issues created by police-only contacts. This empirically-driven
understanding should result in more dispatch triage, police-mental health worker coresponse, and deflection to alternative response options.
Despite the demonstrated value of integrated systems, many police agencies are reluctant
to utilize dispatch triage, deflection, and co-response with mental health professionals.
They cling to old patterns of response that make police de facto mental health workers or
social workers.

333

Human Services Value Curve.
https://aphsa.org/OE/organizational_effectiveness/OE_Consulting_Practice/OE_Framework.aspx
334
Cross-Sector Service Use, op. cit.

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

91

“We try to understand what their situation is and what supports they have in place
already. We see where those supports and care are falling short,” said Maplewood
police Sgt. Mike Dugas. “For those not served, we help connect them with
services.”
Some people are skeptical of police and paramedics taking on this expanded role.
…”If someone is calling us about it, it’s a police issue,” (Maplewood Police Officer)
Burt-McGregor said.
[Sue] Abderholden [executive director of NAMI-MN] said she hopes community
leaders, seeing the benefit of the work now being done by first responders, employ
social workers and mental health workers to carry out this work in the future.335
The separate silos and territorial reflexes of law enforcement must evolve to catch up
with other parts of local government and the undeniable realities of system integration.
The problem is evident when CIT training is the excuse to avoid collaborating with
mental health workers on-scene. Likewise, the problem is evident when the idea of
collaboration becomes the excuse to embed police officers in the actual delivery of social
services (e.g. LEAD programs). We challenge decision makers, and community members
in general, to recognize this problem and address it directly.
C. The Community-Based Approach to Care Management and Coordination
How care is delivered is an important consideration for integrating law enforcement. The
evolving consensus approach to high utilizers is to invest heavily in care
management/coordination with wraparound social and behavioral health support. One
can believe this will be a successful approach because it directly addresses two old public
policy lessons—the Million Dollar Murrays and the Pareto Principle.336 337
The most applicable aphorism is probably the child of the Million Dollar Murray story:
Some problems are cheaper to solve than to manage. This is evident in statistics showing the
high costs of simply managing the crises of high utilizers. But if the decision is made to
solve this problem with intensive care management and coordination, that approach can
take several forms. One researcher broadly categorized them:
1. Health Plan Model. The health plan employs a care management team that operates from the
health plan; usually the care management is mostly telephonic.
2. Primary Care Model. The care management team is embedded in one or more primary care
practices. The team could be employed by a health plan or a provider organization, but its location is
a primary care site.
335

Maplewood PD and Paramedics Launch MH Team, op. cit.
Million Dollar Murray. http://dpbh.nv.gov/uploadedFiles/A%20MillionDollarMurray.pdf
337
Pareto Principle in Healthcare. https://www.valueinhealthjournal.com/article/S1098-3015(16)329291/fulltext#s0380
336

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

92

3. aICU (ambulatory intensive caring unit) Model. High-utilizing, complex patients receive all
their care from a separate high-risk clinic or a high-risk team within a clinic. They no longer receive
care from a primary care provider who sees both complex and non-complex patients. The entire
attention of the high-risk clinic/team is focused on a small panel of high-utilizing patients.
4. Hospital Discharge Model. This model focuses on intensive care management during the
transition from inpatient to home and to primary care. Ideally, patients in this model continue care
management in one of the other models once the transition from inpatient is completed.
5. Emergency Department-Based Model. Patients are recruited in the emergency department
(ED) and an ED-related team provides care management.
6. Home-Based Model. This model is for patients unable to leave the home, or for whom leaving
the home is difficult. Care management takes place entirely in the patient’s home. For homeless or
precariously housed patients the care goes to wherever the patient is.
7. Housing First Model. High-utilizing patients who are homeless or precariously housed are
provided with stable housing, without a medical care component. In some cases, case managers are
available at the housing sites to assist with social services.
8. Community-Based Model. The care management team engages patients wherever the patients
338
are located.

Only the Community-Based Model offers a true path for law enforcement to partner with
other systems to properly address the needs presented in complex cases. If policy makers
truly intend to move from managing the high utilizer problem to solving it, then they
must partner on-scene with law enforcement. Community members and advocates for
vulnerable populations are encouraged to support a community-based model that
includes integration of police contacts. That integration model, not others, would
minimize police-only contacts by enabling co-response and alternative response options.
D. High Quality Initial Co-Response and Alternative Response
In response to the push for integration, the National Council for Community Behavioral
Healthcare (NCCBH) created a tool called the Four Quadrant Clinical Integration Model.
It doesn’t address police directly but illustrates how co-occurring conditions and factors
build layers of complexity for dealing with patients who are high utilizers.

338

CHCS High Utilizer Report, op. cit.

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

93

FOUR QUADRANT MODEL ILLUSTRATES COMPLEXITY WITH CO-OCCURRING SUD339

Policy makers are now willing to make significant investments in broad integration
initiatives to address complex patient needs, all based on the expectation of savings. It is
a welcome rejection of the old disjointed, inefficient systems that too often failed persons
who needed the right service, at the right place, and at the right time.
Yet, these initiatives often fail to create a true, silo-breaking on-scene partnership with
law enforcement. Law enforcement contacts are guaranteed to include high utilizers of
services, persons with co-occurring conditions, and persons who are newly symptomatic.
The stakes are too high to allow initial field contacts to go to under-qualified responders
such as police officers. True integration includes dispatch triage at 911 call centers that
ensures deflection to high-quality alternative responders or co-response when police
contact is unavoidable.
Communities across the nation are being presented with initiatives for improving service
to persons having mental illness. Many of these new initiatives will target high utilizers
of services but fail to address the problems created by avoidable police-only contacts.
Concerned community members should look for this deficiency and demand fully
integrated services.
339

Integrating Behavioral Health and Primary Care, op. cit.

VIII. CO-OCCURRING CONDITIONS, INTEGRATION, AND THE NEED
FOR QUALITY MOBILE RESPONSE

94

IX. FUNDING INNOVATION

95

IX. FUNDING INNOVATION
The services this paper advocates for are really just part of the broader ongoing national
desire for an expansion of community-based mental health services. The niche topics of
this paper are dispatch triage to ensure deflection to alternative responders and, if
deflection is not possible, then real time collaborative co-response to avoid police-only
responses to mental health crisis calls. In many communities, these are either nonexistent or tremendously underfunded needs. Interested community members can expect
strong public support for funding these alternatives to the police-only responses.
To be successful, change agents must understand government funding mechanisms and
how to influence populations and decision-makers in order to make the machinery of
government move. Positive change will not guarantee funding, even when it creates
parallel cost savings and mitigates human suffering.
In some cases the fight for funding is easier because key local government and law
enforcement leaders champion the change. Such was the case in Duluth, Minnesota.
Minnesota’s first collaborative mental health co-responder program was funded in 2015
by unanimous vote of St. Louis County commissioners.340 Support from key leaders and
the culture of local government organizations was key to implementing a program that
became an award-winning example for the rest of the state.341 342
Every government body has forward-thinking individuals who can be convinced to
support better approaches. Sometimes, as in Duluth, there is already a critical mass of
progressive thinkers willing to make change happen. In other cases, that critical mass
must be created through the efforts of concerned community members.
Funding can be a significant obstacle. Community members sometimes overcome
resistance to change with an information campaign. Creating or supporting allies within
government can drive results similar to those in Duluth. Police officials, politicians, and
even local government managers can become important players. The operational and
policy changes central to our topics are typically treated as the exclusive purview of such
insiders. Insiders can be swayed by community members who offer reasoned arguments
showing the humanitarian need, the cost savings, and the demonstrated feasibility of
reform initiatives. The inside game of persuasion must be paired with a concerted effort
to create community support and political pressure for change.
Budgets are, essentially, policy statements. Most would agree that state and local budgets
should efficiently apply limited resources to the important goal of caring for persons
experiencing mental health crises. Oddly, this sentiment is usually not effectively applied
340

Duluth Police Sharpen Social Work Endeavor. https://www.duluthnewstribune.com/lifestyle/4289177breaking-never-ending-cycle-duluth-police-sharpen-social-work-endeavor
341
Duluth PD Award Nomination.
https://mcpa.memberclicks.net/assets/ETI2016/duluth_mantal%20health%20services.pdf
342
Duluth PD Teams with Social Workers. https://www.duluthnewstribune.com/opinion/4021484-policeteam-social-workers

96

IX. FUNDING INNOVATION

when persons experiencing mental health crises have contact with police. This can be
changed by concerned community members willing to invest the energy to create
political momentum for change.
A. Acknowledging Obstacles to Success—An Essential Starting Point
No matter how far you have gone on the wrong road, turn back.
-Turkish proverb
There is great opportunity to implement new approaches for handling and preventing
police-only contacts with persons living with mental illness. However, the returns on
investment in reforms will suffer if bureaucracies preserve old ideas and practices
relating to the use of police. Much of this paper is dedicated to identifying the engrained
failure modes that entrench police as de facto mobile mental health crisis workers. The
reader is encouraged to review this in previous sections. Below is a summary of the harm
created by old thinking and failed practices. We must remove this poison from the
system and maximize return on investment at the initiation of any reform.

PRESERVING OLD APPROACHES CAN REDUCE ROI
APPROACH
CIT officers as de facto mobile
mental health crisis workers

HOW IT REDUCES RETURN ON INVESTMENT









Fail to accurately assess the local
labor supply of licensed clinical
social workers.
These are the key workers for
creating expert mobile mental
health crisis response. There is
often a surplus of these workers in
urban areas, despite shortages of
psychiatrists.






Absence of clinical expertise
Criminalizes mental illness
Missed opportunities to utilize broader care integration
investments
Elevates costs of policing and incarceration
Destabilizes and traumatizes patients despite other
investments
Harmful to key target populations like high utilizers and
early symptomatic persons
Increases the likelihood of physical harm and tragedies for
vulnerable people
Further criminalizes dual diagnosis sufferers who are key
targets of other investments
Prompts utilization of unqualified mental health crisis
workers
Initiatives can be limited or abandoned based on an
incorrect assumption that there is a shortage of qualified
workers, despite good availability in Minnesota
Communities desire alternatives to police and police-only
response to mental health crisis calls for help. Local
government decision-makers who acknowledge an
availability of workers can expect community support for
additional revenue for alternative response and coresponse initiatives. Failing here means lost revenue.

SECTION
REFERENCE

I
III
IV

IV
VII

97

IX. FUNDING INNOVATION

Lack of dispatch triage at 911 call
centers







Failure to require police to
collaborate on-scene in real time
with mobile crisis teams or coresponder teams
Getting mental health clinicians onscene in real time creates an 85%
diversion rate from in-patient care.
[Reforming Mental Health in MN,
op. cit.]

Territorial thinking focused on
preserving monies for existing
siloed budget items















Absence of clinical expertise
Criminalizing mental illness
Inefficiencies and waste from using police as primary
gatekeepers
Missed opportunities to fully utilize broader care
integration funding
Duplicate funding of police in social worker roles in parallel
with existing county social services programs

IV

Creates unnecessary burdens on emergency rooms and
care facilities
Increases costly incarceration of persons with mental
illness
Reduces care system effectiveness by preventing on-scene
counseling and delaying care to people in crisis
Reduces care system effectiveness by preventing clinical
assessment from being performed immediately, on-scene
Precludes a highly effective warm handoff from on-scene
clinician to care facility workers

I

Promotes the idea that any new initiative must have zero
budget impact regardless of potential savings &
efficiencies—comparison to zero
Inhibits on-scene collaborations between law enforcement
and county service providers
Encourages county administrators to off-load their
budgetary responsibilities to local police departments by
using officers as de facto mobile mental crisis workers
Preserves inefficiencies, waste, and human suffering that
collaboration could mitigate
Limits the scope of collaborative work since funding will
primarily rely on outside grants

V

III
IV
V

IV

B. Simultaneous Funding of Both Alternative Response and Co-Response Options
The siloed status quo has resulted in separate paths: one funding alternative responses,
and another funding on-scene real time co-response. This is a problem that must be
overcome. These modalities are both necessary and work in tandem to improve
outcomes by minimizing police-only contacts. In Minnesota, increasing the use of
dispatch triage will deflect mental health calls to the existing county mobile mental crisis
team system. When deflection is not possible there needs to be a real time co-response
option. These two options sometimes get funded separately through the health and
criminal justice systems. The result is that the synergistic response options get uneven
attention or are even treated as conflicting approaches.
Change agents and communities are urged to address this problem. Funding for mental
health professionals for both response options can be provided solely through the

IX. FUNDING INNOVATION

98

healthcare system. Funding for both response options should flow through the same
dedicated budget.
C. Getting City and County Political Support and Funding
City and county governments can be the best policy laboratories of our democracy. So it
should be no surprise that most projects relevant to this writing are funded as budget
items at the city or county level. Unfortunately, funding created as year-to-year local
budget items are not ideal for projects that create safety net emergency services for
vulnerable populations. Political change or a souring economy can result in slashes in
funding. A secure source of funding is critical for retaining key personnel such as highly
skilled mental health crisis responders. The League of Minnesota Cities has online
resources for understanding how your city creates its budget.343 344 345
Still, city and county funding may allow a local community to initiate a pilot project for
introducing change and proving concepts. These pilot projects can create the impetus for
more stable funding from county or state government.
City and county funding is often supplemented by grant money in later budgets. Outside
funding sources can replace city funding or be a means of expanding an existing project.
Projects can be endangered when they do not get increases in funding or see their
funding stream become overly dependent upon outside grants. Projects that demonstrate
efficacy and value should become part of the government services structure. Sometimes
that only happens when engaged community members lobby for expanded funding or
the use of new dedicated funding streams.346
Access to city council members and county commissioners is far easier than reaching
state and federal politicians. Information campaigns targeting voter constituencies are
also more manageable at this level. This access enables community members to partner
with local politicians and other decision-makers on efforts to develop and fund
innovative projects. The support of an open-minded local police chief or sheriff is also
helpful. Like any organization, law enforcement agencies have distinct cultures.
Community members interested in reform initiatives are encouraged to reach out to law
enforcement and create partnerships whenever possible.
Even at the local level, significant time and effort will be required to create the needed
momentum for change. Some of that time should be invested in fostering coalitions
among local social justice and advocacy groups. All counties in Minnesota have
community mental health advisory boards that identify unmet needs, including mobile
crisis responses.
343

Paying for City Services. https://www.lmc.org/resources/paying-for-city-services/
Sources of Revenue. https://www.lmc.org/wp-content/uploads/documents/Sources-of-Revenue.pdf
345
Property Taxation 101. https://www.lmc.org/resources/property-taxation-101/
346
Boston MH Clinicians to Attend 911 Calls, op. cit.
344

IX. FUNDING INNOVATION

99

D. Dedicated Revenue Streams
A dedicated revenue stream promotes the long-term success and stability of reform
initiatives but is often assumed to be a political non-starter. In truth, the community will
support new taxation or fees that create positive change. The public looks favorably on
investments that help vulnerable people and there is broad interest in reducing
unnecessary police contacts. In recent years, communities have been turning to more
local dedicated funding of community mental health and drug addiction services. This is
a reflection of greater community needs and insufficient and erratic funding mechanisms
at the state and federal level.
County governments typically take the lead in regulating local health care services and
providing or contracting for emergency health care services. Counties can fund
collaborative or diversion programs using state funding support for health care or by
dedicating revenue from local property tax and fees.
Lasting change is more likely when communities can dedicate funds from special fees or
tax increments.
1.

Special Sales Taxes

There are many examples of cities and counties around the nation using special sales
taxes to fund needed community mental health services. In Washington State in 2012, the
Tacoma City Council passed Ordinance 28057, which created a special 0.1% sales tax to
fund mental healthcare services. Many other Washington cities and counties now do this,
too.347 348
In 2018, Denver voters approved the Caring for Denver Initiative by a 67.96% vote. It
created a 0.25% dedicated sales tax yielding $45M annually for addiction, mental health
services, and associated housing.349 Social justice groups, unions, mental health groups,
and provider organizations collaborated in the successful political effort. Denver voters
wanted to take the problem out of the hands of police and jails. Mental Health America
Vice President, Debbie Plotnick, welcomed the surge in local initiatives:
For years there had been such discrimination; it was treated as a safety crisis, not a
health problem. “Can you think of any other medical emergency where they send
the police? So localities had to take charge and develop services where there hadn’t
been any before.350

347

WA State Bill 82.14.460. https://app.leg.wa.gov/rcw/default.aspx?cite=82.14.460
Cowlitz County MH Sales Tax. https://www.co.cowlitz.wa.us/2399/110th-of-1-Mental-Health-Sales-Tax
349
Voters Approve MH Tax. https://www.denverpost.com/2018/11/06/denver-ballot-issues-results/
350
Why Denver Voted to Fund MH Treatment. https://www.citylab.com/equity/2018/11/treatment-centersaddiction-mental-health-caring-4-denver/576202/
348

IX. FUNDING INNOVATION

100

Another example is found in Eagle County, CO, where voters easily approved a new
sales tax on recreational marijuana. It passed with 72% approval. The resulting $1.2M per
year of funding is dedicated to mental health and addiction services. Voters were partly
swayed by problems at the Eagle County Jail. In that jail, 73% of inmates were prescribed
psychotropic drugs.351
It’s a lot less expensive and a lot more humane and smarter to treat mental illness
than to ignore it or criminalize it. Turning our jails into mental hospitals is
indefensible, immoral and idiotic.
—Andrew Romanoff, CEO of Mental Health Colorado
In Minnesota, state legislative action would be required to utilize a special sales tax
approach.
2.

Special Tax Levies and Local Mental Health Board Systems

Property tax levies funding mental health services are a common approach at the county
government level. Like the sales tax examples above, these tax levies also enjoy popular
support. In Ohio, 76 of 88 counties have a mental health services levy and all have been
renewed by voters.352
Cities also get some funding through property taxes collected by counties. 353 Where
permitted by state statute, a city can create a dedicated property tax increment to support
added services or a reform initiative.
Chicago, in 2008, provides an inspirational example of community members overcoming
politics and bureaucracy. A coalition of community members got a referendum to the
voters in a bid to save community mental health services which were desperately
underfunded and shrinking. Their referendum for a mere 0.004% increase in property
taxes passed with 71% voter approval. However, this Chicago referendum was nonbinding and city leaders refused to act on it. The steadfast community activists convinced
the Illinois legislature to draft a law allowing Chicago communities to pass binding
referenda to raise property taxes to fund mental health services. This law, the
Community Expanded Mental Health Services Act, was passed into state law.354 In 2012,
the community coalition reintroduced their referendum, now binding, and voters
approved it by a 74% vote.355
351

Eagle County Voters Approve Tax. https://www.mentalhealthcolorado.org/eagle-county-marijuana-tax/
How Communities Can Fund MH Services. https://careforyourmind.org/how-communities-can-fundmental-health-services/
353
Property Taxes Climbing But Needs Are Many. https://www.startribune.com/property-taxes-climbing-butneeds-are-many-activists-say/502275201/
354
IGA 405 ILCS 22. http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=3300&ChapterID=34
355
Why One Community Voted to Tax Itself.
http://inthesetimes.com/article/17636/community_funded_mental_health_clinis
352

IX. FUNDING INNOVATION

101

Very recently, the bi-county Mental Health and Recovery Board of Erie and Sandusky
Counties in Ohio got their voters to renew a 0.5 mill, 10-year property tax levy. (A 0.5
mill levy is the equivalent of a 0.05% tax on assessed value.) This levy results in $1.9M
from both counties to fund mental health and addiction recovery services.356
In 1988, the Ohio legislature required county governments to set up local mental health
boards that oversee the management and financing of county safety net services. The
goal was more local control in developing, planning, managing, and funding
community-based services. This illustrates how government structure can be altered to
increase local control of mental health services, putting decision-making into the hands
of community members.357 358 359
These local boards were created at a time when federal government control of mental
health services was being devolved to states and counties. Ohio and other states chose
systems that emphasized local control.360 It was these local boards that determined the
need for funding and pushed for the referenda to secure that funding.
By contrast, states like Minnesota did not create local mental health boards as the sole
entities to manage mental health services policy. In places like Minnesota, the delivery of
community-based mental healthcare services is driven by state funding and tightly
managed within the county government. The resulting policy choices are made behind
closed doors by county department managers and administrators. Minnesota would be
well-served to adopt a local county-based mental health board system.
Minnesota taxpayers pay out much money for these services, but do they have as much
say in the design and delivery of these services as taxpayers in other states?
In Ohio, devolution was overlaid with a long tradition of “home rule,” in which
county authority is vested with and exercises significant political influence. A
similar context exists for North Carolina counties. Devolution in Ohio spawned an
increased emphasis on the state’s consultation and collaboration with the core
mental health system constituencies: consumers and families, providers of services,
and county authorities.361
Recent financial missteps at the Minnesota Department of Human Services have
triggered discussions about how to restructure that sector of our government. Minnesota
356

MH Board Seeks Levy Renewal. https://sanduskyregister.com/news/3031/mental-health-board-plans-toseek-renewal-of-levy/
357
Monroe County Community Services Board. https://www2.monroecounty.gov/mh-csboard.php
358
Community Boards Community Benefits.
https://www.mhrbeo.org/Downloads/Community%20Boards%20Community%20Benefits2.pdf
359
Ohio Behavioral Healthcare System. https://www.mhrbeo.org/Downloads/Overview_Ohio_System2.pdf
360
Haves and Have Nots. https://www.communitysolutions.com/wp-content/uploads/2019/11/112519-LevyPaper.pdf
361
MH Services in Ohio. https://www.purdue.edu/hhs/hdfs/fii/wp-content/uploads/2015/07/s_ncfis02c03.pdf

IX. FUNDING INNOVATION

102

voters and issue advocates could take this opportunity to push for independent local
mental health boards.
E. State Government Funding
Sometimes state funds can be tapped directly through existing grant programs or by
funding authorized in new legislation. State legislators may be particularly willing to
pass legislation for start-up funding of deflection efforts or law enforcement/mental
health collaborative projects. Consider the example from Martin County, Florida, where a
sheriff successfully lobbied the state legislature for funding to support a new mental
health co-responder team program.
When Governor Scott recently signed the state’s 2017/2018 budget, he approved
funding for a Martin County Sheriff’s Office Mental Health Co-Responder
initiative. I am profoundly grateful to the Governor, Senate President Joseph
Negron, Majority Leader Senator Simpson, and State Representative Gayle
Harrell, who supported our request and made this funding possible.
...It is my fervent hope that this pilot program alleviates some suffering for the most
fragile among us. A compassionate community should do no less.
—Martin County Sheriff William D. Snyder362
This sheriff’s success can be replicated and energetic community groups can play an
important role. This can be done by defining specific program goals, creating community
awareness, and getting a state legislator to sponsor the necessary legislation. This basic
function within our democracy is surprisingly amenable to community groups that
invest the necessary time and energy.
Another example is S.F. 2892 passed by Washington State in 2018. This created grant
funding for police/mental health worker co-response projects in the state to reduce
police-only contacts.363 Broad support helped it pass without a single nay vote in the
state senate and house.364 The funding created the Mental Health Field Response Teams
Program that awards grants of $100,000 with stipulations on data collection and
reporting.365 The requirement for data collection and analysis of outcomes is a common
and beneficial requirement in grant programs.
State level funding in Colorado for collaborative diversion and deflection programs came
through the 2012 legalization of recreational marijuana use. In 2017, state legislators
approved a bill to apply marijuana use tax revenue toward a grant program that would
362

Martin County Sheriff Facebook Post, op. cit.
WA State Legislature Passes HB2892. https://www.youtube.com/watch?v=6xUI8hLNq_w
364
WA State Bill HB2892.
https://apps.leg.wa.gov/billsummary/?BillNumber=2892&Year=2018&Initiative=false
365
Text of WA State Bill HB2892. http://lawfilesext.leg.wa.gov/biennium/201718/Pdf/Bills/Session%20Laws/House/2892.SL.pdf
363

IX. FUNDING INNOVATION

103

fund collaborative co-response projects.366 This law, SB 17-207: Strengthen Colorado
Behavioral Health Crisis System, was part of a push to decriminalize mental illness.
SB 17-207 aims to improve coordination and response for behavioral health crises,
forbids the use of jails for 72-hour holds and identifies psychiatric emergencies as a
healthcare issue that allows the individual to adequately receive necessary
services.367
SB 17-207 directed millions of dollars into treatment and diversion activities for justiceinvolved individuals.368 Part of this went to the creation of a Co-Responder Program that
issued 5-year funding grants to programs which prevent police-only response to calls
involving mental illness.369
In Massachusetts, the state Department of Mental Health offers grants through the
Jail/Arrest Diversion Grant Program. This program shows that state-level funding is
useful in creating cost-effective multi-jurisdictional programs serving several cities or a
region.
The Co-Response Model has been a popular request of grant applicants and has
even been adapted to use as a shared resource among several contiguous towns and
regions. This model is a mental-health based diversion model that pairs clinician,
often a clinician affiliated with the local Emergency Services Program (ESP) with
police to co-respond to calls with mental health elements. The clinician in this
model can be embedded into the police department during their work hours. Calls
in which clinicians participate deliberately involve individuals experiencing
emotional distress and/or psychiatric symptoms and may also have co-occurring
substance use issues.370
Locally, Minnesota has a relevant grant program that has yet to be utilized to directly
prevent police-only contacts on mental health calls. So far the Minnesota Mental Health
Innovation Grant Program has helped justice-involved individuals through improved
follow-up services and drop-off points for officers to take persons they contact.371 This
grant program could be utilized to directly support dispatch triage at 911 centers, more
robust alternative on-scene response capabilities, or more co-response capacity in urban
366

CO Marijuana Tax Cash Fund. https://footprintstorecovery.com/addiction-treatmentlocations/colorado/marijuana-tax-cash-fund/
367
CO Behavioral Health Crisis System. https://cha.com/wp-content/uploads/2017/08/CHA.074-Leg_SB17-207-1.pdf
368
Treatment for Patients in Crisis. https://www.bizjournals.com/denver/feature/mental-healthmatters/2017/giving-patients-in-crisis-the-treatment-they.html
369
Colorado Co-Responder Program, op. cit.
370
Jail/Arrest Diversion Grant Program. https://www.mass.gov/files/documents/2018/01/19/2018-0102%20DMH%20JDP%20mid-year%20report-%20FY18.pdf
371
MH Innovation Grant Program. https://mn.gov/dhs/partners-and-providers/policies-procedures/adultmental-health/mh-innovation-grant-program/

IX. FUNDING INNOVATION

104

areas. These are community-based, high-efficiency services the Minnesota grant program
seems to be intended for, based on the stated goals:
[The] Mental Health Innovation Grant Program is a new grant program intended
to improve access to and the quality of community-based, outpatient mental health
services and reduce the number of people admitted to regional treatment centers
and community behavioral health hospitals.372
The way the Minnesota grant has been used thus far illustrates how decriminalization of
mental illness can be thwarted by CIT-centric thinking. Minnesotans should be funding
collaborative reform approaches at the point of police contact. Witness states like
Colorado, Massachusetts, and Washington which put patient needs first with reforms
that go beyond follow-up services and drop-off centers.
There have been halting efforts to get state funding for deflection and co-response
options. Recently, bills were introduced to the state legislature to fund co-response pilot
projects in Hennepin and Dakota counties.373 374 Both of these unsuccessful bills were
spurred by recommendation from the 2016 Governor’s State Task Force on Mental
Health for more real time co-response.375
Minnesota counties now have mobile mental health crisis response teams staffed with
excellent mental health professionals. They are the foundation for what could be ideal
alternative response or co-response options. What’s missing is dispatch triage to enable
deflection to or co-response with mental health clinicians to minimize police-only
contacts for mental health-related calls. Unfortunately, there have been no efforts at the
state legislature to study, fund, or mandate dispatch triage of mental health-related calls
received by 911 centers.
F. Federal Government Funding
The most common federal-level source of funding is the Criminal Justice Mental Health
Collaboration Grant provided through the U.S. Department of Justice, Bureau of Justice
Assistance.376 377 The grants are typically $100,000–$250,000 over a two-year period for

372

Ibid.
Minnesota SF 2787.
https://www.revisor.mn.gov/bills/text.php?number=SF2787&version=latest&session=ls91&session_year=20
19&session_number=0
374
Minnesota SF 1632.
https://www.revisor.mn.gov/bills/text.php?version=latest&session=ls90&number=SF1632&session_year=20
17&session_number=0
375
Governor’s Task Force on MH. https://mn.gov/dhs/assets/mental-health-task-force-report2016_tcm1053-263148.pdf
376
Justice and MH Grant Announcement.
https://bja.ojp.gov/sites/g/files/xyckuh186/files/media/document/BJA-2019-15099.PDF
373

IX. FUNDING INNOVATION

105

projects in the start-up phase. The funding is available through a competitive application
process for each of three tiers of a project: a planning phase, an implementation phase,
and an expansion phase. The Council of State Governments–Justice Center is a source of
information and direct support for prospective applicants and awardees.378 The grant
support is not intended to be on-going and grant recipients must secure other funding
sources after the grants expire.
G. Private Funding and Support
There are a few sources for private funding of these programs. The MacArthur
Foundation has helped some communities through its Safety and Justice Challenge
grants.379 Milwaukee was able to partially fund their collaborative Crisis Assessment
Response Team with one of these grants.380 The MacArthur Foundation funded criminal
justice reform for 20 communities.381
In 2017, Dallas County, TX, was able to fund its RIGHT Program with many millions of
dollars in private funding. That program included collaborative mobile mental health
crisis response.382 383
H. Savings and Efficiencies
It is very common for new practices, policies, and programs to be justified by expected
cost savings. Often it is part of the justification for changes targeting high utilizers of
emergency services. Yet most plans for changes in services ignore the savings from
avoiding police-only contacts with persons in mental health crisis. For example, money
spent on police training will not prevent the waste and inefficiency created by not having
a clinician on-scene in real time to de-escalate, prevent incarceration, and provide
evaluations. County governments are making large investments in service integration
and case management without working to prevent police-only contacts with the target
populations.

377

JMHCP Overview. https://bja.ojp.gov/program/justice-and-mental-health-collaboration-programjmhcp/overview
378
JMHCP Orientation. https://www.youtube.com/watch?v=8O53r7a0Zg4&feature=youtu.be
379
Criminalizing Homelessness, op. cit.
380
Safety and Justice Challenge. https://www.macfound.org/press/press-releases/safety-and-justicechallenge-expands-52-cities-counties/
381
MacArthur Foundation Press Release. https://www.macfound.org/press/press-releases/20-diversecommunities-receive-macarthur-support-reduce-jail-populations-improve-local-systems-and-model-reformsnation/
382
Dallas RIGHT Program. https://www.dallasjustice.com/2017-dallas-right-program-mentally-ill-avoid-bailjail/
383
Dallas Co-Responder Program. https://www.dallasnews.com/news/2018/01/24/program-pairscounselors-with-cops-to-better-handle-mental-health-calls-in-southern-dallas/

IX. FUNDING INNOVATION

1.

106

Costs of Police-Only Crisis Response—Table

It is common knowledge that a system that puts a clinician on-scene for crisis response
will create efficiencies and better outcomes. The following table summarizes these
consequences and costs of police-only response.

107

IX. FUNDING INNOVATION

CONSEQUENCES AND COSTS OF THE POLICE-ONLY RESPONSE
INEFFICIENT AND
HARMFUL
PRACTICES

CONSEQUENCES

Wasting Money:
Police-only
responses instead
of co-response or
deflection to a
mobile mental
health crisis
response team

Increased costs for the criminal justice system,
mental health facilities, and the persons who need
care.

 Minnesota’s county mobile mental health crisis teams have a return
on investment (ROI) of about $4.10 for every dollar invested.(1)
 These ROI do not fully account for the savings created by reducing
entanglements with the criminal justice system.(2)
 Collaboration helps prevent entanglements with the criminal justice
system; ROI can be as high as $10 per dollar invested.(3)

Police-only
response creates
staffing burden on
police departments

 Calls for service with a mental health
component are time-consuming for patrol
officers.
 Many are hidden in unrelated call descriptors
like “domestic disturbance.”
 The number of mental health-related police
calls has been growing rapidly.

 Police department budgets are typically 35% of a city’s budget.
Increased time spent on mental health calls takes away from other
duties and increases police budgets.(4)
 95% of MN law enforcement agencies report mental health calls have
increased over the last 5 years, with 20% reporting these calls have
more than doubled.(5)
 Albuquerque police report that mental health was the primary factor
in 33% of calls.(6)
 “Calls for assistance, welfare checks, disturbances, domestics, runaways, medicals and other like service calls, places a front-line officer
on over 50% of the calls in direct contact with drug impaired, mentally
unstable, mentally ill, psychotic, suicidal, and others in crisis.”(7)

 Police default to transferring people, forcing
them to pay for ambulance bills that often lead
to no real care.(8) (9)
 UK co-response (street triage) results in
reduction of transfers by 50-75%.(10)
 Dallas reported a 23% reduction in ambulance
transfers within the first 3 months of the RIGHT
Teams program.(11)

Ambulance care is expensive.
 Costs depend on qualifications of the ambulance staff, procedures
used, miles traveled, if the trip is covered by Medicare, if the
ambulance goes to an in-network hospital, and if the service is
contracted by a local municipality.
 One patient was billed $3,660 for a 4-mile ride but would have cost
$1,490 if he was picked up blocks away in a neighboring city.(12)

See discussions in
Sections: III, IV

Police-only
response results in
unnecessary
transfers by
ambulance
See discussions in
Sections: I, III, IV

COSTS

108

IX. FUNDING INNOVATION

Delay of care
resulting from
police-only contact
and police referral

Delaying care with a police-only response is a
risky choice with serious consequences.

 When police-only response is the only option, suicidal persons are
less likely to call and more likely to attempt or commit suicide.(13)
 There is no guarantee a referral from police will result in a successful
reconnection with the individual. Sometimes people can’t be found, or
they decide not to accept help when contacted days later.

 Police transfers create burdens for emergency
rooms. 80% of transfers to ERs result in no
care.(14)
 CIT doctrine promotes investment in
emergency rooms and drop-off centers to
make transfers more convenient for police
operations.(15)
 People are harmed by transfers: “Hours of
waiting in mental misery may only confirm the
patient's feelings of hopelessness and
abandonment, thereby increasing suicide
risk.(16)”

Police transfers to ERs cost a lot.
 From 2010 to 2017, ER visits for mental health and substance abuse
greatly increased. “As a subset of the 75.1 percent increase,
substance abuse ER visits increased 145.6 percent and mental
health ER visits increased 51.4 percent.”(17)
 “The average boarding time for a psychiatric patient ranges between
8 and 34 hours, with an average cost of $2,264.”(18)
 “Eliminating unnecessary ED use for mental illness could save
about $4.6 billion annually."(19)

 There are more mentally ill persons in jails
than in hospitals.(20)
 The prevalence rates of serious mental
illnesses in jails are three to six times higher
than for the general population.(21)
 Revolving door contact with the criminal justice
system traps “frequent fliers” and incurs cost
for the system.(22)
 Jailing of mentally ill people leads to
decompensation (worsening).(23)
 The family of a man with schizophrenia in
Alexandria, MN, hoped police would assist in
transporting him to a care facility. Instead,
police interpreted the situation as a domestic
dispute, arrested him, and put him in jail for 5
days.(24)

 Jails spend 2-3 times more to house and treat the mentally ill. Jails
aren’t set up to assure that mentally-ill persons receive psychiatric
care upon release.(25)
 Inmates with major psychiatric disorders in Texas state prisons were
2.4 times more likely to have four or more repeat incarcerations in
2007 than those without mental illness.(26)
 In Miami-Dade County, FL, 97 high service utilizers with SMI cost
taxpayers $13 million in criminal justice costs over 2005-2010.(27)

See discussions in
Sections: III, IV
Avoiding on-scene
collaboration
because
emergency rooms
and drop-off
centers are more
convenient for
police operations
See discussions in
Sections: I, III, IV
Police-Only
responses elevate
risk of arrest and
incarceration
See discussions in
Sections: I, III, IV

The “decompensation cycle” wastes money.
 Courts require treatment to make people competent to stand trial but
returning them to jail to await trial often results in decompensation.
 Upon return to jail “inmates usually decompensate quickly and
require intensive psychiatric care and/or readmission to inpatient
care.”(28)

109

IX. FUNDING INNOVATION

Missed
Opportunity:
Failure to
reconnect after
referral from
police-only
contacts

 Over 30% of persons with serious mental
illness had contact with police while making, or
trying to make their first contact with the mental
health system.(29)
 Many find it difficult to connect with mental
health treatment after police-only contact.

Delay is inhumane and has cost implications.
 Prolonged suffering and expense are predictable outcomes from
inadequate initial responses to calls for help from high utilizers and
early symptomatic individuals.
 Mental illness increases the odds of homelessness and costs the
U.S. $193.2 billion every year in lost wages.(30)

 Police-only contacts create a tremendous risk
for missed opportunity to help the people.
 Some people who have repeat contact with
police are also high utilizers or even “super
utilizers” of social services and emergency
medical services.
 Many individuals cycle in and out of the group
defined as high utilizers. Thus, all persons in
crisis are potentially on track to become a high
utilizer of services.(31)

Research by Denver Health found:
 3% of adult patients consistently met super-utilizer criteria and
accounted for 30% of healthcare costs. However, fewer than half of
the super-utilizers were in the category seven months later, and only
28 percent were in the category at the end of a year. And at the end
of two years, only 14% were in the category.
 A one-size-fits-all program isn’t the answer to reducing the healthcare
cost impact of super-utilizers.(32)

 It is important to get a clinician on-scene with
the qualifications to do a Rule 25 chemical
dependency assessment. These assessments
help poor people qualify for publicly-funded
chemical dependency treatment.(33)
 Only 1 in 10 people with a substance use
disorder receive any type of specialty
treatment.(34)
 72% of jailed persons with serious mental
illness have a co-occurring substance abuse
problem.(35)

 Every dollar invested in addiction treatment programs yields a return
of between $4 and $7 in reduced drug-related crime, criminal justice
costs, and theft.(36)
 When savings related to healthcare are included, total savings can
exceed costs by a ratio of 12 to 1.(37)
 The average cost for 1 full year of methadone maintenance treatment
is approximately $4,700 per patient, whereas 1 full year of
imprisonment costs approximately $24,000 per person.(38)
 “It is vital to integrate treatment of mental illness and accompanying
substance abuse. This is an especially high priority because the
combination of untreated mental illness and addiction is the best
predictor of violence, suicide, and other poor outcomes.”(39)

See discussions in
Sections: III, IV
Missed
Opportunity:
Police-only
response creates
harm despite any
focused follow-up
See discussions in
Sections: I, III, IV
Missed
Opportunity:
Rule 25 SUD
Assessments
See discussions in
Sections: IV, V, VI

110

IX. FUNDING INNOVATION

Decompensation
of Patients Due to
Police Contact

Police-only contact can traumatize people who
need a mental health professional’s expertise.

 Many victims of police violence experience PTSD, which manifests
as severe agoraphobia and paralyzing panic attacks. This creates a
downward spiral of isolation, depression, and even suicide.(40)

 Untreated mental illness can lead people to
behave erratically or disruptively. Some may
have difficulty responding to directions.(41)
 People in mental health crisis are 16 times
more likely to be killed by police and can
experience excessive force and civil rights
violations, resulting in settlements with
taxpayer funds.(42)

In Minnesota, the cases of David Smith and Dominic Felder stand out.
 Smith died after multiple taser shocks and positional asphyxia.(43)
His family was paid $3 million in settlement.(44)
 Felder was unarmed and having a nervous breakdown when he was
shot to death.(45) His family was paid $2.19M in settlement.(46)

See discussions in
Sections: I, III, IV
Use of Force
(Monetary
settlements and
increased needs
of patient)
See discussions in
Sections: I, III

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

 Most mental health-related calls with bad outcomes don’t make the
news. Between 2006 and 2012 Minneapolis paid out $14M in
settlements for police misconduct, most in unpublicized cases.(47)
 There are numerous cash settlements nationally for police
mishandling of people in mental health crisis. Many more incidents
result in no settlements or publicity.(48)

MHLN Blue Book 2018, op. cit.
Revolving Door Serious Mental Illness in Super Utilizers, op. cit.
New Paradigm Not New Building, op. cit.
How Much Do Cities Spend on Police? https://www.forbes.com/sites/niallmccarthy/2017/08/07/how-much-do-u-s-cities-spend-every-year-on-policinginfographic/#34d121bbe7b7
MCPA Legislative Update, op. cit.
Police Perceptions Albuquerque, op. cit.
St. Anthony PD 2015 Annual Report, op. cit.
New Paradigm Not New Building, op. cit.
Senator Praises MH Crisis Response Program, op. cit.
Avon and Wiltshire MH Partnership, op. cit.
Senator Praises MH Crisis Response Program, op. cit.
Ambulance Bill Surprise. https://www.presspubs.com/white_bear/news/ambulance-ride-bill-may-be-a-surprise/article_deeee8b6-2c0c-11ea-8a89-8f3317f5a6a7.html
Is it a True Emergency? https://www.psychiatrictimes.com/suicide/it-true-emergency-suicidal-patients-access-their-psychiatrists
New Paradigm, Not New Building, op. cit.
CIT Core Elements, op. cit.
Is it a True Emergency? op. cit.
True Cost of MH in ED. https://www.healthcarebusinesstoday.com/true-cost-mental-health-crisis-emergency-department/
Preventable ED Use. https://www.hfma.org/topics/news/2019/02/63247.html
Mental and Behavioral Health Priorities. https://www.mnhospitals.org/newsroom/news/id/2144/mental-and-behavioral-health-priorities

IX. FUNDING INNOVATION

20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.

MI Revolving Door, op. cit.
Revolving Door Serious MI in Super Utilizers, op. cit.
Ibid.
Ibid.
Jailed Amid MH Crisis. https://www.sctimes.com/story/news/local/2018/12/01/alexandria-couple-rebuilds-mental-health-care-jailed-schizophrenia/555155002/
MI Revolving Door, op. cit.
Revolving Door Serious MI in Super Utilizers, op. cit.
Ibid.
Restore, Revert, Repeat. https://cdn.vanderbilt.edu/vu-wp0/wp-content/uploads/sites/278/2018/01/18175600/Restore-Revert-Repeat.pdf
Police MI Interactions. https://cmha.bc.ca/wp-content/uploads/2016/07/policesheets_all.pdf
Treating America’s MH Crisis, op. cit.
Super Utilizer Beliefs. http://www.healthcarebusinesstech.com/super-utilizers/
Ibid.
Rule 25 Assessments, op. cit.
Facing Addiction in America (Ch. 4). https://www.ncbi.nlm.nih.gov/books/NBK424859/
Burden of MI Behind Bars, op. cit.
Is Drug Addiction Treatment Worth its Cost? https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-thirdedition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost
Ibid.
Ibid.
Repairing Our Broken MH Care System. https://www.psychiatrictimes.com/mental-health/repairing-our-broken-mental-health-care-system-advicepolicymakers/page/0/1?utm_source=bibblio_recommendation
Officers with PTSD, op. cit.
Police Use of Force, US Commission on Civil Rights (p. 49-52). https://www.usccr.gov/pubs/2018/11-15-Police-Force.pdf
Ibid.
David Smith Verdict, op. cit.
$3 Million Payout in Smith Case. http://www.startribune.com/may-25-minneapolis-pays-3-million-in-police-misconduct-case/208912661/
Dominic Felder Verdict, op. cit.
$2.1 Million Payout in Felder Case. http://www.citypages.com/news/dominic-felders-family-awarded-21m-by-minneapolis-in-wake-of-police-shooting-6563768
Largest Police Misconduct Payouts in MN. https://www.newsmax.com/FastFeatures/police-misconduct-lawsuits-payouts-Minnesota/2015/08/21/id/671210/
Police Use of Force, US Commission on Civil Rights (p. 49-52), op. cit.

111

IX. FUNDING INNOVATION

2.

112

Hidden Benefits and Savings

Some savings are difficult to measure. Avoidable costs results from the cascade of
consequences created by police-only responses. Destabilizing a patient might result in the
loss of employment or housing. Mental illness increases the odds of homelessness and
costs the U.S. $193.2 billion every year in lost wages.384
Decompensation can mean physical health is affected, an insidious hidden cost. Mental
illness is even tied to decreased life expectancy—10 years lower than the general
population.385 Destabilization creates other costs by exacerbating co-occurring conditions
like SUD. These hidden costs should be part of the consideration to avoid police-only
response to mental health crisis. These larger social costs of policy decisions are real and
other countries actually make them part of decision-making.386
Local governments that fail to evaluate their performance beyond superficial effects to
their own budgets are camouflaging harm. Taxpayers should demand deeper analysis
and the use of Social Return on Investment (SROI) analysis in this age of data-driven
decision-making.387 388

384

Treating America’s MH Crisis. https://www.thewellnessnetwork.net/health-news-and-insights/mentalhealth-crisis/
385
Right to Treatment. https://www.samhsa.gov/sites/default/files/the_right_to_treatment.pdf
386
Social Cost Considerations. https://nrc-publications.canada.ca/eng/view/fulltext/?id=e0a1d165-abe54aed-89c8-ef27d8d88e28
387
Valuing SROI. http://ppidb.iu.edu/Uploads/PublicationFiles/Valuing%20SROINoaber%20Final%20Report-FINAL.pdf
388
Prospective SROI. https://www.wilder.org/sites/default/files/imports/MICC_SROI_Report_3-19.pdf

X. MORAL AND ETHICAL CONSIDERATIONS

113

X. MORAL AND ETHICAL CONSIDERATIONS
Our communities demand that law enforcement stop being primary responders to
mental health calls in place of a proper health care response. For the reasons already
outlined, defaulting to a law enforcement response to mental health crisis is neither
rational nor necessary. Yet this status quo has survived legal and legislative challenges
and has become accepted, despite our better angels.
A. Legal is Not Always Ethical or Moral
In matters of conscience the law of majority has no place.389
—Mahatma Gandhi
The de-institutionalization of the mental health provider system in the 1960s and 1970s
was supposed to harken a great expansion of community mental health services.390 That
did not happen.391 Since then, legislatures and courts have been largely ineffective in
regulating police contacts with persons in crisis. The 1990 passage of the Americans with
Disabilities Act (ADA) sought to create equity and protect the civil rights of disabled
people, including those with mental illness.392 Later, the U.S. Supreme Court’s Olmstead
v. LC decision offered hope for further decriminalizing mental illness.393 Still, police
continue to be primary responders and jails continue to be de facto mental health holding
facilities. Expectations of reasonable accommodation have not prevented police-only
responses or even altered use of force requirements by police.394
In the 2015 Sheehan ruling, the U.S. Supreme Court refused to bind law enforcement by
the ADA requirements for reasonable modifications. It included a nod to the legal
standard of objective reasonableness that gives officers almost unlimited discretion in
their use of force.395 396 397
In this incident, officers knew Sheehan was in mental health crisis, confronted her,
retreated after an initial confrontation, and then immediately re-entered the dwelling
instead of de-escalating. They entered with guns drawn and shot Sheehan at least five
times. These choices were in direct conflict with their police department’s policies and
389

Essence of Democracy. https://www.mkgandhi.org/momgandhi/chap72.htm
Deinstitutionalization of People with MI. https://journalofethics.ama-assn.org/article/deinstitutionalizationpeople-mental-illness-causes-and-consequences/2013-10
391
To Stop Police Shootings of People with MH Disabilities, op. cit.
392
What is the ADA? https://adata.org/learn-about-ada
393
About Olmstead. https://www.olmsteadrights.org/about-olmstead/
394
San Francisco v Sheehan. https://www.scotusblog.com/case-files/cases/city-and-county-of-sanfrancisco-california-v-sheehan/
395
From Garner to Graham and Beyond.
https://scholarship.kentlaw.iit.edu/cgi/viewcontent.cgi?article=4109&context=cklawreview
396
Bad Apple Myth of Policing. https://www.theatlantic.com/politics/archive/2019/08/how-courts-judgepolice-use-force/594832/
397
Excessive Reasonableness. https://mckinneylaw.iu.edu/ilr/pdf/vol43p117.pdf
390

X. MORAL AND ETHICAL CONSIDERATIONS

114

training. Because she lived, Theresa Sheehan was charged with two felony counts for
threatening the officers with a knife.398
The Sheehan case exemplifies why the law and the courts cannot be relied upon to create
ethical and moral boundaries for society. In Sheehan, the court system flatly rejected the
common sense notion that police officers should alter their tactics when they know that
they are interacting with people in mental health crises.
In court, she argued that the police violated the “reasonable modifications”
protections under the ADA. The Federal Appeals Court of San Francisco agreed
with her; however, the San Francisco Police Department has filed an appeal
[successfully] with the United States Supreme Court to exclude the police from
following the ADA.399
The idea that the ADA requires police to make accommodations for people with mental
illness continues to be routinely defeated in court.400 The expression of police power on
mental health calls greatly obscures the competing principle of parens patriae—protecting
disabled persons who cannot protect themselves.401
B. Allowing Fear to Overcome Compassion
Despite the fact that mentally ill people are far more likely to be victims of violence than
perpetrators, common media themes portray the mentally ill as violent, unpredictable,
and untreatable.402 This widely held misconception creates fear of people with mental
illness that justifies the substitution of law enforcement officers for mental health
professionals in responding to people in mental health crisis.
Criminalization of mental illness-induced behavior leads to damaging and unnecessary
trauma for the person in crisis.403 Such encounters can also trigger an officer’s own
unresolved trauma.404 405 406 407 The officer’s response can then escalate trauma in the
398

No New Limit on Police Use of Force. https://www.scotusblog.com/2015/05/opinion-analysis-no-newlimit-on-police-use-of-force/
399
Reasonable Accommodations Not Unreasonable Violence. http://cdrnys.org/blog/disability-dialogue/thedisability-dialogue-reasonable-accommodations-not-unreasonable-violence/
400
Police Didn’t Discriminate. https://www.startribune.com/minnesota-agency-says-police-didn-tdiscriminate-in-hauling-mentally-ill-man-tojail/410321985/?fbclid=IwAR1lVWCFVwWDFueOW57xLNVRUtG7pn6aQIqXvheb66-2EbXFXYuBRbdFenc
401
Police as Streetcorner Psychiatrist, op. cit.
402
Media’s Damaging Depictions of MI. https://psychcentral.com/lib/medias-damaging-depictions-ofmental-illness/2/
403
Police MI Interactions, op. cit.
404
Friends Under Fire. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0099403
405
Childhood Trauma in Police Recruits.
https://www.sciencedirect.com/science/article/abs/pii/S0006322304010728
406
Childhood Trauma and Police Cadets. https://psycnet.apa.org/record/2007-06673-012
407
MH Stigma Among Police Officers. https://link.springer.com/article/10.1007/s11896-018-9285-x

X. MORAL AND ETHICAL CONSIDERATIONS

115

patient. Because trauma is not solely or even primarily a mental health condition, but
actually lives in the body, 408 409 410 the mind may not perceive what is happening. As the
person in crisis moves into “fight or flight” mode in reaction to their own fears, the
situation can reach a dangerous high and the officer may resort to use of force to regain
control of the situation. The officer may say he feared for his life as an explanation for his
reaction.
Law enforcement officers and many others fail to recognize or understand the signs of a
traumatic reaction, treating the person as if they should just stop or get the reaction
under control on their own. If a person has a heart attack, they’re provided with
treatment with no expectation that they can voluntarily stop the heart attack. The same
understanding should apply to mental health crisis.
C. Beyond Control—Valuing Autonomy
There is a strange disconnect between the rights of patients and the actions of police that
must be considered and confronted.
Every human being needs autonomy, competence, and interconnection. This set is
referred to as Basic Psychological Needs.411 If it is immoral to forcibly prevent a person
from accessing water, it is equally immoral to forcibly prevent someone from exercising
their autonomy.
Research consistently shows that creating more space for these needs empowers people
to be more independent, healthier, and more caring towards others.412 413 This strongly
suggests that a police-only response to mental health crisis, with its inherent veneer of
state authority and potential for use of force, will make the person less capable, healthy,
and independent.
D. Acting on a Moral and Ethical Imperative
There is a moral and ethical crisis in the status quo that promotes unnecessary policeonly contacts with people experiencing mental health crisis. It is demonstrably unjust
408

Complex Trauma. https://www.healio.com/psychiatry/journals/psycann/2005-5-35-5/%7B4b9f80301eba-442f-8b32-8504c01a0000%7D/complex-trauma-in-children-and-adolescents#
409
The Body Keeps the Score; Van der Kolk, B. A. (2014).
https://books.google.com/books?hl=en&lr=&id=vHnZCwAAQBAJ&oi=fnd&pg=PA1&dq=dr+van+der+kolk+tr
auma&ots=THsvjkPmw&sig=eUgp7ohrSKwLqjmMS2BXukuqia8#v=onepage&q=dr%20van%20der%20kolk%20trauma&f=fa
lse
410
Polyvagal Theory of Trauma.
http://www.complextrauma.uk/uploads/2/3/9/4/23949705/stephen_porges_interview.pdf
411
Brick by Brick. https://www.sciencedirect.com/science/article/pii/S221509191930001X?via%3Dihub
412
Brick by Brick, op. cit.
413
SDT Applied to Health Contexts. https://journals.sagepub.com/doi/abs/10.1177/1745691612447309

X. MORAL AND ETHICAL CONSIDERATIONS

116

and inhumane to have police officers simultaneously act as law enforcers and de facto
mobile mental health crisis responders. The fact that our legislation and our courts
permit this does not make it ethical or moral.
In truth, the use of police for mental crisis calls in lieu of mental health professionals is
simply bad policy born of fear. It is a policy decision that has been made for our
communities by multiple generations of civil servants and politicians. This paper has
offered all the criticisms. We have shown that this is an avoidable ill. It is inappropriate,
unjust, and inhumane. It is wasteful and stems from a profound failure of leadership.
Most importantly, it persists in defiance of the values and priorities we share as a society.
The time has come for communities to move beyond the inadequate standards set by the
law and the courts and to do the right thing for vulnerable members of the community.
Recognizing this, we must finally choose to move the thin blue line aside and permit
collaboration and direct crisis response by professionals with the appropriate expertise.

XI. CONCLUDING STATEMENTS AND RECOMMENDATIONS

117

XI. CONCLUDING STATEMENTS AND RECOMMENDATIONS
We offer three clear recommendations.



IMPLEMENT DISPATCH TRIAGE AT 911 CALL CENTERS. Assigning calls for help to the
appropriate responders is a necessity. It is imperative to triage 911 calls and deflect
mental health-related calls away from police-only contact whenever possible. Some
calls can be deflected to alternative responders like county mobile mental health crisis
teams. When calls have a public safety consideration that requires a police presence,
dispatch triage can lead to a co-response option.



UTILIZE ALTERNATIVE RESPONDERS. There must be routine deflection to non-police
alternative responders when 911 centers receive mental health-related calls.
Communities must avoid unnecessary police contacts by creating and utilizing
mobile response teams of highly qualified mental health professionals. Availability
and fast response are key and might require the use of mobile crisis teams that are
dedicated to responding to 911 calls. Minnesota has the ideal foundation for this
response with its existing county mobile mental crisis response teams.



ENABLE REAL TIME CO-RESPONSE TO PREVENT POLICE-ONLY CONTACTS. A police-mental
health professional co-response option is needed for some cases where considerations
such as safety require an officer to be present. This puts mental health professionals
on-scene in real time as part of a co-responder team. Real time co-response is
distinctly different from simple follow-up contact. The strong collaboration within coresponder teams makes them the ideal form of co-response. These co-responder
teams are also excellent for assisting on calls where a mental health aspect is
determined only after police arrive. In other cases, county mobile crisis teams can be
staged nearby for co-response after a scene is confirmed to be safe—just as is done
with ambulance services.

XI. CONCLUDING STATEMENTS AND RECOMMENDATIONS

118

It is time for our government to respond to calls for help with the appropriate resources.
Faithfully serving vulnerable community members means enabling real time mobile
mental healthcare responses to 911 calls involving mental illness. Law enforcement-only
responses must be minimized because they criminalize mental illness, waste resources,
and create inferior outcomes for patients.


We call for law enforcement officers to prioritize the needs of persons with mental
illness. Actively promoting and enabling on-scene clinician response is the best way
for law enforcement agencies to serve and protect persons with mental illness.



We call for county health department administrators to fully accept the responsibility
for mobile crisis response and work to minimize police-only contacts with persons in
mental health crisis.



We call for city and county leaders to create the funding and the binding policy
changes needed. Cities and counties must work together to ensure that mental health
crisis calls will be deflected to alternative or co-response options.



We call for state politicians to frame legislation that funds and obligates local dispatch
triage, rapid alternative response, and co-response options. This gap in care requires
the attention of state government.

Most of all, we urge community members to become actively engaged in the issues
presented here. It is far too easy for government actors to maintain the status quo in the
absence of community pressure. You can start by raising awareness and spurring
discussion with your neighbors. The topics of this paper are being discussed by your city,
county, and state officials. Community members can drive change by attending public
meetings and engaging politicians at all levels. We wish you every success.

GLOSSARY

119

GLOSSARY
211 CRISIS LINES: The Federal Communications Commission (FCC) reserved the 211
dialing code for community information and referral services. The FCC intended the 211
code as an easy-to-remember and universally recognizable number that would enable a
critical connection between individuals and families in need and the appropriate
community-based organizations and government agencies. The existence of a 211 system
or similar dedicated number cannot prevent police contacts with persons in mental
health crisis. Dispatch triage and 911 centers and co-response options will continue to be
needed to prevent police-only contacts.414
911 CALL CENTER/EMERGENCY COMMUNICATIONS CENTER: Call centers operated by cities
and counties to receive 911 emergency calls for assistance. 911 operators coordinate the
emergency response by responders such as the fire department and police department.
Dispatch triage in this writing refers to an added capacity at 911 call centers to deflect
mental health-related calls away from the police and to alternative responders such as
mobile mental health crisis teams.415
ACA (Affordable Care Act): A federal statute that was signed into law in March 2010 under
the title of the Patient Protection and Affordable Care Act (PPACA) to ensure that
Americans have access to affordable and quality health insurance. The Act includes
several provisions to increase health insurance coverage by expanding Medicaid
coverage, developing state health insurance exchanges, and prohibiting insurers from
denying coverage due to pre-existing medical conditions.416
ADA (Americans with Disabilities Act): A 1990 federal law that prohibits discrimination in
areas such as access to programs, services, and activities provided by a public agency.
The ADA is one of America's most comprehensive pieces of civil rights legislation that
prohibits discrimination and guarantees the rights of people with disabilities.417
ALTERNATIVE RESPONSE: Response by entities other than law enforcement. Occurs when
mental health-related calls are deflected to mobile mental health crisis teams in lieu of the
customary police response. This refers to the initial response, not follow-up contact.
AUTONOMY: Functioning independently without control by others.
CAD: See Dispatch, CAD
CAHOOTS (Crisis Assistance Helping Out On The Streets): Program started in Eugene,
Oregon to provide mobile outreach and crisis services. The City of Eugene has one of the
worst unsheltered homeless crises in the nation and utilizes CAHOOTS mobile services
to take pressure off police and thin social services infrastructure. CAHOOTS mobile
teams provide valuable outreach services including basic medical care. The teams get
414

What is 211? https://www.helplinecenter.org/2-1-1-community-resources/what-is-211/
What is 911? https://www.nena.org/page/911GeneralInfo
416
NASMHPD Glossary. http://www.nasmhpd.org/node/1394
417
Introduction to the ADA. https://www.ada.gov/ada_intro.htm
415

GLOSSARY

120

many calls deflected directly to them from the police dispatch level. National media
organizations have elevated awareness of these teams with stories. Although they
provide much needed outreach services, these teams utilize people who are unqualified
by most standards (including Minnesota law) to perform mobile mental health crisis care.
CASE MANAGEMENT: Management of an individual’s mental health, rehabilitation, and
social support needs over an indefinite period of time by a team of people with fairly
small client loads (less than 20). The aim is to help develop skills to access medical,
behavioral health, housing, employment, social, and educational services. Case
management teams can offer 24-hour help and see clients in a non-clinical setting. Case
management is already offered as a county health department service. It need not be
recreated within a parallel faux social services initiative based at law enforcement
agencies.418 419
CASE MANAGEMENT SERVICES – MN STATUTORY DEFINITION: “’Case management services’
means activities that are coordinated with the community support services program as
defined in subdivision 6 and are designed to help adults with serious and persistent
mental illness in gaining access to needed medical, social, educational, vocational, and
other necessary services as they relate to the client's mental health needs. Case
management services include developing a functional assessment, an individual
community support plan, referring and assisting the person to obtain needed mental
health and other services, ensuring coordination of services, and monitoring the delivery
of services.”420
CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTERS (CCBHC): Facilities designed to
provide a comprehensive range of mental health and substance use disorder services to
vulnerable individuals. In return, CCBHCs receive an enhanced Medicaid
reimbursement rate based on their anticipated costs of expanding services to meet the
needs of these complex populations. CCBHCs are responsible for directly providing (or
contracting with partner organizations to provide) nine types of services, with an
emphasis on the provision of 24-hour crisis care.421
CIT (Crisis Intervention Training): CIT is a police-based, pre-booking approach with
specially trained officers who provide first-line response to calls involving a person with
mental illness and who act as liaisons to the mental health system. CIT is not considered

418

Glossary of LE and MH Terms.
https://pmhctoolkit.bja.gov/ojpasset/Documents/Glossary%20of%20Law%20Enforcement%20and%20Ment
al%20Health%20Terms.pdf
419
ICM for Severe MI. https://www.cochrane.org/CD007906/SCHIZ_intensive-case-management-peoplesevere-mental-illness
420
MN Statute 245.462, op. cit.
421
What is a CCBHC? https://www.thenationalcouncil.org/wp-content/uploads/2017/11/What-is-a-CCBHC11.7.17.pdf?daf=375ateTbd56

GLOSSARY

121

evidence-based in terms of outcomes, but is proven to garner positive feedback from
police officers.422 423
CIT PARADOX: CIT training grew in usage because police believed they could not count
on an on-scene response from mobile mental health professionals. Paradoxically, the fact
that police officers get CIT training has now become a rationale for not bothering to
collaborate with clinicians on-scene or deflecting mental health-related calls for service to
mobile mental health crisis teams.
CLINICAL (DIAGNOSTIC) ASSESSMENT: A psychological assessment performed by a mental
health professional to diagnose mental illness and determine appropriate care. This
assessment must be performed by a skilled and credentialed clinician and apply the
standards of the DSM-5 for evaluation of symptoms. In Minnesota and most states, this
evaluation qualifies persons for insurance and public funding only when conducted
through an in-person interview. MN law outlines qualifications for professionals
performing these assessments and defines the assessment.424 425 426
CO-LOCATION: Used here to describe the practice of physically basing local mobile mental
health crisis response teams in the same facilities that house law enforcement agencies
(e.g. sheriff’s offices) and/or local 911 emergency call centers. This practice is especially
beneficial in rural settings where it promotes collaboration between local mobile mental
health response personnel, law enforcement, and 911 dispatchers.
COMMUNITY MENTAL HEALTH ACT OF 1963: A milestone in the process of deinstitutionalization. This act was meant to initiate a transition to more community-based
treatment. However, the resources to make that happen were not provided. The result is
a greater likelihood of police contact with persons living with severe mental illness and
experiencing a mental health crisis.427
COMPASSION: Sympathy; to feel pity, accompanied by an urge to help.
CONSENSUS PROJECT REPORT: A 2002 report that examined the criminal justice system's
response to people with mental illness. The Criminal Justice/Mental Health Consensus
Project brought together leaders in corrections, law enforcement, government mental
health services, and the judicial system. The report presents policy statements for

422

San Diego Blueprint for MH Reform, op. cit.
Eleven Johnson County Cities to Partner, op. cit.
424
MN Statute 245.462, op. cit.
425
MDH Diagnostic Assessment.
https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelection
Method=LatestReleased&dDocName=ID_058048#standard
426
Mayo Diagnostic Assessment. https://www.mayoclinic.org/diseases-conditions/mental-illness/diagnosistreatment/drc-20374974
427
Kennedy’s Vision. https://www.usatoday.com/story/news/nation/2013/10/20/kennedys-vision-mentalhealth/3100001/
423

GLOSSARY

122

improvement based on the existing knowledge base. It became a touchstone resource for
studies and reforms that occurred in subsequent years.428
CONSUMER: A person with a mental illness receiving mental health services. Consumer
advocacy groups and many professionals prefer “people first” language so as not to label
a person as diseased. For example, one should say “a person with mental illness” and not
a “mentally ill person.”429
CO-OCCURRING CONDITIONS: Mental illness occurring in combination with substance use
disorder (SUD), homelessness, poverty, medical ailments, and/or other socialpsychological factors.
CO-OCCURRING DISORDERS (COD): Refers to having both a mental health and substance
use disorder.430
CO-RESPONDER TEAM MODEL: The Co-Responder model pairs law enforcement and
behavioral health specialists to respond to behavioral health-related calls for police
service. These teams utilize the combined expertise of the officer and the behavioral
health specialist to de-escalate situations and help link people with appropriate
services.431 432
COUNTY ADULT MENTAL HEALTH ADVISORY COUNCILS (MN): Boards required by MN state
law and are comprised of community members appointed by county commissioners.
They provide community oversight of local mental health systems and are obligated by
law to create an annual public report of the unmet community needs.433
COUNTY JUVENILE MENTAL HEALTH ADVISORY COUNCILS (MN): These boards are analogous
to the County Adult Mental Health Advisory Councils and provide community oversight
of local mental health systems that serve juveniles.434
COUNTY MENTAL HEALTH BOARDS: As discussed in section IX, Subsection D2, in some
states (e.g. Ohio, North Carolina, but not Minnesota), state legislatures empowered
counties to create boards of experts tasked with planning and funding local mental
healthcare services. These boards represent local control of resources to meet the
community’s needs and have the power to fund services by implementing local tax
levies.435
CRISIS STABILIZATION CENTERS: A facility that provides care to persons in crisis. These
facilities are often built to relieve burdens on hospital emergency rooms and police, and
become drop-off centers that enable a police-only mental health crisis response.
428

CSG Consensus Report, op. cit.
Glossary of LE and MH Terms, op. cit.
430
Ibid.
431
Colorado Co-Responder Program, op. cit.
432
LAPD Unit Praised, op. cit.
433
Adult MH Advisory Council. https://mn.gov/dhs/assets/lac-guidebook_tcm1053-386047.pdf
434
Ibid.
435
MH Services in Ohio, op. cit.
429

GLOSSARY

123

CRISIS STABILIZATION UNITS: Crisis Stabilization Units (CSU) are small inpatient facilities
of less than 16 beds for people in mental health crisis whose needs cannot be met safely
in residential service settings. CSUs may be designed to admit on a voluntary or
involuntary basis when the person needs a secure environment that is less restrictive
than a hospital. CSUs try to stabilize the person and get him or her back into the
community quickly.
DECOMPENSATION: Deterioration of a person’s mental health and/or return to a lower
level of psychological adaptation or functioning, often occurring when an individual is
under considerable stress or has discontinued psychiatric medication against medical
advice.436
DECRIMINALIZATION OF MENTAL ILLNESS: This phrase refers to efforts to reduce the high
percentage of persons in jails with untreated mental illness. Criminalization of mental
illness is a result of defaulting to a law enforcement response to mental health calls.
Criminalization can take the form of avoidable incarceration or the harm (stigma,
trauma, and lack of clinical care) that comes with unnecessary police contacts with
persons in mental health crisis.
DECRIMINALIZE: To eliminate or reduce legal penalties.
DE-ESCALATE: To reverse the effect of escalation; reduce or lessen in scope or magnitude.
DE-ESCALATION: Verbal and nonverbal interpersonal skills that enable a law enforcement
officer to recognize and defuse violent behavior, preferably without force, preserving the
suspect’s safety and dignity.437
DE FACTO: Existing or being such in actual fact, though not by legal establishment; official
recognition; by default.
DEFLECTION: Moving a person away from any contact with the criminal justice system
and toward community mental health and social services, avoiding arrest and/or
processing into the criminal justice system. Deflection refers to complete avoidance of
police contact. This is in contrast to the more ambiguous term, diversion. Deflection is
used in this paper for absolute clarity. “Pre-booking diversion” could be considered
synonymous in some circumstances.438
DE-INSTITUTIONALIZATION: The process of replacing long-stay psychiatric hospitals with
community mental health services for those diagnosed with a mental disorder or
developmental disability.

436

Glossary of LE and MH Terms, op. cit.
Ibid.
438
Deflection Surge. https://thecrimereport.org/2017/03/21/the-deflection-surge-key-to-reducing-rearrests/#
437

GLOSSARY

124

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-V): The standard
reference handbook used by behavioral health professionals in the United States to
classify mental health conditions. The current edition is denoted V.439
DISPATCH, CAD (Computer-Aided Dispatch): Computer systems at 911 emergency calls
centers use advanced software and hardware to help dispatchers gather and share
information. CAD systems enable rapid communications with police and fire
departments. Minnesota law allows these systems to also be used for communication
with county-run mobile mental health crisis response teams. CAD systems are mostly
separate from RMS systems used by police agencies for managing information about
calls for service.440 441
DISPATCH, FLAGGING RECORDS: Calls for service are given call descriptors that reflect the
nature of the call as originally understood by 911 call takers. Responding officers find
that many calls for service have a mental health component despite being assigned
unrelated call descriptors (e.g. “domestic disturbance”). CAD and RMS computer
systems are typically not designed to allow dispatchers or officers to flag such calls to
assist data searches if the original call descriptor does not reflect a mental health
component. This is part of the reason why mental health-related calls for service are
significantly undercounted.442 443
DISPATCH, IMMINENCE: Imminence is a term used in 911 emergency call centers while
also referring to the legal doctrine of Imminent Peril. Calls are categorized based on the
immediacy of the danger involved. Imminent danger is certain, immediate, and
impending. When danger is imminent or, more rarely, active, then the call always
requires a police response. In many cities (including Minneapolis) 911 calls describing
suicide attempts are almost always considered to have imminent danger and get a policeonly response. The Imminent Peril Doctrine indemnifies responders from liability.
Mobile mental crisis response teams routinely respond to calls that would get a policeonly response from 911 dispatchers. When mobile mental crisis response teams get a call
that includes the possibility of danger to the responder, they request a police co-response.
Few 911 emergency communications centers utilize a co-response option.444 445 446
DISPATCH, POLICE: Police dispatch exists separately from 911 call centers. Call centers
relay calls for service to police dispatchers who manage police response directly.
Dispatch triage should be a function performed at 911 centers, not at police dispatch.
439

NASMHPD Glossary, op. cit.
Computer-Aided Dispatch. https://en.wikipedia.org/wiki/Computer-aided_dispatch
441
MN Statute 403.03, op. cit.
442
Fulton County PD Tracking. https://www.ajc.com/news/local-govt--politics/fulton-police-consider-specialcrisis-teams-for-mental-health-calls/nYJzO3QkdMw9mDMzomte2M/
443
Survey of Police Officers. https://www.cabq.gov/mental-health-response-advisorycommittee/documents/survey-of-police-officers-for-calls-for-services-as-mental-illness.pdf
444
Imminent. https://law.jrank.org/pages/7485/Imminent.html
445
Imminent Peril Doctrine. https://definitions.uslegal.com/i/imminent-peril-doctrine/
446
MPD Policy 7-100. http://www.ci.minneapolis.mn.us/police/policy/mpdpolicy_7-100_7-100
440

GLOSSARY

125

DISPATCH, RMS (Record Management Systems): Law enforcement agencies use RMS
software to communicate and store information related to calls for service. These are
often purchased as packaged systems and rarely allow patrol officers to flag call records
that were found to have a mental health component. Thus a large number of mental
health-related contacts are hidden under unrelated call descriptors (e.g. “domestic
disturbance”). The inability to document the true nature of contacts reduces the ability of
dispatchers or law enforcement to see patterns when calls come in for the same person
and location. Furthermore, statistical summaries are inaccurate, hindering the ability of
police administrators to measure and manage patrol officer workloads.
DISPATCH TRIAGE: The practice of triaging mental health-related calls at 911 centers and,
when appropriate, diverting them to responders other than police services. This practice
has seen significant use as part of the Street Triage programs in the U.K. beginning in
2011 and is becoming common in the U.S.447 448
DISPATCH, URGENCY: Urgency is a term used in 911 call centers where calls are
categorized based on the immediacy of the danger involved. Calls categorized as urgent
involve danger that is impending but not immediate or even certain. This is a lower
category of 911 call than those having imminent danger. In many cities, including
Minneapolis, calls having a high level of urgency get a police-only response. Some of
these calls can involve persons in mental health crisis. In the past, welfare checks for
persons with mental health issues have been categorized as urgent calls and given policeonly responses. Mobile mental health crisis response teams could routinely respond to
many calls that would get a police-only response from 911 dispatchers.449
DIVERSION: Removing someone from the traditional track or expected process of the
criminal justice system; police diversion (or pre-booking diversion) means that the
person is not taken into custody but either taken home, to some treatment or support
system, or simply released in lieu of charging the person with a crime. Jail diversion
involves a judicial decision that pretrial release or probation is more appropriate than
incarceration. This contrasts with deflection, which refers to alternate response that
avoids contact with law enforcement.450
DSM-5, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL HEALTH DISORDERS (Rev. 5): See
Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
DUAL DIAGNOSIS: “Dual diagnosis describes a practice that treats people who suffer from
both an addiction and a psychiatric disorder.”451

447

Abilene 911 Program, op. cit.
Dallas Dispatching Social Workers. https://www.dallasobserver.com/news/dallas-has-been-dispatchingsocial-workers-to-some-911-calls-its-working-11810019
449
MPD Policy 7-100, op. cit.
450
Glossary of LE and MH Terms, op. cit.
451
Dual Diagnosis. https://www.psychologytoday.com/us/blog/the-anatomy-addiction/201110/what-is-dualdiagnosis
448

GLOSSARY

126

DUTY OF CARE: A duty of care is the legal responsibility to avoid actions or omissions that
could reasonably be foreseen to cause harm to others. This is relevant to whether police
must modify their procedures or take added care in interactions with persons in mental
health crises. The U.S. Supreme Court’s Sheehan ruling sidestepped a potential
opportunity to create a duty of care in police interactions with persons in crises.452
DUTY TO PROTECT: Law enforcement officers have only a general obligation to protect the
populace. There is no legal obligation to protect or rescue any individual person. This
established common law has been solidified by the U.S. Supreme Court decision in
DeShaney v. Winnebago County Dept. of Social Services. Thus, there is no legal
requirement for law enforcement officers to respond to 911 calls, including calls that have
a mental health component.453
ETHICAL: Conforming to the standards of conduct expected or legally required of a
profession or group.
FIRST EPISODE PSYCHOSIS (FEP): Psychosis is a disconnect from reality and it can be very
distressing for young persons. Persons experiencing FEP deserve on-scene clinical
response if it is at all possible.
Early psychosis, also known as first-episode psychosis (FEP), is often frightening,
confusing and distressing for the person experiencing it and difficult for his or her
family to understand. During early psychosis or a first episode is the most
important time to connect with the right treatment. Doing so can be life-changing
and radically alter a person’s future.454
FOLLOW-UP SERVICES: After initial police contact, law enforcement may refer an
individual experiencing mental illness to a social services agency. This is an inefficient
and often unsuccessful process that ensures some people needing assistance will fall
through the cracks. Instead, an initial interaction should be a useful clinical intervention
followed by referrals for services coordinated by mental health professionals to stabilize
the individual. Follow-up helps to reduce negative outcomes and benefits individuals
with co-occurring substance use disorder. For high utilizers of services with complex
needs, mental health follow-up services should be part of a broader case management
effort.
FREQUENT PRESENTERS: Persons with mental illness who have repeated, cyclical contact
with law enforcement. Often co-occurring conditions like substance use disorder
promote this cyclical contact. Whom law enforcement perceives as frequent presenters
might also be observed as high utilizers in local health care systems. Integration of
service systems and multi-layered responses can help break the cycle. See also High
Utilizers.

452

CIF Suicide Calls Presentation, op. cit.
Ibid.
454
MHLN Blue Book 2018, op. cit.
453

GLOSSARY

127

GATEKEEPERS TO CARE, POLICE AS: As the first, and sometimes only, option for mobile
response, police are thrust into a position of providing a type of triage service to the
mentally ill that they are neither trained to deliver nor prepared to perform.455 Many
scholars argue that this forces the police into a precarious position of being “primary
gatekeepers” to care.
HIGH UTILIZERS: High utilizers are a small group of patients who have multiple,
sometimes complex, problems that place a disproportionately high burden on
the healthcare system due to their elevated resource use. Many high utilizers
have mental health problems and are also “frequent presenters” to law
enforcement.456 457
HUMAN SERVICES VALUE CURVE: A model of social service delivery that outlines four
levels of delivery from the perspective of the consumer of those services. Used with
imagination, this model offers public sector planners a pathway toward meeting
community needs. However, because of long-standing use of police as primary
responders, planners using this model often fail to recognize the need to deflect calls for
mental health services away from police.458
INTEGRATION, CARE: Care integration combines primary care and mental health services
in one setting. This approach improves overall wellness and saves money by preventing
relapses of medical, mental health, or socio-economic crises and reducing reliance on
hospital emergency departments. Integration is especially beneficial for persons deemed
“high utilizers” of services.459 460
LAW ENFORCEMENT LEARNING SITES: These are police departments that help other
enforcement agencies interested in collaborative approaches to handling mental healthrelated calls. Officially called Criminal Justice Mental Health Law Enforcement Learning
Sites, they were chosen by the U.S. Department of Justice–Bureau of Justice Assistance.
The LAPD, Houston PD, and Arlington (MA) PD are examples.461
LAW ENFORCEMENT MENTAL HEALTH COLLABORATION GRANT: This program funds
innovative collaborative programs. Grant periods are typically three years and can be
used for program planning, initiation, and expansion. Contact the U.S. Department of
Justice’s Bureau of Justice Assistance (BJA).462
LEAD PROGRAMS: The Law Enforcement Assisted Diversion program. This program
funnels persons to social services through contact with police, with or without criminal
455

Cross-Disciplinary Partnerships, op. cit.
Behavioral Health Occupation Projections, op. cit.
457
Targeting High Utilizers, op. cit.
458
CHCS High Utilizer Report, op. cit.
459
Integrating Behavioral Health and Primary Care, op. cit.
460
Integrating Health Care and Social Services. https://www.shvs.org/wp-content/uploads/2016/11/SHVSBailit-Integrating-Health-Care-and-Social-Services-November-2016.pdf
461
CSG Law Enforcement MH Learning Sites, op. cit.
462
Justice and MH Collaboration Program. https://bja.ojp.gov/funding/opportunities/bja-2020-17114
456

GLOSSARY

128

conduct. While the premise is to provide police with referral resources for frequent
presenters, the emphasis is on the use of police as gatekeepers for these services. Instead
of funding a parallel social services (LEAD) structure, cities could utilize their funds to
create a healthy collaboration with the existing county social services delivery system.
The State of Minnesota notes on its website that: “Contacting the county mobile crisis
team can be an entry point for accessing case management and other county services.”463
LICSW: See Social Worker-Licensed, Clinical.
MEDICAID EXPANSION. Authorized by the Affordable Care Act, the Medicaid Expansion
program provides health coverage to individuals between the ages of 19 and 64 with
incomes 138% below the federal poverty level, regardless of disability, assets, and other
factors that are usually taken into account in Medicaid eligibility decisions. This
expansion of health insurance coverage is key to funding innovations and system
integration efforts aimed at helping high utilizers of services.464
MEDICAL ASSISTANCE (Minnesota): Medical Assistance is Minnesota’s name for Medicaid,
a joint federal/state program that provides healthcare coverage for low-income
individuals as defined by federal law. Mobile mental health responses can be covered by
Medicaid if the response teams include a Mental Health Professional as defined under
Minnesota Law.465
MENTAL HEALTH PRACTITIONER—MN STATUTORY DEFINITION: Under Minnesota Statute
245.462, a mental health practitioner provides services to adults with mental illness or
children with emotional disturbance. To qualify, the practitioner must complete at least
30 semester hours or 45 quarter hours in behavioral sciences or related fields and have at
least 2000 hours of supervised experience in the delivery of services to adults or
children.466
MENTAL HEALTH PROFESSIONAL—MN STATUTORY DEFINITION: Under Minnesota Statute
245.462, a mental health professional provides clinical services in the treatment of mental
illness and who is qualified through at least a master’s degree or as a psychiatric nurse.
The most relevant qualification for staffing mobile mental crisis response teams is a
Licensed Clinical Social Worker (LICSW). A LICSW can perform diagnostic assessments
and provide on-scene clinical care.467 468
MOBILE MENTAL HEALTH CRISIS RESPONSE TEAMS: Teams composed of mental health
service professionals who provide on-scene responses in mental health emergencies.469

463

Mobile Crisis MH Services. https://mn.gov/dhs/people-we-serve/adults/health-care/mentalhealth/programs-services/mobile-crisis.jsp
464
Medicaid Matters. https://www.leg.state.mn.us/docs/2018/other/180391.pdf
465
Ibid.
466
MN Statute 245.462, op. cit.
467
Ibid.
468
MN Board of Social Work LICSW Requirements, op. cit.
469
Glossary of LE and MH Terms, op. cit.

GLOSSARY

129

MOBILE MENTAL HEALTH CRISIS RESPONSE TEAMS—MN STATUTORY DEFINITION: Under
Minnesota Statute 256B.0624, these teams provide “face-to-face, short-term intensive
mental health services initiated during a mental health crisis or mental health emergency
to help the recipient cope with immediate stressors, identify and utilize available
resources and strengths, engage in voluntary treatment, and begin to return to the
recipient's baseline level of functioning. The services, including screening and treatment
plan recommendations, must be culturally and linguistically appropriate.” Teams in
Minnesota are supervised by county health departments.470
MOBILE MENTAL HEALTH CRISIS RESPONSE TEAMS—MINNESOTA COUNTIES: Minnesota state
government funds a system of county-based mobile mental health crisis teams staffed by
licensed mental health professionals. These teams should be given the opportunity to
respond to all mental health calls including those that happen to come through 911
systems. At the time of this writing, only Ramsey County deflects mental health-related
911 calls to the county mobile crisis response team using a dispatch triage process.471
MOBILE MENTAL HEALTH CRISIS RESPONSE TEAMS—STREET TRIAGE: In the United Kingdom,
the National Health Service has adopted a collaborative crisis response called street
triage. This takes different forms depending upon the local circumstances but is generally
implemented with a response team comprised of a mental health professional paired
with a police officer and an EMT. This team responds directly to mental health-related
calls for service in a special van. These programs greatly reduce transfers and holds,
improving services and saving money.472
MORAL: Relating to, dealing with, or capable of making the distinction between right and
wrong in conduct.
MULTI-LAYERED RESPONSE: Utilizing several types and levels of response to enable
integrated systems to serve patients at their current level of need. The LAPD created the
first multi-layered response structures involving law enforcement. Their program
exemplifies collaboration with mental health professionals to keep high
utilizers/frequent presenters out of crisis.473
NAVIGATOR PROGRAMS: Programs that put workers in the community to maintain
contact with persons in need and keep them tied to services. They can be an important
avenue for helping persons with mental illness and complex co-occurring conditions
receive health services, mental health care, employment assistance, housing assistance,
and other social services. As with other social service functions, this role should be based
in the county health departments, not police departments.474 475

470

MN Statute 256B.0624, op. cit.
Mobile Crisis Mental Health Services, op. cit.
472
Nottinghamshire Street Triage, op. cit.
473
LAPD Mental Evaluation Unit, op. cit.
474
Community Navigators Reduce Hospital Utilization. https://www.ajmc.com/journals/issue/2018/2018vol24-n2/community-navigators-reduce-hospital-utilization-in-superutilizers
471

GLOSSARY

130

NO HESITATION TRAINING: Training to law enforcement officers encouraging them not to
hesitate to use force on members of the community. Trainers share pseudo-science about
reaction time and pre-attack indicators and provide summations of how state and federal
law minimizes the likelihood of prosecution or discipline for almost any use of force.
Because mental illness can cause a person to have difficulty understanding instructions,
be argumentative, or move about unpredictably, this training creates risk of injury for
people in mental health crisis.476 477
OLMSTEAD U.S. SUPREME COURT DECISION: This 1999 decision, based on the Americans
with Disabilities Act, held that people with disabilities have a right to receive statefunded supports and services in the community (i.e. “least restrictive environment”)
rather than institutions. This ruling can be interpreted to mean that the government has
an obligation to provide mobile mental health crisis services in the community by
clinicians rather than police officers.478
PARENS PATRIAE: An obligation of government to serve and protect vulnerable persons
who cannot help themselves.
PEER SUPPORT SPECIALIST: Occupational title for a person with lived-experience
providing services. These individuals might not have the credentials required under state
law to perform mobile mental health crisis work but they can be a valuable resource for
creating a multi-layered response system.479
POST-TRAUMATIC STRESS DISORDER (PTSD): A psychological reaction that occurs after
experiencing a highly stressing event, such as wartime combat, physical violence or a
natural disaster. PTSD is usually characterized by depression, anxiety, flashbacks,
recurrent nightmares and avoidance of reminders of the event. Also called delayed-stress
disorder or posttraumatic stress syndrome.480
PSMI (PERSISTENT SERIOUS MENTAL ILLNESS): See SMI.
PSYCHIATRIC EMERGENCY SERVICES—MN STATUATORY DEFINITION: Psychiatric emergency
services are immediate responses by mental health professionals available 24 hours,
seven days a week for people experiencing a psychiatric crisis.481
REASONABLE: Using or showing reason, or sound judgment; sensible; not extreme or
excessive.
475

Community Navigation as a Field of Practice.
http://floodlight.denverfoundation.org/Portals/0/Uploads/Documents/Community%20Navigation%20as%20a
%20Field%20of%20Practice_%20Reframing%20Service%20De.pdf
476
How Police Training Contributes to Avoidable Deaths.
https://www.theatlantic.com/national/archive/2014/12/police-gun-shooting-training-ferguson/383681/
477
Lewinski Defends Excessive Force. http://www.citypages.com/news/bill-lewinski-defends-cops-accusedof-excessive-force-6725973
478
About Olmstead, op. cit.
479
Human Services Glossary. https://www.nd.gov/dhs/info/pubs/docs/dhs-glossary-of-terms-acronyms.pdf
480
What is PTSD? https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
481
MN Statute 245.462, op. cit.

GLOSSARY

131

REVOLVING DOOR: The cycle of police contact and potential incarceration that afflicts
some persons with mental illness. Co-occurring conditions can greatly contribute to
individuals falling into this trap.482

RMS (Record Management Systems): See Dispatch, RMS.
RULE 25 ASSESSMENT: This is a chemical dependency assessment, performed by a
qualified person with state assessor certification. It is very beneficial for mobile mental
health crisis response workers to have this certification. To receive public funding for
chemical dependency treatment, an individual needs to have a chemical use assessment
conducted by a Rule 25 assessor.483 484
SECONDARY TRAUMATIC STRESS (STS): Secondary traumatic stress refers to the presence of
PTSD symptoms caused by indirect exposure to traumatic events. Nurses, police officers,
and social workers providing mobile mental health crisis response work are susceptible
to STS.485 486 487
SEPARATE RESPONSE: Researchers use this term to describe the practice of police and
mental health crisis response teams arriving in separate vehicles from separate locations.
482

MI Revolving Door, op. cit.
MN Rule 9530.6615, op. cit.
484
Rule 25 Assessments, op. cit.
485
Social Worker Burnout, op. cit.
486
Officers with PTSD, op. cit.
487
Work Environment and Officer PTSD, op. cit.
483

GLOSSARY

132

Persons in need of mental health crisis response liked this type of co-response less
because police typically arrive first and these separate responders do not collaborate as
well compared to when they co-respond in the same vehicle.488
SEPARATE SILOS: This refers to the problem of separate organizations not communicating
and collaborating well. The problem of separate silos hinders integration of systems and
collaborations between police and social service agencies.
SEQUENTIAL INTERCEPT MODE: A tool for shaping reform in the criminal justice system
created by the Policy Research Associates. This model divides the system into levels (e.g.
Level 0 is prior to police contact) and promotes brainstorming of services to assist people
with problems like substance abuse or mental illness to avoid law enforcement
entanglements.489
SERIOUS AND PERSISTENT MENTAL ILLNESS (SPMI): A diagnosable mental, behavioral, or
emotional disorder that meets the criteria of DSM and has resulted in functional
impairment which substantially interferes with or limits one or more major life activities
of an adult. Specific diagnoses that often meet the criteria for SMI are: schizophrenia,
schizoaffective disorder, bipolar or manic depressive disorder, severe forms of major
depression or anxiety disorders and some personality disorders and are used to
determine eligibility for state-supported mental health services.490
SHEEHAN U.S. SUPREME COURT DECISION: In the 2015 ruling in City and County of San
Francisco v. Sheehan, the court refused to apply ADA requirements to law enforcement.
This weakened arguments for a duty of care and allows law enforcement officers to base
their use of force decisions on Graham v. Connor, even for individuals whose behaviors
are a result of mental illness.491 492 493 494
SOCIAL WORKER, LICENSED: See Social Worker, Licensed, Clinical, LICSW.
SOCIAL WORKER, LICENSED, CLINICAL (LICSW): This is a master’s degree-prepared social
worker who has 4000 hours of supervised experience in a clinical setting and has earned
state certification. LICSW is the highest level of social worker in Minnesota. LISW is a
lower classification that can only work in clinical settings if supervised by an LICSW.
Minnesota recognizes those with LICSW licensure as mental health professionals,
qualified to perform diagnostic assessments and work on mobile mental health crisis
response teams. These professionals are very well suited to provide crisis response,

488

Consumer Experience of CR Services, op. cit.
Sequential Intercept Model. https://www.prainc.com/wp-content/uploads/2017/08/SIM-BrochureRedesign0824.pdf
490
Glossary of LE and MH Terms, op. cit.
491
San Francisco v Sheehan, op. cit.
492
Excessive Reasonableness, op. cit.
493
From Garner to Graham and Beyond, op. cit.
494
Bad Apple Myth of Policing, op. cit.
489

GLOSSARY

133

ensure system integration, and tie patients to wider services or case management.
Minnesota’s labor market has an abundance of LICSWs.495 496 497
STREET TRIAGE: See Mobile Mental Crisis Response Teams, Street Triage.
SUBSTANCE USE DISORDER (SUD): Substance Use Disorder is a complex brain disease that
occurs when a person has a dependence on alcohol and or other drugs that is
accompanied by intense and sometimes uncontrollable cravings and compulsive
behaviors to obtain the substance.498
TELEHEALTH: See Telepsychiatry.
TELEMENTAL HEALTH: See Telepsychiatry.
TELEPSYCHIATRY: Telepsychiatry, a subset of telemedicine, uses video technology to
provide a range of services including psychiatric evaluations, therapy (individual
therapy, group therapy, family therapy), patient education, and medication
management. Mental health care can be delivered in a live, interactive communication.499
TRIAGE DESK: This is a practice of placing a mental health professional within a 911 call
center or police dispatch to assist in dispatch triage or to be available for immediate
consultation with police officers on the scene. This practice was innovated by the Los
Angeles Police Department.500
TRAUMA: Harm or damage caused by a deeply distressing or disturbing experience.
WARRIOR TRAINING: Law enforcement training that encourages a paramilitary culture
and promotes the image of officers as warriors. Trainers emphasize the dangers of
contact with the public and promote paranoia among officers. This training is shown to
cause officers to quickly default to serious use of force that leads to death or serious
injury for persons in crisis.501 502 503
WRAPAROUND SERVICES: An individually designed set of services and supports provided
to people who have multiple needs due to serious mental illness. Wraparound services
include diagnostic and treatment services, personal support services, and other supports
needed to maintain the person in their home and community-based settings. This is a
particularly effective approach in assisting people who are being served by multiple
systems.
495

MN Board of Social Work LICSW Requirements, op. cit.
Social Work Licensure in Minnesota. https://www.humanservicesedu.org/minnesota-social-workrequirements.html
497
MN Statute 245.462, op. cit.
498
Human Services Glossary, op. cit.
499
What is Telepsychiatry? https://www.psychiatry.org/patients-families/what-is-telepsychiatry
500
LAPD Unit Praised, op. cit.
501
Professor Carnage. https://newrepublic.com/article/141675/professor-carnage-dave-grossman-policewarrior-philosophy
502
Law Enforcement’s Warrior Problem, op. cit.
503
The Truth About the Philando Castile Verdict. https://www.youtube.com/watch?v=wqgz7kRGVxg
496

GLOSSARY

134

REFERENCES

135

Introduction
 ‘An explosion of growth’: Wichita PD on mental health calls, taxing on officers. Tiffany Lane. KSN News.
June 19, 2019. https://www.ksn.com/news/local/an-explosion-of-growth-wichita-pd-on-mental-healthcalls-taxing-on-officers/
 2016 Legislative Agenda. Chief Jeff Potts. Minnesota Police Chief. Spring 2016.
https://mcpa.memberclicks.net/assets/Magazine/final_spring_2016.pdf
 2017 Police Suicides—A Continuing Crisis. Andy O’Hara. Law Officer News. January 1, 2018.
https://www.lawofficer.com/2017-police-suicides-continuing-crisis/
 A Crisis in Search of Data: The Revolving Door of Serious Mental Illness in Super Utilization. Office of
Research & Public Affairs. Treatment Advocacy Center. April 2017.
https://www.treatmentadvocacycenter.org/storage/documents/smi-super-utilizers.pdf
 Across Nation, Unsettling Acceptance When Mentally Ill in Crisis are Killed. Kelley Bouchard. Portland
Press Herald. December 9, 2012. https://www.pressherald.com/2012/12/09/shoot-across-nation-a-grimacceptance-when-mentally-ill-shot-down/
 Apply for LICSW. License Requirements. Minnesota Board of Social Work. https://mn.gov/boards/socialwork/applicants/applyforlicense/licsw.jsp
 CIT Officer Loses Control. https://youtu.be/QT4_EXD-PtU
 Conceptual Divides and Practice Synergies in Law Enforcement and Public Health: Some Lessons from
Policing Vulnerability in Australia. Isabelle Bartkowiak-Théron, Nicole L. Asquith. Policing and Society,
Vol 27, Issue 3. 2017. Pages 276-288. DOI: 10.1080/10439463.2016.1216553
 Cops and PTSD. Ellen Kirschman, Ph.D. Psychology Today. November 30, 2018.
https://www.psychologytoday.com/us/blog/cop-doc/201811/cops-and-ptsd
 Criminal Justice/Mental Health Consensus Project. Council of State Governments. June 2002.
https://csgjusticecenter.org/publications/the-consensus-project-report/
 Crisis Intervention Team Core Elements. University of Memphis. September 2007.
http://cit.memphis.edu/pdf/CoreElements.pdf
 Cross Disciplinary Partnerships Between Police and Health Services for Mental Health Care. Inga
Heyman, Emma McGeough. Journal of Psychiatric and Mental Health Nursing. Vol 25, Issue 5-6. JuneAugust 2018. Pages 283–284. https://onlinelibrary.wiley.com/doi/full/10.1111/jpm.12471
 CUAPB Stolen Lives. https://www.cuapb.org/stolen_lives
 Factors Which Put Social Workers at a Greater Risk for Burnout. Brittney Wacek. 2017. St. Catherine
University. https://sophia.stkate.edu/cgi/viewcontent.cgi?article=1806&context=msw_papers
 Family of man shot by Mpls police wins $1.8M award. Brandt Williams. MPR News. October 25, 2010.
https://www.mprnews.org/story/2010/10/25/excessive-force-verdict
 Half Of People Killed Have Disability: Report. Marti Hause and Ari Melber. NBC News. March 14, 2016.
https://www.nbcnews.com/news/us-news/half-people-killed-police-suffer-mental-disability-reportn538371
 Half of Police Shootings Involve People with Mental Illness. John M. Grohol, Ph.D. Psych Central. July
8, 2019. https://psychcentral.com/blog/half-of-police-shootings-involve-people-with-mental-illness/
 Hiring for the 21st Century Law EnforcementOfficer: Challenges, Opportunities, and Strategies for
Success. Patrick Oliver. Cedarville University. 2019.
https://digitalcommons.cedarville.edu/history_and_government_presentations/190
 Improving police interventions during mental health-related encounters: past, present and future.
Jennifer D. Wood, Amy C. Watson. Policing and Society: An International Journal of Research and
Policy. Vol 27, Issue 3. 2017. http://dx.doi.org/10.1080/10439463.2016.1219734
 It’s time to rethink Minnesota’s system of police education and training. James Densley. MinnPost. July
11, 2016. https://www.minnpost.com/community-voices/2016/07/it-s-time-rethink-minnesotas-systempolice-education-and-training/
 Justifiable Homicides by Law Enforcement Officers: What is the Role of Mental Illness? 2013. Treatment
Advocacy Center. https://www.treatmentadvocacycenter.org/storage/documents/2013-justifiablehomicides.pdf
 Lakeville police team formed to follow up on mental health calls. Stephen Montemayor. Star Tribune.
June 16, 2015. http://www.startribune.com/lakeville-police-team-formed-to-follow-up-on-mental-healthcalls/307636751/

REFERENCES

136

 Law Enforcement’s “Warrior” Problem. Seth Stroughton. Harvard Law Review Forum. April 10, 2015.
https://harvardlawreview.org/2015/04/law-enforcements-warrior-problem/
 Man’s death puts Minneapolis police tactic under scrutiny. Randy Furst. Star Tribune. May 24, 2013.
http://www.startribune.com/feb-7-2012-man-s-death-puts-minneapolis-police-tactic-underscrutiny/138821999/
 Mental health assistance now available during police response. Alycin Bektesh. Aspen Daily News. June
19, 2019. https://www.aspendailynews.com/news/mental-health-assistance-now-available-during-policeresponse/article_e7cfdafe-9246-11e9-a8b6-abf0e499a7f0.html
 Mental Health Problems of Prison and Jail Inmates. Doris J. James, Lauren E. Glaze. Bureau of Justice
Statistics, US Department of Justice. September 2006. https://www.bjs.gov/content/pub/pdf/mhppji.pdf
 Mental Health Services in County Jails. Office of the Legislative Auditor, State of Minnesota. March
2016. https://robinainstitute.umn.edu/sites/robinainstitute.umn.edu/files/mn_leg_auditors_report.pdf
 Mental illness in Hennepin County jail far higher than previous estimates, new study finds. Chris Serres.
Star Tribune. September 22, 2016. http://www.startribune.com/mental-illness-in-hennepin-county-jail-farhigher-than-previous-estimates-new-study-finds/394483221/
 Minneapolis to ban ‘warrior’ training for police, Mayor Jacob Frey says. Andy Mannix. Star Tribune. April
18, 2019. http://www.startribune.com/minneapolis-to-ban-warrior-training-for-police/508756392/
 Minnesota Rule 9530.6615. https://www.revisor.mn.gov/rules/9530.6615/
 Minnesota Statute 256B.0624. https://www.revisor.mn.gov/statutes/cite/256B.0624
 More Mentally Ill People Are in Jails and Prisons Than Hospitals: A Survey of the States. E. Fuller
Torrey, MD, et al. Treatment Advocacy Center and National Sheriff’s Association. May 2010.
https://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf
 More Than Half of LA County Inmates Who Are Mentally Ill Don't Need To Be in Jail, Study Finds.
Alyssa Jeong Perry. LAist. January 7, 2020. https://laist.com/2020/01/07/mentally-health-jail-ladiversion.php
 NYPD’s Mental-Illness Response Breakdown. Greg. B. Smith. Intelligencer. March 21, 2019.
http://nymag.com/intelligencer/2019/03/special-report-nypds-mental-illness-response-breakdown.html
 Officers with PTSD at Greater Risk for Police Brutality. Robert T. Muller, Ph.D. Psychology Today.
November 12, 2015. https://www.psychologytoday.com/us/blog/talking-about-trauma/201511/officersptsd-greater-risk-police-brutality
 Pasco Sheriff creates new unit to tackle mental health crisis. Mahsa Saeidi. WFLA. June 17, 2019.
https://www.wfla.com/news/pasco-county/pasco-sheriff-creates-new-unit-to-tackle-mental-health-crisis/
 People with Untreated Mental Illness 16 Times More Likely to be Killed By Police. Treatment Advocacy
Center. https://www.treatmentadvocacycenter.org/key-issues/criminalization-of-mental-illness/2976people-with-untreated-mental-illness-16-times-more-likely-to-be-killed-by-law-enforcement Police ‘Command and Control’ Culture is Often Lethal—Especially for People with Disabilities. Susan
Mizner. Disability Council, American Civil Liberties Union. May 10, 2018.
https://www.aclu.org/blog/criminal-law-reform/reforming-police/police-command-and-control-cultureoften-lethal-especially
 Police as Streetcorner Psychiatrist: Managing the Mentally Ill. Linda Teplin, Nancy Pruett. International
Journal of Law and Psychology. Vol 15, Issue 2, 1992, pp. 139-156.
https://www.sciencedirect.com/science/article/abs/pii/016025279290010X?via%3Dihub
 Police calls involving mental health have doubled. St. Paul now devotes a unit to them. Mara H.
Gottfried. Pioneer Press. March 31, 2018. https://www.twincities.com/2018/03/31/new-st-paul-mentalhealth-officers-look-at-policing-differently/
 Police encounter many people with mental health crises. Could psychiatrists help? Nathaniel Morris.
Washington Post. July 23, 2018. https://www.washingtonpost.com/national/health-science/policeencounter-many-people-with-mental-health-crises-could-psychiatrists-help/2018/07/20/20561c26-748411e8-b4b7-308400242c2e_story.html?noredirect=on
 Police Encounters Gone Wrong Draw Attention to Mental Health Issues. Jennifer Sarrett. The National
Interest. November 14, 2019. https://nationalinterest.org/blog/buzz/police-encounters-gone-wrong-drawattention-mental-health-issues-96161

REFERENCES

137

 Police perceptions of the percentage of contacts in Albuquerque,NM that involve people living with
mental illness. Matthew Tinney, Nils Rosenbaum. December 2015. https://www.cabq.gov/mental-healthresponse-advisory-committee/documents/survey-of-police-officers-for-calls-for-services-as-mentalillness.pdf
 Responding to Sharp Increases in Mental Health Related Calls, Brooklyn Center Police Launch Vitals™
App to Serve Vulnerable Community Members. Vitals Aware Services. January 30, 2020.
https://thevitalsapp.com/announcements/brooklyn-center-police-launch-app
 Road Runners. The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental
Illness, a National Survey. Treatment Advocacy Center. May 2019.
https://www.treatmentadvocacycenter.org/storage/documents/Road-Runners.pdf
 Routine Work Environment Stress and PTSD Symptoms in Police Officers. Shira Maguen et al. Journal
of Nervous and Mental Disease. Vol 197, Issue 10. Pages 754-760. October 2009.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974929/
 Secret Social Service. M. Punch. National Criminal Justice Reference Service. 1979.
https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=66566
 Serious Mental Illness (SMI) Prevalence in Jails and Prisons. Office of Research & Public Affairs.
Treatment Advocacy Center. September 2016.
https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-in-jails-andprisons.pdf
 St. Anthony Village Police Department 2015 Annual Report.
https://www.savmn.com/Archive/ViewFile/Item/52
 Stillwater Mom Speaks Out After Son is Shot, Killed by Police. William Bornhoft. Patch. December 10,
2018. https://patch.com/minnesota/stillwater/stillwater-mom-speaks-out-after-son-shot-killed-police
 The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency.
County of Orange, California. Grand Jury 2014-2015. https://www.calhospital.org/sites/main/files/fileattachments/grand_jury_mental_illness_website_0.pdf
 To stop police shootings of people with mental health disabilities, I asked them what cops—and
everyone—could do to help. Jennifer Sarrett. The Conversation. November 12, 2019.
https://theconversation.com/to-stop-police-shootings-of-people-with-mental-health-disabilities-i-askedthem-what-cops-and-everyone-could-do-to-help-126229
 When Political Will is Not Enough: Jails, Communities and Persons with Mental Health Disorders. Henry
J. Steadman, Ph.D. et al. Policy Research Associates, Inc. January 2015.
http://www.safetyandjusticechallenge.org/wp-content/uploads/2015/05/White-Paper-hjs-jpm-final.pdf
 Where Police Violence Encounters Mental Illness. Matthew Epperson. New York Times. January 13,
2019. https://www.nytimes.com/2016/01/13/opinion/where-police-violence-encounters-mentalillness.html
Section III
 A cry for help summoned the police—and ended in his death. Alisa Roth. MPR News. November 23,
2019. https://www.mprnews.org/story/2019/11/21/a-cry-for-help-summoned-the-police-and-ended-in-hisdeath
 After police kill St. Paul man, brother says they ‘were supposed to help.’ Nicole Norfleet, Chao Xiong.
Star Tribune. December 23, 2015. http://www.startribune.com/st-paul-man-killed-in-officer-involvedshooting-is-identified/329566071/
 Blue Print for Mental Health Reform. Office of San Diego District Attorney Summer Stephan. February
2019. https://www.sdcda.org/Content/Preventing/Blueprint%20for%20Mental%20Health%20Reform.pdf
 Council of State Governments Justice Center. https://csgjusticecenter.org/about-jc/
 Eleven Johnson County, KS, Cities to Partner a Mental Health Co-Responder with Law Enforcement.
Justice Center, Council on State Governments. August 28, 2016. https://csgjusticecenter.org/elevenjohnson-county-ks-cities-to-partner-a-mental-health-co-responder-with-law-enforcement/
 Hennepin County plans to build its first secure mental health facility. David Chanin. Star Tribune. July
24, 2018. http://www.startribune.com/hennepin-county-plans-to-build-its-first-secure-mental-healthfacility/489066261/

REFERENCES

138

 Hennepin County steps up plans to address mental illness in jail. Chris Serres. Star Tribune. September
3, 2016. http://www.startribune.com/hennepin-county-aims-for-treatment-not-jail-for-mentalillness/392256331/
 In Los Angeles, a national model for how to police the mentally ill. Noelle Swan. The Christian Science
Monitor. June 15, 2015. https://www.csmonitor.com/USA/Justice/2015/0615/In-Los-Angeles-a-nationalmodel-for-how-to-police-the-mentally-ill
 In push to keep mentally ill out of jail, county to expand crisis centers. Abby Sewell. Los Angeles Times.
November 12, 2014. https://www.latimes.com/local/lanow/la-me-ln-mental-health-diversion-20141112story.html
 Ketamine Used to Subdue Dozens at Request of Minneapolis Police, Report Says. Christopher Mele.
New York Times. June 16, 2018. https://www.nytimes.com/2018/06/16/us/ketamine-minneapolispolice.html
 Los Angeles Police Department Mental Evaluation Unit.
http://www.lapdonline.org/detective_bureau/content_basic_view/51704
 Minn. lawmakers consider better police training for mental health crises. Riham Feshir. MPR News. April
11, 2016. https://www.mprnews.org/story/2016/04/11/police-mentally-ill-training-law
 Overland Park Police Department’s Mental Health Co-Responder Project. Alex M. Holsinger, Ph.D.
Department of Criminal Justice and Criminology, UMKC.
https://www.jocogov.org/sites/default/files/documents/CMO/Overland%20Park%20Coresponder%20Program%20Evaluation.pdf?fbclid=IwAR3gvfMuCvvsx6bs33GQFQU4WAMBXYPbczNc2
DYjXnOc7lQhGXmJ8LurEds
 Police crisis intervention training: We need a new paradigm, not a new building. Jillian Peterson, James
Densley. MinnPost. March 23, 2018. https://www.minnpost.com/community-voices/2018/03/police-crisisintervention-training-we-need-new-paradigm-not-new-building/
 Policy Action Network Updates. Jeanne Oliver. Jefferson Center for Mental Health. March 31, 2017.
https://myemail.constantcontact.com/Policy-Action-NetworkNewsletter.html?soid=1102181462552&aid=ZHy6miUK0TI
 Psychiatric Emergency Response Team. Escondido Police Department.
https://police.escondido.org/pert.aspx
 Regional effort better equips officers for behavioral health disorders. Jonathan Phelps. MetroWest Daily
News. October 27, 2018. https://www.metrowestdailynews.com/news/20181027/regional-effort-betterequips-officers-for-behavioral-health-disorders
 Severe mental health crises end in fatal encounters with MN cops. Alisa Roth. MPR News. November
29, 2018. https://www.mprnews.org/story/2018/11/29/several-mental-health-crises-end-in-fatalencounters-with-mn-cops
 Support SB17-207: Strengthen Colorado’s Behavioral Health Crisis System.
https://files.constantcontact.com/812722f9001/2edf93e6-b7fb-427f-b7f0-dca19e9dabf9.pdf
 What the Hell Happened to the Chicago Police’s “Crisis Intervention” Training? Jaeah Lee. Mother
Jones. January 15, 2016. https://www.motherjones.com/politics/2016/01/chicago-police-program-wassupposed-prevent-deaths-quintonio-legrier/
Section IV
 2018 Legislative Issues. Mental Health Legislative Network of Minnesota.
https://mentalhealthmn.org/wp-content/uploads/2017/05/2018-MHLN-Blue-Book.pdf
 Birkeland v. Jorgenson et al, No. 0:2017cv01149 - Document 67 (D. Minn. 2019). Justia US Law. May 1,
2019. https://law.justia.com/cases/federal/district-courts/minnesota/mndce/0:2017cv01149/163727/67/
 CAHOOTS Crisis Intervention Worker Job Posting. White Bird Clinic. https://whitebirdclinic.org/jobpostings/
 Catching psychosis early. Heather Stringer. American Psychological Association. October 2016, Vol. 47,
No. 9. https://www.apa.org/monitor/2016/10/psychosis
 Consumer experience of formal crisis-response services and preferred methods of crisis intervention.
Boscarato, Lee, Kroschel, Hollander, Brennan, Warren. International Journal of Mental Health Nursing.
February 27, 2014. doi: 10.1111/inm.12059

REFERENCES

139

 Cops Morphing into Social Workers Not a Solution. Helen Redmond. Filter. April 23, 2019.
https://filtermag.org/cops-morphing-into-social-workers-is-not-a-solution/
 Could mental health experts prevent Phoenix officer-involved shootings? KTAR News. April 22, 2019.
https://ktar.com/story/2542809/could-mental-health-experts-prevent-phoenix-officer-involvedshootings/?show=comments
 Crisis averted: How consumers experienced a police and clinical early response (PACER) unit
responding to a mental health crisis. Evangelista, Lee, Gallagher, Peterson, et al. International Journal
of Mental Health Nursing. March 1, 2016, Vol. 25, Issue 4, pp. 367–376. doi: 10.1111/inm.12218
 Crisis Clinician/Practitioner Job Posting. Canvas Health.
https://www.indeed.com/viewjob?jk=da003adc51f7a2da&q=mobile+crisis&l=Ramsey+County,+MN&tk=1
e0p862lbp9p7801&from=web&vjs=3
 Discretion and Diversion in Albany’s Lead Program. Robert E. Worden and Sarah J. McLean. Criminal
Justice Policy Review. May 10, 2018, Vol. 29, Issue 6-7, pp. 584–610. 10.1177/0887403417723960.
 Don’t pretend every cop can play social worker. Stephen Eide. New York Post. April 3, 2019.
https://nypost.com/2019/04/03/dont-pretend-every-cop-can-play-social-worker/
 Duluth case shows police body camera footage is new legal battleground. Jessica Glenza. The
Guardian. January 1, 2015. https://www.theguardian.com/us-news/2015/jan/01/duluth-police-bodycamera-footage-legal-battleground
 Hennepin County Senior Psychiatric Social Worker Job Posting. Hennepin County Human Resources.
March 27, 2018.
https://agency.governmentjobs.com/hennepin/job_bulletin.cfm?jobID=2020787&sharedWindow=0
 In crisis: Utah police on front lines of the lack of mental health care. Jeremy Harris. KUTV. February 10,
2017. https://kutv.com/news/local/in-crisis-utah-police-on-the-front-lines-of-the-lack-of-mental-healthcare
 In Milwaukee, $1.2 million police mental health training plan misses the mark. Dan Rabb, Aisha Abdool
Karim, Mustafa Zafar Mirza, Amanda Rosengarten and Meg Kissinger. Milwaukee Journal Sentinel.
June 8, 2018. https://www.jsonline.com/story/news/investigations/2018/06/08/resentful-officers-dubmental-health-program-hug-thug/680618002/
 In the matter of City of Duluth and Duluth Police Union re: Adam Huot use of force discharge. Mario F.
Bognanno. June 22, 2018. https://mn.gov/bms/documents/BMS/134813-20180622-Duluth.pdf
 Investigation of the Chicago Police Department. United States Department of Justice Civil Rights
Division and United States Attorney’s Office Northern District of Illinois. January 13, 2017.
https://archive.org/stream/chicago_police_department_findings/chicago_police_department_findings_djv
u.txt
 Is Crisis Intervention Team (CIT) Training Evidence-Based Practice? A Systematic Review. Jillian
Peterson, James Densley. Journal of Crime and Justice. Vol 41:5. Pages 521-534. July 9, 2018. DOI:
10.1080/0735648X.2018.1484303
 Lakeville police team formed to follow up on mental health calls. Stephen Montemayor. Star Tribune.
June 16, 2015. http://www.startribune.com/lakeville-police-team-formed-to-follow-up-on-mental-healthcalls/307636751/
 LEAD Program Evalution: Recidivism Report. Susan E. Collins, Heather S. Lonczak, and Seema L.
Clifasefi. Harm Reduction Research and Treatment Lab. University of Washington—Harborview Medical
Center. March 27, 2015.
 Letter on Investigation of the Portland Police Bureau. Thomas E. Perez and Amanda Marshall. U.S.
Department of Justice, Civil Rights Division. September 12, 2012.
https://www.portlandoregon.gov/police/article/469399
 Maplewood police, paramedics launch mental health team. Shannon Prather. Star Tribune. July 4, 2019.
http://www.startribune.com/maplewood-police-paramedics-launch-mental-health-team/512238992
 Mental Health and Criminal Justice Reform. C-Span. https://youtu.be/p5JmL0fIOFU
 Mental Health Cops Help Reweave Social Safety Net in San Antonio. Jenny Gold. National Public
Radio. August 19, 2014. https://www.npr.org/sections/health-shots/2014/08/19/338895262/mentalhealth-cops-help-reweave-social-safety-net-in-san-antonio
 Minneapolis City Council LEAD Presentation. November 13, 2019. https://youtu.be/proXKzWmpC8
 Minneapolis Police Department Community Navigator Program.
http://www.minneapolismn.gov/police/about/WCMSP-220186

REFERENCES

140

 Minnesota cops rethink how to respond to suicide calls. Jon Collins. MPR News. December 11, 2019.
https://www.mprnews.org/story/2019/12/11/minnesota-cops-rethink-how-to-respond-to-suicide-calls
 Minnesota Statute 403.03 https://www.revisor.mn.gov/statutes/cite/403.03
 Minutes, Police Conduct Oversight Commision. 3/12/19 Meeting.
http://www2.minneapolismn.gov/meetings/pcoc/WCMSP-217510
 Mobile Crisis Intervention—Brenton Gicker and Chelsea Swift (transcript of radio show). Shimon Cohen.
Doin’ the Work: Frontline Stories of Social Change, Episode 26.
https://drive.google.com/file/d/1F9yNxZJoG2G4CNwIQmFZtaifwuYMgurC/view
 Omaha police have options on mental health calls, but available resources aren't always used. Alia
Conley, Mara Klecker. World Herald. September 10, 2017.
https://www.omaha.com/livewellnebraska/omaha-police-have-options-on-mental-health-calls-butavailable/article_676485ec-9db7-547b-aa84-d796cd33abdd.html
 Police fear ‘suicide by cop” cases. So they’ve stopped responding to some calls. Anita Chabria. Los
Angeles Times. August 10, 2019. https://www.latimes.com/california/story/2019-08-09/suicide-callscalifornia-cops-stopped-responding
 Police Perspectives on Responding to Mentally Ill People in Crisis: Perceptions of Program
Effectiveness. Randy Borum, Psy.D. et al. Behavioral Sciences and the Law. Vol. 16. Pages 393-405.
1998. https://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=1567&context=mhlp_facpub
 Portland mental health responders, an alternative to police, usually bring cops. Emily Green. Street
Roots News. May 3, 2019. https://news.streetroots.org/2019/05/03/portland-mental-health-respondersalternative-police-usually-bring-cops
 Position Statement 59: Responding to Behavioral Health Crises. Mental Health America. March 3, 2017.
https://www.mentalhealthamerica.net/issues/position-statement-59-responding-behavioral-health-crises
 Roseville police won’t be charged in February shooting death. Richard Chin. Pioneer Press. July 7,
2016. https://www.twincities.com/2016/07/07/roseville-police-no-charges-shooting-death-mentally-illman/
 Study in Blue and Grey, Police Interventions with People with Mental Illness: A Review of Challenges
and Responses. Judith Adelman, Ph.D. Canadian Mental Health Association BC Division. December
2003. https://cmha.bc.ca/wp-content/uploads/2016/07/policereport.pdf
 Suicide Calls: Debating How Best to Respond to People in Crisis. Critical Issues Forum. Minnesota
Chiefs of Police. December 11, 2019.
https://mcpa.memberclicks.net/assets/NEWSLETTER/CIF%202020.pdf
 The Burden of Mental Illness Behind Bars. Vera Institute of Justice. June 21, 2016.
https://www.vera.org/the-human-toll-of-jail/inside-the-massive-jail-that-doubles-as-chicagos-largestmental-health-facility/the-burden-of-mental-illness-behind-bars
 The Five-Legged Stool: A Model for CIT Program Success. Nick Margiotta, MEd. Police Chief
Magazine. https://www.policechiefmagazine.org/the-five-legged-stool-a-model-for-cit-programsuccess/?ref=84d53c861e50b658985bf7b63f4e6d1f
 There Has to Be a Better Way. Michael Gregory Consulting. July 7, 2019.
https://www.mikegreg.com/blog/there-has-be-better-way
 Watson, A., Compton, M. & Draine, J. (2017). The Crisis Intervention Team (CIT) Model: An EvidenceBased Policing Practice? Amy C. Watson, et al. August 30, 2017. Behavioral Sciences & the Law. 35.
10.1002/bsl.2304. https://www.ncbi.nlm.nih.gov/pubmed/28856706
Section V
 911 Crisis Call Diversion Program. Houston Police Department, Harris Center for Mental Health and
IDD, Houston Emergency Communications.
https://www.houstontx.gov/council/committees/pshs/20151119/911diversion.pdf
 A descriptive evaluation of theSeattle Police Department’s crisis response team officer/mental health
professional partnership program. Jacqueline Helfgott, Matthew J. Hickman, Andre P. Labossiere.
International Journal of Law and Psychiatry, Vol. 44. August 2015.
https://www.researchgate.net/publication/281310578_A_descriptive_evaluation_of_the_Seattle_Police_
Department's_crisis_response_team_officermental_health_professional_partnership_pilot_program

REFERENCES

141

 A scheme that prevents people who are having a mental health crisis being detained in police custody
has received national recognition at the Nursing Standard Nurse Awards. RCNi.
https://rcni.com/newsroom/nurse-awards/caring-approach-street-triage-nurses-people-mental-healthcrisis-26411
 Advocates Jail Diversion Program: A Step-by-Step Tool Kit. Advocates.
https://mn.gov/dhs/assets/czech-advocates-jds-manual-12_tcm1053-256994.pdf
 Baltimore police add crisis response team. Meredith Cohn. The Baltimore Sun. July 27, 2017.
https://www.baltimoresun.com/maryland/baltimore-city/bs-hs-police-crisis-response-20170727-story.html
 Beyond Road Runners: Insights from Other Countries. Jessica Walthall. Fixing the System: Features
and News. Treatment Advocacy Center. https://www.treatmentadvocacycenter.org/fixing-thesystem/features-and-news/4168-research-weekly-beyond-road-runners-insights-from-other-countries
 Boston Police Ride Along. The Stepping Up Initiative. https://stepuptogether.org/people/boston-policeride-along-2
 City eyes staffing mental health clinicians to attend to 911 calls. Dan Atkinson. Boston Herald. February
15, 2017. https://www.bostonherald.com/2017/02/15/city-eyes-staffing-mental-health-clinicians-toattend-to-911-calls/
 CMPD pairing officers with social workers to help de-escalate mental health calls. Elsa Gillis.
WSOCTV.com. January 23, 2019. https://www.wsoctv.com/news/local/cmpd-pairing-officers-with-socialworkers-to-help-de-escalate-mental-health-calls/908753927/
 County mental health change exposes large need. Andrew Hazzard. Southwest News Media.
September 9, 2018. https://www.swnewsmedia.com/shakopee_valley_news/county-mental-healthchange-exposes-large-need/article_7133a52c-b45a-5bfd-9a36-c1770fbc1bd8.html
 County Votes to Expand ‘Mental Evaluation Teams,’ Establish Mental Health ‘Triage Help Desk.’
SCVNews.com. https://www.printfriendly.com/p/g/gkRxzr
 Crisis Call Diversion Program. Houston Police Department, Mental Health Division. October 18, 2017.
https://perma.cc/XW5L-TCXB
 Does the use of telemental health alter the treatment experience? Inmates' perceptions of telemental
health versus face-to-face treatment modalities. Robert D. Morgan, Amber R. Patrick, Philip R.
Magaletta. Journal of Consulting and Clinical Psychology, Vol. 76, Issue 1. 2008.
https://psycnet.apa.org/record/2008-00950-018
 DPD’s Co-responder Unit Hopes to Get a Boost From Caring 4 Denver. Conor McCormick-Cavanagh.
November 5, 2019. https://www.westword.com/news/part-of-caring-4-denver-money-would-go-to-coresponder-unit-10935094
 First-year follow-up of the Psychiatric Emergency Response Team (PAM) in Stockholm County,
Sweden: A descriptive study. Olof Bouveng, Fredrik A. Bengtsson, Andreas Carlborg. International
Journal on Mental Health. Vol. 46, Issue 2. February 14, 2017.
https://www.tandfonline.com/doi/full/10.1080/00207411.2016.1264040
 Grant to Help Tulsa’s Community Response Team expand beyond pilot program. Corey Jones. Tulsa
World. February 11, 2018. https://www.tulsaworld.com/news/crimewatch/grant-to-help-tulsa-scommunity-response-team-expand-beyond/article_0f183e3e-5070-53df-a452ca014a425f64.html?fbclid=IwAR05DFpkXKmOZCb7vZdTHhEsZVtVsETjRq1g7CVaTLZQ7AKUTziSCA
bw1uo
 Guidelines for the Practice of Telepsychology. Joint Task Force for the Development of Telepsychology.
American Psychologist. December 2013. https://www.apa.org/pubs/journals/features/amp-a0035001.pdf
 How co-responder teams are changing the way Minneapolis police deal with mental health calls. Jessica
Lee. MinnPost. January 2, 2019. https://www.minnpost.com/metro/2019/01/how-co-responder-teamsare-changing-the-way-minneapolis-police-deal-with-mental-healthcalls/?fbclid=IwAR1lp9HY0VyAyVH7vq93WbHeMzF4G5E3Ulf2K7E_wYxDsV442oS4LxBMJFw
 Jail Diversion Program Impact & Outcomes. Advocates. 2020. https://www.advocates.org/services/jaildiversion/jail-diversion-program-impact-outcomes
 Jail Project Priorities, Blue Earth County. Yellow Line Project.
https://static1.squarespace.com/static/59a9b5a96f4ca376db822022/t/59c2c888197aea0c2f8207db/150
5937548753/continuum+of+care.png
 Johnson County Hiring More Mental Health Co-responders. https://youtu.be/VlW9r0V4YqE

REFERENCES

142

 Law Enforcement Mental Health Learning Site-Arlington Police Department. Justice Center, Council of
State Governments. https://csgjusticecenter.org/projects/police-mental-health-collaboration-pmhc/lawenforcement-mental-health-learning-sites/arlington-police-department/
 Law Enforcement Mental Health Learning Sites. Justice Center, Council of State Governments.
https://csgjusticecenter.org/projects/police-mental-health-collaboration-pmhc/law-enforcement-mentalhealth-learning-sites/
 Law Enforcement—Mental Health Learning Site, Houston Police Department. Justice Center, Council of
State Governments. https://csgjusticecenter.org/wp-content/uploads/2020/02/Law-Enforcement-MentalHealth-Learning-Sites_Houston3.26.19_508accessible.pdf
 Los Angeles Police Department Mental Evaluation Unit Program Overview. September 2016.
https://pmhctoolkit.bja.gov/ojpasset/Documents/MEU-Program-Outline-Sept-2016.pdf
 Managing risks of telepsychology. Julie Jacobs. The National Psychologist. August 6, 2018.
https://nationalpsychologist.com/2018/08/managing-risks-of-telepsychology/104807.html
 Marin County Sheriff’s Office Letter to Treasure Coast Newspapers Editorial Board. William D. Snyder.
June 20, 2017.
https://www.facebook.com/MartinCountySheriffsOffice/photos/a.316726388337911/1565414696802401/
?type=3&theater
 Mental Health Advocates Want 911 Linked with Crisis Response Teams. Katherine Johnson. KSTP
News. October 11, 2018. https://kstp.com/news/mental-health-advocates-want-911-linked-with-crisisresponse-teams/5105208/
 Mental Health Crisis Response Services—Adult. Hennepin County Human Services and Public Health
Department. July 24, 2020.
https://www.minnesotahelp.info/Providers/Hennepin_County_Human_Services_and_Public_Health_Dep
artment/Mental_Health_Crisis_Response_Services_Adult/1?returnUrl=%2FSpecialTopics%2FYouth%2
F19590%3F
 Minnesota Statute 245.462. https://www.revisor.mn.gov/statutes/cite/245.462/pdf
 New Abilene 911 program helps callers in mental health crisis. Laura Gutschke. Abilene Reporter News.
February 1, 2019. https://www.reporternews.com/story/news/2019/02/01/new-abilene-programaddresses-911-mental-health-call/2747350002/
 New Crisis Response Unit in Washington County helps answer mental health crisis calls. Beth
McDonough. KSTP.com. February 17, 2019. https://kstp.com/medical/new-crisis-response-unit-inwashington-county-helps-answer-mental-health-crisis-calls/5249677/
 Nottinghamshire street triage scheme. NHS Mental Health Case Studies.
https://www.england.nhs.uk/mental-health/case-studies/notts/
 Police and the mentally ill: LAPD unit praised as model for nation. Stephanie O’Neill. KPCC Radio.
March 9, 2015. https://www.scpr.org/news/2015/03/09/50245/police-and-the-mentally-ill-lapd-unitpraised-as-m/
 Police Response to People with Mental Illnesses in a Major U.S. City: The Boston Experience with the
Co-Responder Model. Melissa S. Morabito, Jenna Savage, Lauren Sneider, Kellie Wallace. Victims &
Offenders, Vol. 13, Issue 8. November 20, 2018.
https://www.tandfonline.com/doi/full/10.1080/15564886.2018.1514340
 Presentation by Brian Theine at the Critical Issues Forum. Minnesota Association of Police Chiefs.
https://youtu.be/nbET9b8p80c
 Psychiatric Emergency Response Team and Homeless Outreach Team: San Diego Police Department.
https://popcenter.asu.edu/sites/default/files/library/awards/goldstein/2005/05-12.pdf
 Ramsey County tries new approach for some 911 crisis calls. Mara Gottfried. Pioneer Press. February
29, 2016. https://www.twincities.com/2016/02/29/ramsey-county-911-will-send-mental-health-workersto-crises/
 RCPD happy with mental health co-responders. Bryan Richardson. The Mercury. August 18, 2017.
https://themercury.com/news/city/rcpd-happy-with-mental-health-co-responders/article_d1b9ee25-f94f59d4-9843-0c781d64b2cd.html?fbclid=IwAR12GncQNvGul34pueoQycFt4aNNxCH9E0TEaLGWSL0ARrcs49-3EtahFU
 Reasonable Accommodations, Not Unreasonable Force. Center for Disability Rights.
http://cdrnys.org/blog/disability-dialogue/the-disability-dialogue-reasonable-accommodations-notunreasonable-violence/

REFERENCES

143

 Recommendations for Reform: Restoring Trust between the Chicago Police and the Communities they
Serve. Police Accountability Task Force. April 2016. https://chicagopatf.org/wpcontent/uploads/2016/04/PATF_Final_Report_4_13_16-1.pdf
 Sen. John Cornyn praises Dallas police mental health crisis response program. Samantha J. Gross. The
Dallas Morning News. July 28, 2018. https://www.dallasnews.com/news/2018/07/28/sen-john-cornynpraises-dallas-police-mental-health-crisis-response-program/
 Solutions. Campaign Zero. https://www.joincampaignzero.org/solutions#solutionsoverview
 St Paul police expanding new mental health unit. Alisa Roth. MPR News. December 24, 2018.
https://www.mprnews.org/story/2018/12/24/st-paul-police-already-want-to-expand-new-mental-healthunit?fbclid=IwAR0doyxcYdMdecy6roJ_x39NYaJZAMXOfGnQ7wWaokM3Yuv2zYjQ5-Yl6oM
 Street triage service. Avon and Wiltshire Mental Health Partnership.
http://www.awp.nhs.uk/services/community/street-triage-service/
 Street triage’ to help the vulnerable. Ed Thomas. BBC News. May 14, 2015.
https://www.bbc.com/news/health-32739451
 Successful Launch of World’s First Mental Health Ambulance in Stockholm. Tor Kjolberg. Daily
Scandinavian. January 8, 2018. https://www.dailyscandinavian.com/successful-launch-worlds-firstmental-health-ambulance-stockholm/
 The Police and Mental Health. H. Richard Lamb, Linda E. Weinberger, Walter J. DeCuir. Psychiatric
Services, Vol. 53, No. 10. October 2002.
https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.53.10.1266
 The True Cost of the Mental Health Crisis in the Emergency Department. Robyn Baek. Heathcare
Business Today. August 30, 2019. https://www.healthcarebusinesstoday.com/true-cost-mental-healthcrisis-emergency-department/
 The Yellow Line Project. https://www.yellowlineproject.com/history-of-ylp/
 Too much detention? Street Triage and detentions under Section 136 Mental Health Act in the NorthEast of England: a descriptive study of the effects of a Street Triage intervention. Patrick Keown, Jo
French, Graham Gibson, Eddy Newton, Steve Cull, et al. BMJ Open, Vol. 6. July 20, 2016.
https://bmjopen.bmj.com/content/bmjopen/6/11/e011837.full.pdf
 Transferring 911 Mental-Health Calls Could Reduce Harm. Caroline Cournoyer. Governing. December
5, 2011. https://www.governing.com/idea-center/Transferring-911-Mental-Health-Calls-Could-ReduceHarm.html
 WATCH: Duluth, St. Louis Co. officials recognize Mental Health Unit. Krystal Frasier. CBS 3 Duluth.
May 22, 2019. https://cbs3duluth.com/2019/05/22/watch-live-at-130-p-m-duluth-st-louis-co-officials-torecognize-mental-health-unit/
 What Works? Collaborative Police and Health interventions for mental health distress. Emma
McGeough and Rebecca Foster. Justice Analytical Services, Scottish Government.
https://www.gov.scot/binaries/content/documents/govscot/publications/research-andanalysis/2018/08/works-collaborative-police-health-interventions-mental-healthdistress/documents/00537517-pdf/00537517-pdf/govscot%3Adocument/00537517.pdf
Section VI
 2018 Annual Homeless Assessment Report (AHAR) to Congress: Part 1. Meghan Henry, Anna
Mahathey, Tyler Morrill, Anna Robinson, Azim Shivji, and Rian Watt, Abt Associates. U.S. Department
of Housing and Urban Development, Office of Community Planning and Development. December 2018.
https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf
 A civilized approach to mental illness pays off in Duluth. Bob Collins. MPR News. May 23, 2019.
https://blogs.mprnews.org/newscut/2019/05/a-civilized-approach-to-mental-illness-pays-off-in-duluth/
 Baltimore County Crisis Response. Affiliated Sante Group. https://www.thesantegroup.org/baltimorecounty-crisis-services
 Behavioral Advisory Team to change how mental health emergencies are handled. Lindsey Ragas.
KTXS. February 1, 2019. https://ktxs.com/news/local/behavioral-advisory-team-to-change-how-mentalhealth-emergencies-are-handled
 CAHOOTS Crisis Intervention Job Description. https://whitebirdclinic.org/job-postings/
 CAHOOTS FAQ. White Bird Clinic. March 13, 2014. https://whitebirdclinic.org/services/cahoots-2/

REFERENCES

144

 CAHOOTS Interview. https://youtu.be/kbhpjGTybK4
 Co-Responder Programs. State of Colorado, Department of Human Services.
https://www.colorado.gov/pacific/cdhs/co-responder-programs
 Council Action Form to Authorize Co-Responder Memorandum of Understanding. Johnson County
Council. April 14, 2016. https://drive.google.com/drive/folders/0B28l5JpCZgBfYTVMWnJLckRHT1U
 Criminalizing Homelessness: Data show the unhoused are disproportionately ticketed in Eugene. Kenny
Jacoby. Eugene Weekly. June 1, 2017. https://www.eugeneweekly.com/2017/06/01/criminalizinghomelessness/
 Crisis Clinician/Practitioner Job Posting. Canvas Health.
https://www.indeed.com/viewjob?jk=da003adc51f7a2da&q=mobile+crisis&l=Ramsey+County,+MN&tk=1
e0p862lbp9p7801&from=web&vjs=3
 Crisis Intervention Response Team: A Community Mental Health Task Force. Harris Center for Mental
Health and IDD. July 26, 2019. https://www.theharriscenter.org/Portals/0/CIRT.pdf
 Devon Street Triage. NHS and Northern, Eastern and Western Devon Clinical Commissioning Group.
https://youtu.be/q2La-Hq3xB0
 Downtown Eugene in ‘crisis,’ seen as unsafe, consultant says, citing homelessness. Associated Press.
Seattle Times. February 20, 2017. https://www.seattletimes.com/seattle-news/downtown-eugene-incrisis-consultant-says/
 Embedded social worker working with St. Paul police mental health unit. Mara H. Gottfried. Pioneer
Press. August 1, 2018. https://www.twincities.com/2018/08/01/embedded-social-worker-working-with-stpaul-police-mental-health-unit-with-a-second-starting-soon/
 Eugene Budget Committee 05232018. https://youtu.be/wYCcYwVT6bw
 Eugene Makes National Headlines for Homeless Crisis. KEZI. October 14, 2019.
https://www.kezi.com/content/news/Eugene-makes-national-headlines-for-homeless-crisis509933051.html
 Eugene police chief says homeless problem worst he’s seen. Christian Hill. The Register-Guard.
September 10, 2016. https://www.bendbulletin.com/nation/eugene-police-chief-says-homeless-problemworst-he-s-seen/article_f9a1dc5f-1fb3-5ad9-a7c7-02194ee0a360.html
 Eugene Police Service STATS. https://www.eugene-or.gov/archivecenter/viewfile/item/4801
 Gainesville’s Mental Health Co-Responder Team Diverts Arrests and Saves Taxpayers Money. Angel
Ransby. WUFT. April 26, 2019. https://www.wuft.org/news/2019/04/26/gainesvilles-mental-health-coresponder-team-diverts-arrests-and-saves-taxpayers-money/
 Helping people in crisis. The Register-Guard. December 24, 2017.
https://www.registerguard.com/rg/opinion/36272835-78/helping-people-in-crisis.html.csp
 iPads Could Change How Harris County Deputies Assess Mental Health Crises. Allison Lee. Houston
Public Media. July 26, 2018. https://www.houstonpublicmedia.org/articles/news/indepth/2018/07/26/297294/ipads-could-change-how-harris-county-deputies-assess-mental-health-crises/
 Lane County Shelter Feasibility Study. Technical Assistance Collaborative. December 2018.
https://lanecounty.org/UserFiles/Servers/Server_3585797/File/HSD/Lane%20County%20Final%20Repo
rt_1.14.19.pdf
 Mental health professionals discuss client confidentiality, uniform choice, funding issues at first National
Co-Responder Conference. Leah Wankum. Shawnee Mission Post. March 12, 2020.
https://shawneemissionpost.com/2020/03/12/mental-health-professionals-discuss-client-confidentialityuniform-choice-funding-issues-at-first-national-co-responder-conference-88360/
 Mental Math: Statewide fixes to Oregon’s mental healthcare system move forward–but not fast enough.
Caleb Diehl. Oregon Business. May 17, 2018. https://www.oregonbusiness.com/article/healthcare/item/18330-mental-health
 New $3.5 million program will pair up CMPD officers and mental health experts. Jane Wester. Charlotte
Observer. January 23, 2019. https://www.charlotteobserver.com/news/local/crime/article224956705.html
 Nottinghamshire Street Triage Model. Nottinghamshire Police. https://youtu.be/J3sJ0xMVEzQ
 Patients’ experiences of the caring encounter with the psychiatric emergency response team in the
emergency medical service: A qualitative interview study. Veronica Lindström and Andreas Carlborg.
Health Expectations. 2020. https://onlinelibrary.wiley.com/doi/pdf/10.1111/hex.13024

REFERENCES

145

 Program pairs counselors with cops to better handle mental health calls in southern Dallas. Dana
Branham. Dallas Morning News. January 24, 2018.
https://www.dallasnews.com/news/2018/01/24/program-pairs-counselors-with-cops-to-better-handlemental-health-calls-in-southern-dallas/
 Rule 25 Assessments. Northstar Behavioral Health. https://www.northstarbehavioralhealthmn.com/whatis-a-rule-25-assessment
 Sarah Abbott presents research about jail diversion program. Advocates. November 27, 2018.
https://www.advocates.org/news/sarah-abbott-presents-research-about-jail-diversion-program
 Social Worker, Senior Psychiatric Job Posting. Hennepin County.
https://www.indeed.com/viewjob?jk=731a72b7b6411d7d&tk=1e0p83antp9p7800&from=serp&vjs=3
 Street Outreach Worker Job Posting. The Link.
https://www.indeed.com/viewjob?jk=73f67fc06a73335e&tk=1e0p80r3vp9p7800&from=serp&vjs=3
 Street Triage Services in England: service models, national provision and the opinions of police. Abirami
Kirubarajan, Stephen Puntis, Devon Perfect, Marc Tarbit, Mary Buckman, and Andrew Molodynski.
BJPsych Bulletin, Vol. 42. 2018.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465222/pdf/S2056469418000621a.pdf
 Street Triage: Report on the evaluation of nine pilot schemes in England. Dr. Bianca Reveruzzi and
Professor Stephen Pilling. University College London. March 2016.
https://www.ucl.ac.uk/pals/sites/pals/files/street_triage_evaluation_final_report.pdf
 Sweden has unveiled a dedicated mental health ambulance. Tegan Hedley. VT. February 28, 2018.
https://vt.co/news/world/sweden-unveiled-amazing-dedicated-mental-health-ambulance/
 Why American departments are sending social workers to answer 911 calls. The Economist. May 11,
2019. https://www.economist.com/united-states/2019/05/11/why-american-departments-are-sendingsocial-workers-to-answer-911-calls
Section VII
 State-Level Projections of Supply and Demand for Behavioral Health Occupations: 2016-2030. U.S
Department of Health and Human Services, Health Resources and Services Administration, Bureau of
Health Workforce, National Center for Health Workforce Analysis. September 2018.
https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/state-level-estimates-report-2018.pdf
Section VIII
 Building Hope–One by One. Connections. Greater Lakes Mental Healthcare. Winter 2016.
https://www.glmhc.org/wp-content/uploads/2016/11/Greater_Lakes_Connections_2016.pdf
 Co-Occurring Disorders. Psychology Today. February 22, 2019.
https://www.psychologytoday.com/us/conditions/co-occurring-disorders
 Cross-Sector Service Use Among High Health Care Utilizers In Minnesota After Medicaid Expansion.
Katherine Diaz Vickery, Peter Bodurtha, Tyler N. A. Winkelman, Courtney Hougham, Ross Owen, Mark
S. Legler, Erik Erickson, and Matthew M. Davis. Health Affairs. January 2018.
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0991?rfr_dat=cr_pub%3Dpubmed&url_ver=Z
39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=hlthaff
 Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries. Martha Hostetter, Sarah
Klein, and Douglas McCarthy. Commonwealth Fund. October 7, 2016.
https://www.commonwealthfund.org/publications/case-study/2016/oct/hennepin-health-care-deliveryparadigm-new-medicaid-beneficiaries
 Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State
Mental Health Authorities. Joe Parks, MD, David Pollack, MD, Stephen Bartels, MD, Barbara Mauer,
MSW, CMC. National Association of State Mental Health Program Directors, Medical Directors Council.
January 2005.
https://www.integration.samhsa.gov/workforce/Final_Technical_Report_on_Primary_Care__Behavioral_Health_Integration.final.pdf
 LAPD’s Mental Evaluation Unit is Selected as a National Law Enforcement/Mental Health Learning Site.
News Release. Los Angeles Police Department. November, 9, 2010.
http://www.lapdonline.org/newsroom/news_view/46481

REFERENCES

146

 Million-Dollar Murray. Malcolm Gladwell. New Yorker. February 13, 2006.
http://dpbh.nv.gov/uploadedFiles/A%20MillionDollarMurray.pdf
 Moving Beyond Parity–Mental Health and Addiction Care. Colleen L. Barry, Ph.D. and Haiden A.
Huskamp, Ph.D. New England Journal of Medicine. September 15, 2011.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359059/pdf/nihms375613.pdf
 OE Framework: Human Services Value Curve. American Public Human Services Association.
https://aphsa.org/OE/organizational_effectiveness/OE_Consulting_Practice/OE_Framework.aspx
 Reforming Mental Health in Minnesota. Governor’s Task Force. July 2016.
https://static1.squarespace.com/static/5a32b14bccc5c5b7c9b19622/t/5a9c44e4e2c48369e043cfec/152
0190697410/Overview-Mental-Health-Prese.pdf
 Research analysis: Why integration of public health and public safety data makes sense. Catherine R.
Counts. Police1. June 7, 2018. https://www.policeone.com/crime/articles/research-analysis-whyintegration-of-public-health-and-public-safety-data-makes-sense-gUVAkLS5kWUVrfXD/
 Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on
Pioneering Programs. Thomas Bodenheimer, MD. Center for Health Care Strategies, Inc. October 2013.
https://www.chcs.org/media/HighUtilizerReport_102413_Final3.pdf
 Study shows integrated care affects health care use among vulnerable adults. News Release. University
of Minnesota. May 14, 2018. https://twin-cities.umn.edu/study-shows-integrated-care-affects-healthcare-use-among-vulnerable-adults
 Targeting High Utilizers of Health Care. Sophia Anderson. University of Pennslyvania: Leonard Davis
Institute of Health Economics, SUMR Blog. August 16, 2016. https://ldi.upenn.edu/sumr-blog/targetinghigh-utilizers-health-care
 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review.
Madeline Guth, Rachel Garfield, Robin Rudowitz. Kaiser Family Foundation. March 2020.
http://files.kff.org/attachment/Report-The-Effects-of-Medicaid-Expansion-under-the-ACA-UpdatedFindings-from-a-Literature-Review.pdf
 The Pareto Principle (“80-20 Rule”) in Healthcare Services in Greece. V. Naoum, D. Kyriopoulos, A.
Charonis, K. Athanasakis, and J. Kyriopoulos. Value in Health. November 1, 2016.
https://www.valueinhealthjournal.com/article/S1098-3015(16)32929-1/fulltext#s0380
Section IX
 1/10th of 1% Mental Health Sales Tax. Department of Health and Human Services, Cowlitz County,
Washington. https://www.co.cowlitz.wa.us/2399/110th-of-1-Mental-Health-Sales-Tax
 20 Diverse Communities Receive MacArthur Support to Reduce Jail Populations, Improve Local
Systems, and Model Reforms for the Nation. Press Release. MacArthur Foundation. April 12, 2016.
https://www.macfound.org/press/press-releases/20-diverse-communities-receive-macarthur-supportreduce-jail-populations-improve-local-systems-and-model-reforms-nation/
 2017 Dallas RIGHT Program: Mentally Ill Avoid Bail and Jail. Michael Lowe. January 4, 2017.
https://www.dallasjustice.com/2017-dallas-right-program-mentally-ill-avoid-bail-jail/
 2019 JMHCP Orientation Webinar Part 1. Justice Center, Council of State Governments. November 8,
2019. https://www.youtube.com/watch?v=8O53r7a0Zg4&feature=youtu.be
 Breaking the ‘never-ending cycle’: Duluth police sharpen social work endeavor. Brady Slater. Duluth
News Tribune. June 26, 2017. https://www.duluthnewstribune.com/lifestyle/4289177-breaking-neverending-cycle-duluth-police-sharpen-social-work-endeavor
 Broad Support: Washington Legislature Passes HB2892 to Fund More Co-Responder Programs. Public
Hearing. Policing Mental Illness–Helping Those in Crisis. April 29, 2018.
https://www.youtube.com/watch?v=6xUI8hLNq_w
 Changing Focus: The Right to Treatment of Serious Mental Illness. Elinore F. McCance-Katz, MD, Ph.D.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration. April 16, 2018. https://www.samhsa.gov/sites/default/files/the_right_to_treatment.pdf
 Chapter 19: Sources of Revenue. Handbook for Minnesota Cities. League of Minnesota Cities. August
18, 2019. https://www.lmc.org/wp-content/uploads/documents/Sources-of-Revenue.pdf

REFERENCES

147

 Chapter Three: Mental Health Services in Ohio (Part I). Leslie Brower, Ph.D., RN. North Carolina Family
Impact Seminar. May 17, 2006. https://www.purdue.edu/hhs/hdfs/fii/wpcontent/uploads/2015/07/s_ncfis02c03.pdf
 Colorado’s Behavioral Health Crisis System. Issue Brief: Senate Bill 17-207. Colorado Hospital
Association. August 2016. https://cha.com/wp-content/uploads/2017/08/CHA.074-Leg_SB-17-207-1.pdf
 Community Boards…Community Benefits. Mental Health and Recovery Board of Erie and Ottawa
Counties. https://www.mhrbeo.org/Downloads/Community%20Boards%20Community%20Benefits2.pdf
 Community Services Board Overview. Monroe County, New York. https://www2.monroecounty.gov/mhcsboard.php
 Denver ballot issues: Voters approve new taxes for mental health, parks and more. Jessica Seamen.
Denver Post. November 20, 2018. https://www.denverpost.com/2018/11/06/denver-ballot-issues-results/
 Eagle County voters approve marijuana tax to fund mental health programs. Randy Wyrick. Mental
Health Colorado. https://www.mentalhealthcolorado.org/eagle-county-marijuana-tax/
 Embedded St. Louis County Social Worker in the Duluth Police Department Program: MCPA Excellence
in Innovation Award Nomination. Memorandum from Patrick Boyle, St. Louis County Commissioner,
Chair of the Public Health and Human Services Committee. St. Louis County.
https://mcpa.memberclicks.net/assets/ETI2016/duluth_mantal%20health%20services.pdf
 Establishing the mental health field response teams program. HB 2892 – 2017-18. Washington State
Legislature. https://apps.leg.wa.gov/billsummary/?BillNumber=2892&Year=2018&Initiative=false
 Giving patients in crisis the treatment they deserve. Moe Keller. Denver Business Journal. May 25,
2017. https://www.bizjournals.com/denver/feature/mental-health-matters/2017/giving-patients-in-crisisthe-treatment-they.html
 Governor’s Task Force on Mental Health: Final Report. State of Minnesota, Department of Health
Services, Mental Health Division. November 15, 2016. https://mn.gov/dhs/assets/mental-health-taskforce-report-2016_tcm1053-263148.pdf
 Haves and have nots: County property taxes provided $2.5 billion in local health and social service
funding, but it was unevenly distributed. Emily Campbell. Center for Community Solutions. November
25, 2019. https://www.communitysolutions.com/wp-content/uploads/2019/11/112519-Levy-Paper.pdf
 House Bill 2892: Mental Health Field Response Teams Program. Washington State Legislature.
Effective June 7, 2018. http://lawfilesext.leg.wa.gov/biennium/201718/Pdf/Bills/Session%20Laws/House/2892.SL.pdf
 How Communities Can Fund Mental Health Services. Care For Your Mind. May 10, 2016.
https://careforyourmind.org/how-communities-can-fund-mental-health-services/
 Jail/arrest diversion grant program: FY2018 mid-year report. Massachusetts Department of Mental
Health. December 2017. https://www.mass.gov/files/documents/2018/01/19/2018-0102%20DMH%20JDP%20mid-year%20report-%20FY18.pdf
 Justice and Mental Health Collaboration Program (JMHCP): Overview. U.S. Department of Justice,
Office of Justice Programs, Bureau of Justice Assistance. February 19, 2012.
https://bja.ojp.gov/program/justice-and-mental-health-collaboration-program-jmhcp/overview
 Justice and Mental Health Collaboration Program FY 2019 Competitive Grant Announcement. U.S.
Department of Justice, Office of Justice Programs, Bureau of Justice Assistance. June 19, 2019.
https://bja.ojp.gov/sites/g/files/xyckuh186/files/media/document/BJA-2019-15099.PDF
 Marijuana Tax Cash Fund. Footprints to Recovery. https://footprintstorecovery.com/addiction-treatmentlocations/colorado/marijuana-tax-cash-fund/
 Mental Health and Developmental Disabilities (405 ILCS 22): Community Mental Health Services Act.
Illinois General Assembly. Effective January 1, 2012.
http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=3300&ChapterID=34
 Mental health board plans to seek renewal of levy. Tom Jackson. Sandusky Register. May 23, 2019.
https://sanduskyregister.com/news/3031/mental-health-board-plans-to-seek-renewal-of-levy/
 Mental Health Innovation Grant Program. State of Minnesota, Department of Human Services. January
8, 2020. https://mn.gov/dhs/partners-and-providers/policies-procedures/adult-mental-health/mhinnovation-grant-program/

REFERENCES

148

 MIIP (Municipal Infrastructure Investment Planning) Report: Social Cost Considerations for Municipal
Infrastructure Management. S. Rahman, D. J. Vanier, and L. A. Newton. National Research Council of
Canada, Institute for Research in Construction. May 2005. https://nrcpublications.canada.ca/eng/view/fulltext/?id=e0a1d165-abe5-4aed-89c8-ef27d8d88e28
 Minnesota SF 1632: Dakota County Law Enforcement and Mental Health Co-Response Pilot Project.
Minnesota Legislature, Office of the Revisor of Statutes. Mary 2, 2017.
https://www.revisor.mn.gov/bills/text.php?version=latest&session=ls90&number=SF1632&session_year
=2017&session_number=0
 Overview of Ohio system of public behavioral healthcare. Mental Health and Recovery Board of Erie
and Ottawa Counties. https://www.mhrbeo.org/Downloads/Overview_Ohio_System2.pdf
 Paying for City Services. League of Minnesota Cities. February 13, 2020.
https://www.lmc.org/resources/paying-for-city-services/
 Police team up with social workers. Mike Tusken. Duluth News Tribune. April 29, 2016.
https://www.duluthnewstribune.com/opinion/4021484-police-team-social-workers
 Program pairs counselors with cops to better handle mental health calls in southern Dallas. Dana
Branham. Dallas Morning News. January 24, 2018.
https://www.dallasnews.com/news/2018/01/24/program-pairs-counselors-with-cops-to-better-handlemental-health-calls-in-southern-dallas/
 Property Taxation 101. League of Minnesota Cities. August 2019.
https://www.lmc.org/resources/property-taxation-101/
 Property taxes climbing, but needs are many, activists say. Anthony Lonetree. Star Tribune. December
8, 2018. https://www.startribune.com/property-taxes-climbing-but-needs-are-many-activistssay/502275201/
 Prospective Social Return on Investment (SROI): Prepared for Minnesota Independence College and
Community (MICC). Justin Hollis. Wilder Research. March 2019.
https://www.wilder.org/sites/default/files/imports/MICC_SROI_Report_3-19.pdf
 Safety and Justice Challenge Expands to 52 Cities, Counties. Press Release. MacArthur Foundation.
October 24, 2018. https://www.macfound.org/press/press-releases/safety-and-justice-challengeexpands-52-cities-counties/
 Sales and use tax for chemical dependency or mental health treatment services or therapeutic courts.
Revised Code of Washington (RCW) 82.14.460. https://app.leg.wa.gov/rcw/default.aspx?cite=82.14.460
 SF 2787: Hennepin County Law Enforcement and Mental Health Co-Response Pilot Project. Minnesota
Legislature, Office of the Revisor of Statutes. April 4, 2019.
https://www.revisor.mn.gov/bills/text.php?number=SF2787&version=latest&session=ls91&session_year
=2019&session_number=0
 Treating America’s Mental Health Crisis. The Wellness Network. March 14, 2019.
https://www.thewellnessnetwork.net/health-news-and-insights/mental-health-crisis/
 Valuing SROI: Social Return on Investment Techniques and Organizational Implementation in the
Netherlands and United States. Michael Moody, Laura Littlepage, John Marron, Naveed Paydar, and
Pattijean McCahill. Grand Valley State University, Johnson Center for philanthropy. September 2013.
http://ppidb.iu.edu/Uploads/PublicationFiles/Valuing%20SROI-Noaber%20Final%20Report-FINAL.pdf
 Why Denver Voted to Fund Mental-Health Treatment. Jason Plautz. Bloomberg. November 21, 2018.
https://www.citylab.com/equity/2018/11/treatment-centers-addiction-mental-health-caring-4denver/576202/
 Why One Community Voted to Tax Itself. Anne-Marie Cusac. In These Times. March 2, 2015.
http://inthesetimes.com/article/17636/community_funded_mental_health_clinis
Section X
 Association between childhood trauma and catecholamine response to psychological stress in police
academy recruits. Christian Otte, Thomas C. Neylan, Nnamdi Pole, Thomas Metzler, Suzanne Best,
Clare Henn-Haase, Rachel Yehuda, and Charles R. Marmar. Biological Psychiatry. January 1, 2005.
https://www.sciencedirect.com/science/article/abs/pii/S0006322304010728

REFERENCES

149

 Associations between childhood trauma and emotion-modulated psychophysiological responses to
startling sounds: A study of police cadets. N. Pole, T. C. Neylan, C. Otte, T. J. Metzler, S. R. Best, C.
Henn-Haase, and C. R. Marmar. Journal of Abnormal Psychology. 2007.
https://psycnet.apa.org/record/2007-06673-012
 Chapter Four–Brick by Brick: The Origins, Development, and Future of Self-Determination Theory.
Richard M. Ryan and Edward L. Deci. Advances in Motivation Science. 2019.
https://www.sciencedirect.com/science/article/pii/S221509191930001X?via%3Dihub
 City and County of San Francisco v. Sheehan. Supreme Court of the United States Blog.
https://www.scotusblog.com/case-files/cases/city-and-county-of-san-francisco-california-v-sheehan/
 Complex Trauma in Children and Adolescents. Alexandra Cook, PhD; Joseph Spinazzola, PhD; Julian
Ford, PhD; Cheryl Lanktree, PhD; Margaret Blaustein, PhD; Marylene Cloitre, PhD; Ruth DeRosa, PhD;
Rebecca Hubbard, LMFT; Richard Kagan, PhD; Joan Liautaud, PsyD; Karen Mallah, PhD; Erna
Olafson, PhD, PsyD; Bessel van der Kolk, MD. Psychiatric Annals, Vol. 35, Issue 5. 2005.
https://www.healio.com/psychiatry/journals/psycann/2005-5-35-5/%7B4b9f8030-1eba-442f-8b328504c01a0000%7D/complex-trauma-in-children-and-adolescents#
 Deinstitutionalization of People with Mental Illness: Causes and Consequences. Daniel Yohanna, MD.
American Medical Association Journal of Ethics, Virtual Mentor. October 2013.
https://journalofethics.ama-assn.org/article/deinstitutionalization-people-mental-illness-causes-andconsequences/2013-10
 Essence of Democracy. Bombay Sarvodaya Mandal and Gandhi Research Foundation.
https://www.mkgandhi.org/momgandhi/chap72.htm
 Excessive Reasonableness. Diana Hassel. Indiana Law Review. 2009.
https://mckinneylaw.iu.edu/ilr/pdf/vol43p117.pdf
 Friends under fire: Cross-cultural relationships and trauma exposure among police officers. J. P.
Andersen and K. Papazoglou. Traumatology. 2014.
https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0099403
 From Garner to Graham and Beyond: Police Liability for Use of Deadly Force–Ferguson Case Study.
Kyle J. Jacob. Chicago-Kent Law Review. January 29, 2016.
https://scholarship.kentlaw.iit.edu/cgi/viewcontent.cgi?article=4109&context=cklawreview
 Media’s Damaging Depictions of Mental Illness. Margarita Tartakovsky, M.S. Psych Central. March 18,
2019. https://psychcentral.com/lib/medias-damaging-depictions-of-mental-illness/2/
 Minnesota agency says police didn’t discriminate in hauling mentally ill man to jail. Jennifer Bjorhus. Star
Tribune. January 10, 2017. https://www.startribune.com/minnesota-agency-says-police-didn-tdiscriminate-in-hauling-mentally-ill-man-tojail/410321985/?fbclid=IwAR1lVWCFVwWDFueOW57xLNVRUtG7pn6aQIqXvheb662EbXFXYuBRbdFenc
 Olmstead V. LC: History and Current Status (The Olmstead Supreme Court Decision in a Nutshell).
Atlanta Legal Aid Society, Disability Integration Project. https://www.olmsteadrights.org/about-olmstead/
 Opinion analysis: No new limit on police use of force. Lyle Denniston. Supreme Court of the United
States Blog. May 18, 2015. https://www.scotusblog.com/2015/05/opinion-analysis-no-new-limit-onpolice-use-of-force/
 Predictors of Mental Health Stigma among Police Officers: The Role of Trauma and PTSD. Sara
Soomro and Philip T. Yanos. Journal of Police and Criminal Psychology. Published June 20, 2018.
https://link.springer.com/article/10.1007/s11896-018-9285-x
 Reasonable Accommodations Not Unreasonable Violence. Leah Smith. Center for Disability Rights.
http://cdrnys.org/blog/disability-dialogue/the-disability-dialogue-reasonable-accommodations-notunreasonable-violence/
 Self-Determination Theory Applied to Health Contexts: A Meta-Analysis. Johan Y. Y. Ng, Nikos
Ntoumanis, Cecille Thøgersen-Ntoumani, Edward L. Deci, Richard M. Ryan, Joan L. Duda, and
Geoffrey C. Williams. Perspectives on Psychological Science. Published June 29, 2012.
https://journals.sagepub.com/doi/abs/10.1177/1745691612447309
 The Bad-Apple Myth of Policing. Osagie K. Obasogie. The Atlantic. August 2, 2019.
https://www.theatlantic.com/politics/archive/2019/08/how-courts-judge-police-use-force/594832/

REFERENCES

150

 The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Bessel A. Van der Kolk,
MD. Penguin Books. 2014.
https://books.google.com/books?hl=en&lr=&id=vHnZCwAAQBAJ&oi=fnd&pg=PA1&dq=dr+van+der+kol
k+trauma&ots=THsvjkPmw&sig=eUgp7ohrSKwLqjmMS2BXukuqia8#v=onepage&q=dr%20van%20der%20kolk%20trauma&f
=false
 The Polyvagal Theory for Treating Trauma. Stephen W. Porges, Ph.D. and Ruth Buczynski, Ph.D.
National Institute for the Clinical Application of Behavioral Medicine.
http://www.complextrauma.uk/uploads/2/3/9/4/23949705/stephen_porges_interview.pdf
 What is the Americans with Disabilities Act (ADA)? ADA National Network. https://adata.org/learn-aboutada
Glossary
 Bill Lewinski defends cops accused of excessive force. Nick Pinto. City Pages. April 28, 2010.
http://www.citypages.com/news/bill-lewinski-defends-cops-accused-of-excessive-force-6725973
 Community Navigation as a Field of Practice: Reframing Service Delivery to Meet the Needs of
Communities’ Marginalized Populations. Joby Schaffer, M. Julie Patiño, P. Barclay Jones, and LaDawn
Sullivan. The Foundation Review. 2018.
http://floodlight.denverfoundation.org/Portals/0/Uploads/Documents/Community%20Navigation%20as%
20a%20Field%20of%20Practice_%20Reframing%20Service%20De.pdf
 Community Navigators Reduce Hospital Utilization in Super-Utilizers. Michael P. Thompson, Ph.D.;
Pradeep S. B. Podila, MS, MHA; Chip Clay, MDiv, BCC; Joy Sharp, BS; Sandra Bailey-DeLeeuw,
MSHS; Armika J. Berkley, MPH; Bobby G. Baker, DMin, BCC; and Teresa M. Waters, Ph.D. American
Journal of Managed Care. February 15, 2018. https://www.ajmc.com/journals/issue/2018/2018-vol24n2/community-navigators-reduce-hospital-utilization-in-superutilizers
 Computer-aided dispatch. Wikipedia. https://en.wikipedia.org/wiki/Computer-aided_dispatch
 Dallas Has Been Dispatching Social Workers to Some 911 Calls: It’s Working. Lucas Manfield. Dallas
Observer. December 10, 2019. https://www.dallasobserver.com/news/dallas-has-been-dispatchingsocial-workers-to-some-911-calls-its-working-11810019
 Diagnostic Assessment. State of Minnesota, Department of Human Services. February 13, 2020.
https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelecti
onMethod=LatestReleased&dDocName=ID_058048#standard
 Fulton police consider special crisis teams for mental health calls. Arielle Kass. Atlanta JournalConstitution. February 1, 2019. https://www.ajc.com/news/local-govt--politics/fulton-police-considerspecial-crisis-teams-for-mental-health-calls/nYJzO3QkdMw9mDMzomte2M/
 FY 2020 Justice and Mental Health Collaboration Program. Department of Justice, Office of Justice
Programs, Bureau of Justice Assistance. March 19, 2020. https://bja.ojp.gov/funding/opportunities/bja2020-17114
 Glossary of Human Services Terms and Acronyms. North Dakota Human Services. January 2019.
https://www.nd.gov/dhs/info/pubs/docs/dhs-glossary-of-terms-acronyms.pdf
 Glossary of Law Enforcement and Mental Health Terms. U.S. Department of Justice, Office of Justice
Programs, Bureau of Justice Assistance.
https://pmhctoolkit.bja.gov/ojpasset/Documents/Glossary%20of%20Law%20Enforcement%20and%20M
ental%20Health%20Terms.pdf
 Glossary. National Association of State Mental Health Program Directors.
http://www.nasmhpd.org/node/1394
 How Police Training Contributes to Avoidable Deaths: To save lives, cops must be taught to think
beyond the gun belt. Seth W. Stoughton. The Atlantic. December 12, 2014.
https://www.theatlantic.com/national/archive/2014/12/police-gun-shooting-training-ferguson/383681/
 Imminent. Free Legal Encyclopedia. Law Library–American Law and Legal Information.
https://law.jrank.org/pages/7485/Imminent.html
 Imminent-Peril Doctrine Law and Legal Definition. USLegal. https://definitions.uslegal.com/i/imminentperil-doctrine/

REFERENCES

151

 Integrating Health Care and Social Services: Moving from Concept to Practice. Margaret Trinity, Mary
Beth Dyer, and Michael Bailit. Robert Wood Johnson Foundation. November 2016.
https://www.shvs.org/wp-content/uploads/2016/11/SHVS-Bailit-Integrating-Health-Care-and-SocialServices-November-2016.pdf
 Intensive case management for people with severe mental illness. M. Dieterich, C. B. Irving, H.
Bergman, M. A. Khokhar, B. Park, and M. Marshall. Cochrane Database of Systematic Reviews.
January 6, 2017. https://www.cochrane.org/CD007906/SCHIZ_intensive-case-management-peoplesevere-mental-illness
 Introduction to the ADA. U.S. Department of Justice, Civil Rights Division.
https://www.ada.gov/ada_intro.htm
 JFK’s mental health plan never realized. Associated Press. USA Today. October 20, 2013.
https://www.usatoday.com/story/news/nation/2013/10/20/kennedys-vision-mental-health/3100001/
 LAC Guidebook: Leading from Experience (A guide for Local Mental Health Advisory Councils in
Minnesota). State of Minnesota, Department of Human Services, Behavioral Health Division.
https://mn.gov/dhs/assets/lac-guidebook_tcm1053-386047.pdf
 Medicaid Matters: The impact of Minnesota’s Medicaid Program. State of Minnesota, Department of
Human Services. https://www.leg.state.mn.us/docs/2018/other/180391.pdf
 Mental Illness: Diagnosis and treatment. Mayo Clinic Staff. Mayo Foundation for Medical Education and
Research. https://www.mayoclinic.org/diseases-conditions/mental-illness/diagnosis-treatment/drc20374974
 Mobile Crisis Mental Health Services. State of Minnesota, Department of Human Services. July 3, 2019.
https://mn.gov/dhs/people-we-serve/adults/health-care/mental-health/programs-services/mobilecrisis.jsp
 MPD Policy and Procedure Manual: 7-100.00 Communications. Minneapolis Police Department.
October 5, 2018. http://www.ci.minneapolis.mn.us/police/policy/mpdpolicy_7-100_7-100
 Police perceptions of the percentage of contacts in Albuquerque, NM that involve people living with
mental illness. Matthew Tinney and Nils Rosenbaum. December 2015. https://www.cabq.gov/mentalhealth-response-advisory-committee/documents/survey-of-police-officers-for-calls-for-services-asmental-illness.pdf
 Professor Carnage: Dave Grossman teaches police officers to think like “warriors.” Steve Featherstone.
New Republic. April 17, 2017. https://newrepublic.com/article/141675/professor-carnage-davegrossman-police-warrior-philosophy
 Sequential Intercept Model: Advancing Community-Based Solutions for Justice-Involved People with
Mental and Substance Use Disorders. Brochure. Policy Research Associates.
https://www.prainc.com/wp-content/uploads/2017/08/SIM-Brochure-Redesign0824.pdf
 Social Work Licensure in Minnesota. HumanServicesEdu.org.
https://www.humanservicesedu.org/minnesota-social-work-requirements.html
 The ‘Deflection’ Surge: Key to Reducing Re-Arrests. Jac Charlier. Crime Report. March 21, 2017.
https://thecrimereport.org/2017/03/21/the-deflection-surge-key-to-reducing-re-arrests/#
 The Truth About the Philando Castile Verdict. The Daily Show with Noah Trevor. June 21, 2017.
https://www.youtube.com/watch?v=wqgz7kRGVxg
 What is 211? Helpline Center. https://www.helplinecenter.org/2-1-1-community-resources/what-is-211/
 What is 911? National Emergency Number Association (NENA).
https://www.nena.org/page/911GeneralInfo
 What is a CCBHC? Mental Health First Aid. National Council for Behavioral Health.
https://www.thenationalcouncil.org/wp-content/uploads/2017/11/What-is-a-CCBHC11.7.17.pdf?daf=375ateTbd56
 What is Dual Diagnosis?: Dual Diagnosis emerged 20 years ago but is still misunderstood. Morteza
Khaleghi, Ph.D. Psychology Today. October 10, 2011. https://www.psychologytoday.com/us/blog/theanatomy-addiction/201110/what-is-dual-diagnosis
 What is Posttraumatic Stress Disorder? Ranna Parekh, MD, MPH and Felix Torres, MD, DFARA, MBA.
American Psychiatric Association. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
 What is Telepsychiatry? Jay H. Shore, MD, MPH. American Psychiatric Association.
https://www.psychiatry.org/patients-families/what-is-telepsychiatry