The Mentally Ill and Crisis Intervention Teams

Learning About the Mentally Ill

As a youth growing up in the state capital of Kansas, I was aware of the Topeka State Hospital, a large institution in the western part of Topeka for housing the mentally ill. Yet, other than walking through its grounds on the way to a weekend camp site a few miles west, I had no knowledge of what occurred inside the hospital buildings.

Later, I unexpectedly became acquainted with this institution when a high-school student friend was institutionalized there for more than a year. Each week, I pedaled 2 miles on my bicycle from my home to the state mental institution. Once inside the building, I questioned my friend about the daily routine. He explained that patients got up early—5:30 a.m.—in his “dorm,” and they waxed floors in the institution for an hour and one half. Then, they walked to the dining hall for breakfast; after eating, they returned to the dormitory. At noon, the mentally ill group ambled down to the dining hall for lunch. The same routine was repeated at 5:30 p.m. for supper. “Lights out” for bedtime came between 8:30 and 9:00 p.m. This dull, tedious, uneventful routine continued 7 days a week, month after month. Lack of programs added to the boredom. Admittedly, as a teenager, I did not understand the implications of the absence of programs that stood as a negative factor in the daily lives of mentally ill patients.

On moving on to graduate school in Washington, D.C., I worked part-time for a Kansas Congressman, who asked me if I would visit the state mental hospital in Topeka. A constituent had written to him to inquire about her son confined there, and she wanted to know about his treatment. Linking this request to a planned vacation, I agreed to make the inquiries.

It was déjà vu after an 8-year absence from the visits to my high-school friend; nothing it seemed had changed. There were the same dark, drab dorms. Programs still did not exist. ¹

This abysmal treatment of the mentally ill was addressed with the passage of the National Mental Health Act of October 31, 1963. Signed by President John F. Kennedy who campaigned for its passage, the Act provided grants to encourage community-based mental health care. Part of the vision included the construction of community mental health centers (CMHC) for the delivery of treatment. Media coverage of the time included many stories about the neglect and bad treatment of patients in state mental hospitals, and public pressure grew to rid the country of these institutions. Unfortunately, inadequate funding failed to finance the number of CMHC needed to accommodate those released from state hospitals (The Community Mental Health Act of 1963). In Kansas, the closing of Topeka State Hospital eliminated 300 beds, leaving the remaining two licensed state mental hospitals at Larned and Osawatomie with beds for 282 patients. State funding did not keep pace with the increasing demands in the communities where mental health centers were in operation (Ranney, 2014).

Jail Visits, American Jails Magazine, and Mental Health

In 1978, I traveled to my first visit to a jail outside the state of Maryland. This was the first of 828 jails I would visit across 49 U.S. states. Travel to these institutions spanned three decades, from 1978 to 2009, in conjunction with my work as Managing Editor for American Jails, the magazine launched by the American Jail Association.

Checking the table of contents of American Jails during my 22-year tenure, there were 78 separate articles on mental health, suicide, and suicide-prevention training. In the August, 1989 issue, I was even photographed for the front cover, portraying a mentally ill inmate being booked into the Washington County Jail in Hagerstown, Maryland. The issue title, Jails and the Mentally Disturbed, conveyed the theme of the articles published over those years—the problems and challenges of housing the mentally ill and the impact on jails and their communities.

Jails as Mental Hospitals

As the incarceration of mentally ill increased year by year going back to the days of President Kennedy’ advocacy for community care, the training of police officers, sheriffs’ deputies, and jail corrections officers on how to deal with persons with mental disturbances has become crucial. Many of the patients who disappeared when escorted out of the defunct state hospitals reappeared as “new patients” in the local jails. Although the vast majority of individuals with mental illness are not violent, many citizens believe otherwise. The current national publicity about individuals who have committed acts of mass murder has intensified stereotypes and myths of the “crazy,” a label that has easily returned to everyday discourse.

Jails in particular have become the new “asylums.” The recent VERA Institute Report, “Incarceration’s Front Door: The Misuse of Jails in America,” finds that U.S. jails have admissions that are nearly 19 times greater than annual admissions to prisons and that the number of U.S. jail admissions doubled from 6 million in 1983 to 11.7 million in 2013 (Subramanian, Delaney, Roberts, Fishman, & McGarry, 2015, pp. 4, 7). Jails now house seriously mentally ill men and women at rates 4 to 6 times higher than the general population—14.5% men and 31% women. Reflecting the nation’s War on Drugs, 72% of jailed individuals have both a serious mental illness diagnosis and a substance abuse disorder (Subramanian et al., 2015, p. 12). The Shawnee County Corrections Director, Brian Cole, noted that the mentally ill comprise 18% to 20% of the jail population, with one third of 2014 jail drug expenditures going to psychotropic drugs. The county is considering adding a 30-bed mental health module, estimated to cost between US$4 and US$5 million (Bush, 2015a, p. 7A). ²

Introduction to Crisis Intervention Teams (CIT)

The first article on CIT to appear in American Jails appeared in 2004 (Stratton, Blough, & Hawk, 2004). It discussed the Ohio Supreme Court’s Advisory Committee emphasis on a criminal justice team approach for addressing the serious community challenge of mentally ill citizens. The Ohio NAMI (National Alliance on Mental Illness) developed a curriculum aimed at jail and court personnel, which at that time had been focused on law enforcement officers. The model in Franklin County, Ohio, was offered as an example of a collaborative model, resulting in CIT training, initiation of a mental health docket at the municipal court level, and supportive mental health inmate funding for the Franklin County Jail in Columbus, Ohio.

CIT originated in Memphis, Tennessee, in 1987 after Memphis police had shot and killed a mentally disturbed person and local Memphis citizens demanded reform. The Memphis police chief appointed a police lieutenant, Sam Cochran, to “attack the problem.” He organized a coalition of Memphis citizens to work on diverting the mentally ill from the criminal justice system, focusing on mental health treatment, and ensuring involvement of all components of the criminal justice system (Vickers, 2000).

The Memphis CIT training ultimately resulted in a decline in the use of deadly force and resultant reduction in injuries for the mentally ill (40%) and officers (85%; Connecticut Alliance to Benefit Law Enforcement, 2005).

A year after the first CIT operation began in Memphis, the National Association of Counties (NACo), with funding from the National Institute of Mental Health, launched an initiative to divert “people with mental illness from jails and in-jail mental health services.” Five goals were emphasized as part of the provision of emergency mental health services:

The project’s final report, “Exemplary County Mental Health Programs: The Diversion of People With Mental Illness From Jails and In-Jail Mental Health Services” (Adams, 1988) identified programs that had mental health and correctional personnel working together. For example, Galveston County, Texas prioritized high levels of communication among county departments and community groups in this effort, including the Galveston County Sheriff’s Department, the Gulf Coast Regional Mental Health/Mental Retardation Center, The University of Texas Medical Branch Hospital, and the municipal police departments in the county. In Pinellas County, Florida, an in-jail mental health treatment program included a misdemeanor program and a forensic-in-jail mental health program—two separate and distinct programs staffed by psychologists, three master’s level social workers, a forensic evaluator, and a secretary—all under the authority of the county sheriff.

What Pushed Topeka, Kansas, Into CIT

Back in August, 2006, Topeka police shot and killed a 45-year-old man suffering from schizophrenia. According to a newspaper report, the subject had lived with schizophrenia for 25 years. Prior to the shooting, the individual had visited his ex-girlfriend’s home, and she called the police. When an officer arrived, the subject punched him and fled, only to die later in that day. The sister of the deceased was motivated to work with Kansas NAMI in starting a program with the goal of teaching law enforcement methods designed to reduce use of force.

Moving back to Topeka the summer of 2008, I connected with a CIT program for the first time in my 40+ years in the criminal justice field. I was reminded of a comment a person made back in the 1970s at the National Institute of Corrections Jail Center. The individual explained that personnel across all criminal justice agencies needed to be involved with agencies such as mental health, alcohol/drug treatment, elected government officials, and so on. This effort would encourage cooperation among community agencies to achieve common criminal justice goals. I observed that the Topeka CIT program was clearly intent on the criminal justice system functioning as a true system.

On my first visit to the Topeka Police Department in September 2008, I observed representatives from the police department, sheriff’s department, Shawnee County Department of Corrections, court services, county attorney’s office, the Topeka Rescue Mission (for the homeless), Valeo Mental Health (including alcohol/drug treatment) meeting in one room committed to making CIT training a success. I attended Topeka’s 40-hr, 5-day CIT training the last week of September 2008, and drove 70 miles in November to attend the first CIT training offered in the Kansas City, Missouri area. An incident involving the shooting of a mentally ill young man in his own Kansas City dining room and covered in my last issue of American Jails as managing editor led to the development of this program (Dougherty, 2009).

Since 2013, a crisis response unit in Topeka answers mental health calls. At this time, the officers and deputy sheriffs had access to a Mobile Response Unit that operated from 5:00 p.m. to 8:00 a.m., Monday through Friday, and on weekends and holidays. Funded by a grant, the Shawnee County Mental Health Agency, Valeo, enabled a mental health specialist to work with one CIT officer, spending full-time on house calls to assist those mentally ill that had encounters with the police.

Furthermore, a grant from the Kansas Department of Aging supported a mental health specialist and CIT officer to establish a direct connection to Valeo, also conducting follow-up calls with mental health consumers. Two more positions providing 16 hr on two shifts of coverage (instead of the current 8) will also come on board (Bush, 2015b).

The most recent information reveals that Topeka police responded to 506 crisis calls in 2014. Nearly 50% were “out of control, agitated, or aggressive,” followed by people experiencing “hallucinations or delusions, medication issues, and people with anxiety or post-traumatic stress disorder.” Only 6 were jailed, and 150 were hospitalized (Hart, 2015). Most recently, a grant is providing funding to the city of Topeka to hire a crisis co-responder and crisis peer support specialist, with the goal of diverting 90% of those arrested (Hart, 2015).

Ongoing Challenges to Serving the Seriously Mentally Ill in Kansas

CIT has become an important aspect of my continued role as jails advocate. Since the completion of the 2008 40-hr CIT basic training, I accepted the offer to work as a CIT Board member in Topeka/Shawnee County. I have now attended 15 of these 40-hr CIT training sessions at the Topeka Police Department, as well as four international CIT annual training conferences. In addition, the Kansas NAMI now conducts an annual 1-day training conference of CIT groups in different cities, providing a venue for individuals from around the state to communicate about CIT challenges and successes in their jurisdictions. Kansas NAMI moved a resolution, adopted by the Kansas Legislature’s Senate Judiciary Committee, recognizing CIT as a valuable tool to help the mentally disturbed receive better treatment and to keep low-level offenders out of jail (KHI News Service, 2012).

As CIT has progressed, the plight of the mentally ill in Kansas is exacerbated by continued challenges in the state mental hospital system. The two remaining hospitals, Osawatomie and Larned, are designated as “drop offs” for police transporting the mentally ill for hospitalization. Yet, current reports indicate that staff shortages are rampant, with 189 positions vacant at Osawatomie, and 322 at Larned. Osawatomie was found out of compliance with Centers for Medicare and Medicaid (CSM) standards in November 2014; the report noted crowding and not enough being done to ensure proper medical care. This is occurring in one of the two state institutions responsible for adults with severe and persistent mental illness. In January 2015, another CSM inspection found Osawatomie deficient in medication management and infection control, failing to keep on top of patients attempting to hang themselves (Ranney, 2015). On January 30, 2015, the 50-bed state Rainbow facility in the Kansas City area that had been closed down was re-opened, designated as a place for short-term intervention (for 50 patients being moved out of Osawatomie). With these shortages, the Topeka police are placed in the position of driving patients back to the city with but one obvious solution—taking them to the jail to be housed.

A Topeka city editor commented recently on the failure of Kansas politicians to sufficiently fund these state programs, relying instead on local jails to hold the seriously mentally ill and/or community agencies to step forward and render treatment—“It is one thing to be fiscally prudent, but it is quite another to ignore necessary maintenance and the needs of a group of people who cannot care for themselves” (The Topeka Capital-Journal Editorial, 2015, p. 4A).

Conclusion

After the elimination of the majority of U.S. mental hospitals, correctional agencies—especially jails and prisons—absorbed untold thousands of the mentally ill charged with misdemeanors and felonies. CIT, which began in 1987 in Memphis Tennessee, has now spread throughout the country. CIT emphasis on diversion and treatment of the mentally ill outside of the criminal justice system has had a major impact on the way the mentally ill are treated in this society.

The emphasis on criminal justice agency cooperation across the community, teaming with mental health providers, has initiated a better and more humane way to handle the mentally ill in our society. CIT can never solve all the problems of the mentally ill. The jail as asylum model is fully entrenched in urban jails, now operating as the “largest mental health hospitals” in the country. ³ Locking up all mentally ill law violators has proved to be extremely expensive. It makes political sense to divert the non-violent mentally ill charged with misdemeanors out for the criminal justice system and into the community for care. There is much more to be accomplished politically if treatment for the mentally ill is to improve. However, thanks to CIT, there is a “lot more light in the tunnel than there was 29 years ago.”

Clearly, more emphasis needs to be placed on tailoring CIT programs for jails and prisons because staff members must supervise and manage them in settings 24 hr a day, 7 days a week. The general public, too, needs to be much better educated on the implications for government at all levels in addressing this issue in a humane and successful manner. Getting communities across the country to appreciate the implications of locking up the mentally ill in jails on minor charges and using jails as hospitals for the seriously mentally ill remains a serious challenge.