1. Megan Davidson, PhD Assistant Professor Department of Criminal Justice East Carolina University A CRIMINAL JUSTICE RESPONSE TO MENTAL ILLNESS: AN EVALUATION OF THE MEMPHIS CRISIS INTERVENTION TEAM (CIT) TRAINING PROGRAM

2. INTRODUCTION  Mental illness is prevalent among individuals coming into contact with the criminal justice system:  An estimated 7-10% of all police contacts involve a person with a mental illness (Borum, Deanne, Steadman, & Morissey, 1998)  Over 50% of all State prisoners local jail inmates report having a mental health issue (James & Glaze, 2006)  Many problem-solving programs have been developed to address this issue:  Focus on utilizing the criminal justice system as a pathway to treatment  Jail diversion to redirect flow of persons with a mental illness away from incarceration toward appropriate treatment setting

3.  Emerged in the late 1980s in response to a fatal police shooting of a person with a history of mental illness.  Developed by task force comprised of law enforcement, mental health providers, advocates, and academics.  Began as a jail diversion program to improve law enforcement response to mental health crises.  Has diffused to corrections, now system-wide model.  Two main components: 1) 40 hour training curriculum for first responders 2) Community-wide collaboration between mental health & criminal justice agencies. BACKGROUND OF MEMPHIS CRISIS INTERVENTION TEAM (CIT) MODEL

4.  Presentations from local mental health providers, advocates, consumers, and legal experts covering:  Signs & symptoms of common mental illnesses  Pharmacology and related side effects  Suicide prevention  PTSD among veterans  Tour of local mental health facilities  Overview of de-escalation techniques  Substance abuse  Developmental disabilities  Role playing of verbal de-escalation KEY ELEMENTS OF CIT TRAINING

5. PRIOR CIT LAW ENFORCEMENT STUDIES Surveys or focus groups Assess effectiveness of training Officer-level studies Officer or agency reports Examines diversionary element Disposition of CIT calls Utilize referral records Compares CIT referrals to other MH referrals – nature & outcome Characteristics and outcomes of CIT referrals

6.  CIT training effectively:  Improves knowledge and perceptions of mental illness, mental health referral process & available community resources.  Enhances self-efficacy when responding to mental health crises.  Reduces use of force and injury to officers and others. SUMMARY OF OFFICER-LEVEL STUDIES

7.  Mixed results concerning CIT and diversion:  Some studies have found that the implementation of CIT reduces arrest rates.  Studies have also found that mental health referral rates increase when agencies adopt CIT.  Other studies have revealed a minimal effect of CIT implementation on arrest & MH referrals. SUMMARY OF CIT DISPOSITION STUDIES

8.  Characteristics of CIT referrals do not differ significantly from other referral sources meaning:  CIT-trained officers correctly identify individuals in need of emergency psychiatric treatment  CIT referred patients more likely than the mental health inquest warrant patients and less likely than routine referrals to receive outpatient follow-up referral.  CIT referred patients less likely than MH inquest and routine referrals to be hospitalized after evaluation.  More likely than other types of referrals to already have some involvement in MH system:  Suggests chronic nature of CIT MH referrals vs. short-term crisis SUMMARY OF CIT REFERRAL CHARACTERISTICS AND OUTCOMES

9.  Only two studies conducted to-date examined implementation of CIT in several Maine jails.  Assessed effects of CIT training on officer response to inmates with mental illness.  Examined impact of CIT implementation on use of force incidents in the facility.  Found similar results to law enforcement studies:  Improves officer self-efficacy when responding to inmates with mental illness  Increased use of verbal de-escalation and decreased use of force CIT IN CORRECTIONS

10.  Small sample sizes  Cover narrow geographical areas  Lack of follow-up period after CIT training  Limited assessment of CIT in corrections  No comparison of law enforcement & correctional officers LIMITATIONS OF PREVIOUS STUDIES

11.  Dual-pronged approach to examining the Crisis Intervention Team (CIT) Model: SCOPE OF DISSERTATION PROJECT Training Evaluation Prong #1 Exploring Impact of CIT implementation on CJ Agencies Prong #2

12.  Key Objective:  Assess CIT training effectiveness  Sample:  Law enforcement and correctional officers that completed CIT training between June and December of 2012 in nine Florida counties.  Total Sample Size= 279 total officers (LEOs=179, COs=100)  Research Design:  Panel study with three data collection points:  1) Pre-test (First day of CIT training)  2) Post-test (Last day of CIT training)  3) Follow-up (One month upon completion of CIT training)  Methodology:  Pre and post-test: Paper questionnaires distributed in-person  Follow-up: Online questionnaire delivered via email CURRENT STUDY: PRONG 1- TRAINING EVALUATION

13. 1)Knowledge of Mental Illness  8 True/False Questions derived from CIT curricula 2)Perceptions of Self-Efficacy  6 Likert-scale questions (Strongly Disagree-Strongly Agree) measuring perceptions of ability to mange incidents involving persons with a mental illness 3)Perceptions of Verbal De-Escalation  3 Likert-scale questions (Strongly Disagree-Strongly Agree) measuring perceptions of verbal de- escalation techniques KEY MEASURES

14. DEMOGRAPHICS (N=279) VariableN% N% # Officer Type Volunteer Status Age Law Enforcement17964Volunteer17262Minimum20 Correctional10036Non-Volunteer10337Maximum60 White Missing41Mean36 White20875Prior MH Training SD9 Non-White7125Yes15054 Hispanic No12344Years of Service Hispanic4516Missing62Minimum0 Non-Hispanic23283Know Someone with MI Maximum32 Missing21Yes8932Mean8 Sex No or “Don’t Know”18767SD7 Male22079Missing31 Female5921 Rank Line Officer21878 Supervisor5921 Missing21

15.  Paired-samples t-tests were conducted to examine mean changes between the pretest and posttest IMMEDIATE TRAINING EFFECTS (N=279) Measures Pretest Mean SDtdf H1: Knowledge of Mental Illness 5.85 (out of 8)6.671.3759.836***271 H2: Self Efficacy15.71 (out of 24)19.624.5514.09***268 H3: Perceptions of Verbal De-escalation 9.89 (out of 12)10.652.524.980***271 Note: *** = p <.001

16.  Significant increase across all three measures between pretest and posttest.  Perceptions of self-efficacy increased by approximately 16%.  Knowledge of Mental Illness increased by 10%  Perceptions of Verbal De-escalation improved by 6%.  Any growth on these measures is considered an indication of training effectiveness. IMMEDIATE TRAINING EFFECTS

17.  Paired-samples t-tests were conducted to examine mean changes between the posttest and follow-up for 3 measures INTERMEDIATE TRAINING EFFECTS (N=117) Variable Posttest Mean Follow-Up Mean SDtdf H1: Knowledge of Mental Illness 6.69 (out of 8)6.67.95.2295 H2: Self-Efficacy 20.12 (out of 24)14.613.9014.07***98 H3: Perceptions of Verbal De-escalation 11.03 (out of 12)7.732.6112.64***99 Note: *** = p <.001

18.  No real change on Knowledge of Mental Illness measure  22% decline on Self-Efficacy measure  28% decrease on Perceptions of Verbal De- escalation  These declines represent a diminishing effect, or decay, of the training over time. INTERMEDIATE TRAINING EFFECTS

19. EffectβSE Model 1: Knowledge of Mental Illness Time 1 (Pretest)-.694**.128 Time 2 (Posttest).031.122 Sex (Female)-.078.127 Prior Mental Health Training-.064.120 Volunteer Status.074.126 Model 2: Self-Efficacy Time 1 (Pretest)1.27**.451 Time 2 (Posttest)5.39**.390 Sex (Female)-1.25.536 Model 3: Perceptions of Verbal De-escalation Time 1 (Pretest)2.545**.244 Time 2 (Posttest)3.227**.228 Race (Non-White).234.282 Rank (Patrol)-.074.250 MEASURING CHANGE OVER TIME: GROWTH CURVE MODELS (N=117) Note: **= p <.01 Note: Reference categories for variables: Time 3 (Follow-Up), Sex (Male), Prior mental health (Yes), Volunteer status (Volunteer), Race (White), Rank (Supervisor)

20.  Time 1 (pretest) and Time 2 (posttest) were compared to Time 3 (follow-up)  Time was a significant predictor of growth in all three models  Knowledge of Mental Illness  Officers’ scores at Time 1 were significantly lower (9%) than Time 3.  Officers’ scores at Time 2 were slightly greater (<1%) than Time 3.  Self-Efficacy  Officers’ scores at Time 1 and Time 2 were significantly higher than Time 3, (5% and 22% respectively).  Perceptions of Verbal De-Escalation  Officers’ scores at Time 1 and Time 2 were significantly higher than Time 3, (21% and 28% respectively). GROWTH CURVE MODELS (N=117)

21.  A series of independent samples t-tests were conducted & change variables were created  Tested the relationships between the variables below and the immediate and intermediate training effects: OFFICER CHARACTERISTICS & TRAINING EFFECTIVENESS Sex Race Ethnicity Rank Age Years of Service Volunteer Status Prior Mental Health Training Know Someone with Mental Illness

22.  Immediate Training Effects:  Knowledge of Mental Illness:  Officers without prior mental health training gained significantly more than officers with prior mental health training.  Non-volunteers gained significantly more than officers that volunteered for the training.  Self-Efficacy:  Females gained significantly more than males.  Verbal De-Escalation:  No significant differences noted. FINDINGS: OFFICER CHARACTERISTICS & TRAINING EFFECTIVENESS

23.  Intermediate Training Effects:  Self-Efficacy:  Unranked officers lost more than ranked officers.  Non-white officers experienced a greater deterioration than white officers.  Verbal De-Escalation:  No significant differences noted.  Knowledge of Mental Illness:  No significant differences noted. FINDINGS: OFFICER CHARACTERISTICS & TRAINING EFFECTIVENESS

24.  On follow-up survey: Officers were asked how their knowledge & perceptions of MH services & referral process changed as a result of CIT training ADDITIONAL TRAINING FINDINGS Correctional OfficersLaw Enforcement Officers MeasureN%N% Perceptions of MH Services Worsened1300 Stayed the Same15401625 Improved21574775 Knowledge of MH Referral Worsened0000 Stayed the Same18491523 Improved19514876 Knowledge of MH Services Worsened0000 Stayed the Same1438914 Improved23625486

25.  Over 85% of officers indicated these elements have been somewhat or very useful in their encounters since the training:  How to recognize signs and symptoms of various mental illnesses  How to distinguish between developmental disorders and mental illnesses  How to identify and respond to a person engaging in self-harming or suicidal behavior  How to access available community mental health resources  Understanding the mental health referral process in your community  How to verbally de-escalate a person experiencing a mental health crisis  How to physically approach an individual experiencing a mental health crisis MOST IMPORTANT ASPECTS OF CIT TRAINING

26.  Nature of Incidents Involving Law Enforcement officers:  Most likely to encounter individual with mental illness when individual was subject of call for assistance.  NOT as a suspected offender  Nearly 2x as likely to take no action or initiate a MH referral than to arrest when encountering a person with a mental illness.  Nature of Incidents Involving Correctional Officers:  Most likely to encounter inmate with mental illness when inmate was perpetrator of an attack/exploitation of another inmate and/or the subject of a rule violation.  More likely to take no action or initiate a MH referral than to initiate the disciplinary process when encountering inmates with a mental illness. OTHER KEY OFFICER FINDINGS

27.  Sample:  Representatives of law enforcement and correctional agencies that participate in the CIT program in the nine Florida counties in which officers were trained  Total Sample Size= 24 representatives of CJ agencies  6 correctional, 18 law enforcement  Research Design:  Cross-sectional survey distributed at one point in time (November 2012)  Methodology:  Online questionnaire delivered via email  Analytical Strategy:  Content Analysis CURRENT STUDY: PRONG 2- IMPACT OF CIT ON CJ AGENCIES

28.  All representatives indicated their agency has a positive relationship with local mental health providers and/or advocacy organizations.  Impact on Operations & Outcomes:  13/18 (72%) indicated CIT decreased incidence of officer injury  15/18 (83%) indicated CIT decreased incidence of injury to persons with a mental illness  15/18 (83%) indicated CIT decreased use of force in situations involving persons with a mental illness  13/18 (72%) indicated CIT decreased use of SWAT or Hostage Negotiation Teams *** Remaining respondents indicated these factors stayed the same after CIT implementation IMPACT OF CIT IMPLEMENTATION ON LAW ENFORCEMENT AGENCIES

29.  All representatives indicated their agency has a positive relationship with local mental health providers and/or advocacy organizations.  Impact on Operations & Outcomes:  6/6 (100%) indicated CIT decreased incidence of officer injury  5/6 (83%) indicated CIT decreased incidence of inmate injury  The remaining representative did not answer this question.  5/6 (83%) indicated CIT decreased use of force in situations involving inmates with a mental illness  The remaining representative did not answer this question.  4/6 (67%) indicated CIT decreased use of cell extraction teams  One person did not answer and one person indicated no change.  4/6 (67%) indicated CIT decreased use of segregation or isolation  One person did not answer and one person indicated no change. IMPACT OF CIT IMPLEMENTATION ON CORRECTIONAL AGENCIES

30.  The training achieves the intended officer-level objectives measured in this study.  The training is effective for both law enforcement and correctional officers.  Officers experience a significant decline on self-efficacy and perceptions of verbal de-escalation measures between posttest and follow-up.  May indicate CIT gives false sense of security and incidents may not be resolved as easily as expected when returning to duty.  Officer sex, race, rank, prior mental health training, and volunteer status are related to susceptibility to training.  Law enforcement and correctional officers are more likely to initiate a MH referral or take no action rather than arrest or initiate a disciplinary infraction in CIT-related incidents. CIT TRAINING CONCLUSIONS

31.  CIT improves communication between law enforcement/correctional agencies and mental health providers/advocates.  CIT implementation has positive impact on CJ agencies by decreasing:  Use of force  Incidence of officer/suspect/inmate injury  Use of specialty units (SWAT, cell extraction)  Use of segregation CIT IMPACT ON AGENCIES CONCLUSIONS

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