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Law Enforcement Are Critical Stakeholders in Behavioral Health Crisis Services

It was September 24th, 1987, and Memphis police answered a 911 call made by a mother desperate to help her 27-year-old son experiencing an episode of Paranoid Schizophrenia. Joseph DeWayne Robinson had cut himself 120 times with a butcher’s knife, and his mother was fearful that he was going to kill himself. When police arrived at the scene at LeMoyne Gardens public housing project, it was a tight perimeter, and the officers asked Robinson to drop the knife. He didn’t. What happened next is disputed: the officers said Robinson lunged toward them; witnesses said he did not. The officers shot and killed Robinson, prompting community outrage and charges of racial bias against the Memphis administration. Robinson was Black, and the two officers who shot him were White. Sabrina Taylor, Crisis Intervention Team Training Coordinator at the Phoenix Police Department, says this tragedy was the tipping point that led to the creation of the Memphis Crisis Intervention Team (CIT).

Robinson was what law enforcement calls a frequent flier: he had a history of psychiatric hospitalizations and was a high use 911 caller, but the police officers who answered the emergency call were not trained in behavioral health crisis or how to deescalate the situation. Taylor says that people in crisis may not be easy to engage and appear out-of-control. Law enforcement can interpret the behavior as an imminent threat. Officers trained in crisis intervention have additional tools to respond to behavioral health emergencies such as knowledge, understanding, empathy, and listening techniques that may calm people down and negate the need for force. The approach decreases conflict and diverts people from jail. Instead, says Taylor, police officers often take people experiencing behavioral health crises to psychiatric emergency centers.

Nick Margiotta, president of Crisis System Solutions and retired Phoenix police officer, says CIT sounds simple, and in many ways it is, but it takes leaders in behavioral health who understand that police officers are critical stakeholders in crisis services. “Historically, the expectation has been that law enforcement officers fall in line with whatever policy leaders in behavioral health make. That doesn’t factor in our culture and, as a result, officers won’t do it.” Margiotta was first introduced to CIT in 2001 in a training program. He says that trainings are essential, but without an infrastructure to support actual implementation, it’s a disservice. In training, Margiotta learned about mobile crisis teams and psychiatric centers, where he and his colleagues could do a warm handoff. “The training shifted my perception and made me realize we can’t arrest our way out of this problem, and I was excited to start applying CIT to my job.” Margiotta answered a call from a frequent caller with Serious Mental Illness (SMI). She was depressed, had been drinking, and threatened to take 100 Advils. Margiotta thought this was an ideal opportunity to do his first psychiatric center dropoff. When he went to the facility, the staff rejected the dropoff because the woman had been drinking. Then he took her to the detox facility, and they rejected her because she was suicidal. “I was proud to apply my CIT training only for the person to be denied in both locations, so I didn’t do again for years. All I could do was take her to the parking lot of the county hospital and say, ‘Good luck.’”

Even though Margiotta didn’t use the CIT training as initially designed, it made him rethink how law enforcement was engaging with the community. Over the next few years, he built a diversion program and housing first initiatives during the day while patrolling downtown Phoenix at night. Three years later, Margiotta worked to restart CIT, and this time it was successful. The reason, says Margiotta, is he spent 90% of his time working with the behavioral health system, educating leaders on police culture. “Law enforcement will default to the more convenient solution, which means dropoffs need to be easier than what it takes to book someone.”

Police Dropoffs

The more limitations and challenges behavioral health facilities present, the less likely they will get police to drop off people in behavioral health crises. What law enforcement needs, says Margiotta, is a no-refusal policy, allowing officers to do dropoffs and return to their patrol duties. He says that initially, when he restarted CIT at his station, law enforcement faced numerous roadblocks. It took patience, collaboration, and walking crisis services staff and leadership through why service design must include a law enforcement voice to facilitate change. Margiotta says psychiatric centers were requiring police officers to take off their guns, refusing patients who had been drinking, requiring officers to obtain medical clearance, and the only door for dropoffs sometimes was the front door, with the seclusion and restraint room far away from the dropoff door. These were all barriers that, if they continued, would have made dropoffs unlikely. He says facilities also feared police officers were going to bring people experiencing delirium. If a person was clearly in need of a hospital, that’s where Margiotta would take him, but in cases of delirium, which is harder for a law enforcement official to determine, the center could call for an ambulance. “If I’m going to get medically screened out and have to put the person back in my car and drive him somewhere else, why should I even bother going there in the first place? Psychiatric centers need to function like Emergency Medical Treatment and Labor Act (EMTALA) applies to them, accepting anyone police officers bring in and integrating cop culture into the development of their policies. Meaning, 100 percent of crisis workers must be trained to work with law enforcement effectively. Otherwise, officers will default to the hospital or jail.”

Margiotta says successful collaboration also required law enforcement buy-in, which any refused dropoff could derail. “Years later, we’ve had a tremendous cultural shift here in Phoenix. Police officers automatically believe dropoffs allow them to do their job better and help people.” He says increasing buy-in from law enforcement and crisis services required holding each other accountable. Side-by-side, they looked over data each month. The goal, says Margiotta, was for police dropoffs to take less than seven-to-eight minutes. “When that didn’t happen, we all took a closer look at what went wrong and how to improve performance.”

A threat to collaboration is inviting law enforcement officers to be part of the design and processes, but then not integrating any of their recommendations. Margiotta says this is what happened with one facility. “They brought me in, and we worked alongside one another for months, but during the grand opening, it was clear they didn’t follow any of our recommendations. They were pretending to collaborate. I was there as window dressing to show that leadership had worked with us, and to keep me quiet during the implementation phase.” He says the facility was unsafe for police: staff would need to buzz officers in and couldn’t let anyone in or out. “It was a lockbox with nearby instruments that were dangerous. I made it clear there was no way officers would be coming there until they made the necessary changes.” In the end, the facility did an entire redesign. It took three years before police regularly started bringing dropoffs there.

Mobile Crisis

Margiotta says mobile crisis teams are a vital partnership for law enforcement, but working with them required similar collaborations. It took at least three years to create a robust, productive relationship. At first, they struggled with inconsistent mobile unit dispatch and crisis service provider fear of escalation. A good crisis mobile response team has rapid response and goes out 24/7, but, initially, that wasn’t happening. “We were getting a 25% denial rate from mobile units. That’s a no-no in our culture; officers will stop calling. We worked together and eventually, every time we called, a mobile unit was dispatched immediately. That’s the compliance we needed.” Police also need to be able to do a warm handoff of 5-15 minutes to the mobile unit and quickly get back to their jobs, but crisis services personnel often wanted officers to stick around for fear that the person might escalate. “This makes sense only if the person is violent, and suicidal ideation alone doesn’t mean police need to be present.” In one instance, says Margiotta, a caseworker was answering a call where the person hadn’t taken her medication for a few weeks. The caseworker sent the mobile crisis team and simultaneously called police to go to the location. “There was no danger, she wasn’t violent, and when I said that to the two-person mobile unit, they responded, ‘She has Schizophrenia. She could be hearing voices.’ They are the ones trained in behavioral health. I didn’t need to be there.”

Today, a person in a leadership role has to authorize if a mobile unit can call law enforcement, but if a situation escalates, the unit can immediately call the police. As a result, calls for police to respond have gone down between 70% and 80%. If the crisis line gets 18,000 calls a month, Margiotta says less than 10% will triage to mobile crisis units, and less than 1% need police response. Part of the struggle, says Margiotta is viewpoint, “Behavioral health workers believe these issues to be in the community, and that they are helping us. We view it quite differently; we are bringing them their customers for who they receive state and federal dollars. We see ourselves as critical stakeholders.” He has spent most of his career developing and maintaining partnerships between law enforcement and crisis services. “You can’t keep people out of the Emergency Department and jail without these relationships. It’s a public safety and public health issue: we are in this together.”

#CrisisTalk is committed to sparking ongoing dialogue on behavioral health crisis and including diverse perspectives and experiences. We’d like to hear what you think about this or any of our articles. Here’s how to send a letter to the editor.

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