Hogg Foundation for Mental Health

Crisis Intervention Training

Projects Expand and Evaluate De-escalation Strategies for Police Interactions with Persons with Mental Illness

June 1, 2005

It was late on a Saturday night when Daryl Jones walked into the Exxon convenience store on Interstate 35. Although he made no attempt to intimidate anyone, his erratic and confused behavior – mumbling and pacing of the aisles – made both customers and employees uncomfortable. Finally, the clerk called out from behind the counter for Daryl to leave. When Daryl ignored him, the police were called.

The arrival of the first police unit appeared to irritate and upset Daryl, and the officers' loud and forceful commands only seemed to incite him further. Just when the situation seemed to be escalating to a dangerous level, another patrol unit rolled onto the scene.

This newly arrived officer quietly assumed control of the situation. Taking a non-confrontational approach, the officer kept his distance while actively and empathetically listening to Daryl. His assurances and demeanor helped calm the situation to the point in which Daryl went with the officers to a local mental health facility for assessment and observation. It was not until later that authorities determined that Daryl, who has been diagnosed with schizophrenia, had neglected his medication regimen.

In the past, confrontations such as Daryl's had the potential of ending violently – and sometimes tragically – for both citizens and officers. In this instance, however, the officer successfully diffused the situation by using specialized techniques he learned through a Crisis Intervention Training

(CIT) program offered through his department. Crisis intervention strategies teach officers how to recognize psychiatric symptoms and to de-escalate potentially dangerous situations so that people in psychological distress can be diverted to facilities or services in a safe and appropriate manner.

Recognizing the importance of the CIT program, the Hogg Foundation for Mental Health has awarded two grants totaling $173,180 to help expand and enhance the program for law enforcement officers in Texas.

"At a time when law enforcement officers are increasingly being called upon to deal with persons with mental illness, the need for officers to appropriately and safely manage these situations is becoming increasingly important," said the Hogg Foundation's Jeffery R. Patterson, who, along with Reymundo Rodríguez, serves as Hogg Foundation liaison to the project. "It is estimated that in Texas cities whose populations exceed 100,000, anywhere up to 10 percent of all police calls – in both investigations and complaint responses – involve a person either diagnosed with, or suspected of suffering from, a mental illness."

According to officials with the Texas Department of State Health Services, people with serious mental illness who do not receive services are twice as likely to spend time in jail or prison. Perhaps as important as the underlying causes are the ways in which communities, policymakers, law enforcement officials, courts and corrections administrators are attempting to address these issues in a safe, fair and cost-effective manner.

Although CIT is not new (it originated in Memphis, Tennessee in 1988) the model has been gradually adopted by police and sheriffs' departments across the country. The Houston Police Department

(HPD) implemented a modified version as part of a pilot project in 1999. The feedback was so positive – from both mental health professionals and officers – that the department expanded the program to a goal of training 25 percent of Houston's police force in crisis intervention techniques.

Over the past five years, the CIT program grew not only within the department, but also in other Texas law enforcement agencies, who looked to HPD to train officers in the Greater Houston area and as far away as Dallas, Austin and San Antonio. Officer Frank Webb, coordinator of the Houston Police Department's CIT program, says that it quickly became obvious that the CIT was a valuable tool for patrol officers in handling individuals in a mental health crisis.

"Generally, we began to receive reports of improved officer confidence in dealing with offenders suspected of having a mental illness and more cases where individuals were being diverted to appropriate services instead of being arrested," Webb stated. "That translated into improved departmental relations with the community."

"The CIT program is diametrically different from the standard training that law officers normally receive," Webb said. "Traditionally, officers are taught to take control of situations through authority, attitude, and – when necessary – force. Crisis intervention training, however, encourages officers to use measured tones, active listening, and firm reassurances to de-escalate tense situations safely and appropriately."

One counselor at Houston's Ben Taub Emergency Psychiatric Center says she has witnessed big differences in the way CIT officers interact with persons with mental illness, largely because "they communicate more effectively and have a better understanding of different mental illnesses and symptoms."

As the reputation of the CIT grew, it became more evident how necessary the program was elsewhere in the state to provide law enforcement with a comprehensive and uniform training program to peacefully resolve crisis situations and divert offenders with mental illness from jails to services. Recognition of the growing needs for such training began to be clearly and consistently voiced by law enforcement agencies, state policymakers, mental health consumers and advocacy groups.

The HPD model has quickly become the "gold standard" for crisis de-escalation strategies in law enforcement agencies in Texas. Under Webb, the program now consists of four separate curricula – ranging from 8-, 16-, 24-, and 40-hours in duration – that can be tailored to meet specific needs and generate greater numbers of CIT instructors and coordinators within departments.

The costs and resources required of small to medium-sized police and sheriffs' departments to develop and implement CIT for their officers are frequently prohibitive. Nonetheless, the 79th Texas Legislature felt the training important enough to mandate that all veteran Texas law enforcement officers take a required16 hours of a specialized Crisis Intervention Training (CIT) to fulfill their certification requirements. Lawmakers instituted a similar training requirement for rookie officers in 2003 as part of the Texas Basic Peace Officer Curriculum managed by the Texas Commission on Law Enforcement Officer Standards and Education (TCLEOSE).

Until now, expansion of the CIT program has progressed under a strong sense of its effectiveness, but not a formal evaluation that documented those successes. To better understand the operations and document specific outcomes of the program, the Hogg Foundation for Mental Health awarded a grant of $73,180 to the School of Public Health at The University of Texas Health Science Center at Houston for Dr. Pamela Diamond to explore the logical links between different activities in the CIT curriculum.

The Hogg Foundation awarded a separate grant of $100,000 to the Houston Police Department to help facilitate the evaluation and expand the number of HPD officers who will receive crisis intervention training. The police academy will expand its CIT program by two, 40-hour classes (approximately 70 additional officers) in conjunction with TCLEOSE. Diamond, with the assistance of HPD Officer Kristen McGray, will explore the logical links between the CIT curriculum and its expected outcomes. The intent is to identify processes to inform efforts to improve, expand, and replicate the program. In doing so, Diamond will focus upon three areas.

First, the evaluation will document the benefits of CIT on the availability, access, and appropriateness of training officers and then deploying them across different shifts and patrol regions as a suitable means to respond to incidents involving the mentally ill. Second, the evaluation will examine how the CIT program has improved opportunities for change at the community and policy levels. CIT grew out of recognition by both stakeholders and law enforcement officers of the need for collaboration to develop policies and procedures to divert persons with mental illness from jail and into appropriate services. Hence, the evaluation will measure whether there has been an increased collaboration among agencies working with persons with mental illnesses, and the frequency and procedures involving such jail diversion.

Finally, the evaluation will examine whether the CIT program has contributed to greater community awareness and mutual understanding involving law enforcement and persons with mental illnesses. One of the core goals of the CIT program is for police departments to develop a level trust and collaboration within the community, especially among the families of persons with mental illness. When families feel that they can trust officers to be helpful in crisis situations, they are more likely to call officers earlier in the crisis, when intervention can have its best outcome.

The Houston Police Department has traditionally cited the last achievement as being a certifiable benefit. In Houston, for example, the process for individuals needing emergency mental health evaluation has been dramatically streamlined as a result of the cooperation between law enforcement and the mental health system. Previously, it took hours for an officer to complete a seven-page assessment request form, that needed to be signed by a judge before an individual could even be taken to a facility. Today, after having built cooperative arrangements, officers take an individual directly to a mental health facility, complete a one-page form, then return to service – a process that now takes about 15 minutes.

Officers say that such collaboration also improves law enforcement's rapport with the community – particularly the families of persons with mental illnesses. If family members feel comfortable in calling law enforcement in tense situations, then interventions can be made earlier, when better outcomes are achieved. The evaluation will attempt to measure the confidence and attitudes of consumers, families, and officers in communicating with one another and in resolving crises peacefully.

There are already programs in place to survey police cadets prior to and after completing the CIT to evaluate their knowledge of mental illness and their ability to de-escalate situations involving individuals who may have mental illness. These data allow for surveying these same officers after six months and later in their careers to determine what experiences on the street have prompted changes in their attitudes or behaviors. Follow-up surveys will also measure these officers' perceptions of the usefulness of the CIT program and their satisfaction with the refresher courses.

Ultimately, the project will help identify those aspects of the CIT program that are most effective and inform program development for departments across Texas. Most importantly, it will provide officers on the street with skills to better deal with persons with mental illnesses.

Computer Simulation Helps Officers Better Understand Schizophrenic Symptoms

To assist Houston Police officers in honing their skills at identifying and understanding the symptoms and feelings of mental illness, Janssen Pharmaceutical has developed a computerized virtual reality program that approximates the auditory and visual experiences of someone experiencing a psychotic episode.

With the simple set up of a laptop computer and specially devised earphones, officers experience firsthand a four-minute-long simulation of a psychotic episode. Frequently, symptoms of schizophrenia cause perplexity that manifests itself as extreme agitation and hallucinations - commonly "hearing voices."

The scenario of the computer program tries to simulate that experience by portraying an inner-dialogue of an individual going to a pharmacy to refill a prescription. Difficulty in locating the pharmacist, combined with an increasingly incessant number of internal voices both confuse and castigate the subject until he is irritated and disoriented to the brink of paranoia and potentially dangerous behavior. The pharmacist is shown treating this virtual customer normally, but when he tells the patient that he needs to contact the doctor for a refill, this confused virtual character believes "they are all against me."

Such an experience can be valuable in underscoring to officers trained in Crisis Intervention Techniques, who are taught to speak to subjects calmly, repeating phrases and instructions over and over to become the prevailing "voice" of the many that someone experiencing schizophrenic symptoms may be hearing. The intent is for the person to distinguish the voices and eventually focus on what the officer is trying to communicate.

Officer Dennis Eckenrode of HPD's South Central described the experience for Badge and Gun as "sensory."

It sounds as if you're in a crowded room and voices are coming from all over the place," Eckenrode said. "I now have a better perception of what a schizophrenic person goes through and what they hear."

The goal is to help officers recognize a potential mental illness and better understand how the strategies help to make managing a person with mental illness much safer. HPD Officer Frank Webb, who coordinates the CIT program for the Houston Police Academy, said the department hopes that each of the 600 CIT-trained officers will have the chance to utilize the computerized system as part of their continuing education coursework.