CUSTODY CRISIS INTERVENTION TEAMS:
ADAPTING THE MEMPHIS MODEL TO THE CUSTODY SETTING
A Project
Presented to the faculty of the Division of Criminal Justice
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
Criminal Justice
by
Kimberly Lorraine Vester
SPRING
2014
© 2014
Kimberly Lorraine Vester
ALL RIGHTS RESERVED
ii
CUSTODY CRISIS INTERVENTION TEAMS:
ADAPTING THE MEMPHIS MODEL TO THE CUSTODY SETTING
A Project
by
Kimberly Lorraine Vester
Approved by:
____________________________, Committee Chair
Sue C. Escobar, J.D., Ph.D.
_______________
Date
iii
Student: Kimberly Lorraine Vester
I certify that this student has met the requirements for format contained in the University format
manual, and that this project is suitable for shelving in the Library and credit is to be awarded for
the project.
____________________________, Graduate Coordinator
Yvette Farmer, Ph.D.
Division of Criminal Justice
iv
_______________
Date
Abstract
of
CUSTODY CRISIS INTERVENTION TEAMS:
ADAPTING THE MEMPHIS MODEL TO THE CUSTODY SETTING
by
Kimberly Lorraine Vester
Several interrelated factors over the last few decades have contributed to an
increasing number of encounters between law enforcement and people with mental
illness. The problem with these encounters is that law enforcement is usually requested
because the person is in a crisis state, exhibiting unpredictable and threatening behavior,
causing surrounding people to fear for their safety. Limited law enforcement training in
dealing with these types of encounters, paired with little to no available mental health
resources, often leaves the responding officer no choice but to take the consumer to jail to
resolve the situation.
The overrepresentation of people with mental illness in the criminal justice
system is a nationwide problem. In response to this and various other associated
problems, the Crisis Intervention Team (CIT) concept was created to help improve the
outcomes of these law enforcement encounters. CIT members are trained to recognize
v
signs of mental illness along with de-escalation techniques to try to prevent a crisis event
from escalating to a physical confrontation.
Although it is considered a patrol intervention, the CIT model can be adapted to the
custody setting to help improve interactions between inmates with mental illness and law
enforcement staff. This purpose of this project was create and implement a Custody CIT
(CCIT) at the Rio Cosumnes Correctional Center in Sacramento, CA. The CCIT will
consist of two to three CIT trained deputies per shift, who are also provided additional
custody specific information. They would continue to work their regular assignment, but
are available to respond to an inmate in crisis. The main goals of the CCIT are the same
as the CIT, to reduce the likelihood of a crisis event escalating to a physical
confrontation, and increase communication with jail psychiatric services to help improve
services for the inmates.
____________________________, Committee Chair
Sue C. Escobar, J.D., Ph.D.
_______________
Date
vi
ACKNOWLEDGEMENTS
I have no idea how to even begin to thank all of my friends and family who
helped me get through this process. Whether it was listening to me hash out ideas,
offering words of encouragement or advice, a shoulder to cry on, or a good kick in the
butt, I know I would not have been able to complete this without them.
Thank you Dr. Escobar for all of your patience, understanding, and encouraging
words, especially through all my meltdowns, and for never losing faith in me, even
though I probably gave you plenty of reasons to! Thank you Dr. Farmer for believing in
me as well, and for helping to keep me focused. I never had any doubt that you wanted
me to succeed. Donna Vasiliou, your positive energy and encouragement always meant
so much to me whenever I talked to you, especially on those occasions when I felt like I
wasn’t going to make it. Also, thank you to Andrea Javist for being so helpful in
providing information and suggestions, even when I needed something last minute, which
seemed to be pretty often!
Finally, a huge thank you to my mom, Nancy, my dad, John, and my brother,
Bryan, for the countless things you have done for me over the last few years; like coming
over to sit with me while I typed to help keep me from getting distracted, washing my
dishes when simple house chores got to be too much, helping me deal with taking my car
to the shop when it broke down…again, bringing me coffee to wake me up when I knew
I’d sleep though all five of my alarms, empathizing with me and the stress I was going
through, and most of all, just always being there if I needed anything! THANK YOU!
vii
TABLE OF CONTENTS
Page
Acknowledgements .................................................................................................... vii
Chapter
1. INTRODUCTION ................................................................................................. 1
2. LITERATURE REVIEW ....................................................................................... 8
Law Enforcement and Consumers .................................................................... 9
Crisis, Intervention, and Crisis Theory ........................................................... 15
Crisis Intervention in Law Enforcement ......................................................... 18
Crisis Intervention Team (CIT): The Memphis Model................................... 21
Adapting the Memphis Model to the Custody Setting.................................... 26
Legal Considerations ...................................................................................... 31
Consumer Inmates .......................................................................................... 32
Safety Cell Placement ..................................................................................... 33
RCCC Specific Issues ..................................................................................... 35
Here and Now ................................................................................................. 37
3. PROJECT PROCESS ........................................................................................... 41
What was Done ............................................................................................... 42
Custody CIT (CCIT) – Benefits and Implementation..................................... 49
4. CONCLUSIONS AND RECOMMENDATIONS ............................................... 51
viii
Appendix A. Memphis Model CIT Core Elements Outline ..................................... 56
Appendix B. RCCC CCIT Program Outline............................................................. 58
Appendix C. RCCC CCIT Orientation Manual ........................................................ 61
References ................................................................................................................... 70
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1
Chapter 1
Introduction
According to the National Alliance on Mental Illness (NAMI), approximately one
in four adults in the United States has a diagnosable mental disorder, compared to over
half of the jail inmates in the US who are suffering from some sort of mental illness
(Baillargeon, Binswanger, Penn, Williams & Murray, 2009; Ross, 2008). While only
about 6% of the US adult population is considered to have a serious or severe mental
illness, such as major depressive disorder, bi-polar disorders, schizophrenia and nonschizophrenic psychotic disorders, that percentage jumps to anywhere from 15% to 25%
when looking at the US jail and prison populations (Baillargeon et al., 2009; James &
Glaze, 2005). Inmates with mental illness present a significant problem for jails and
prisons, as these facilities and custody staff are generally not prepared or intended to deal
with the needs and characteristics of this type of inmate (Adler, 1986; Dooley, 2010;
Human Rights Watch, 2003; Ross 2008).
One of the main reasons for the increased number of inmates with mental illness
within the last four decades is the closing of mental health institutions, often referred to
as deinstitutionalization, and the subsequent increase in encounters between law
enforcement and people with mental illness (Adler, 1986; Baillargeon et al., 2009; Engel
& Silver, 2001). In the early 1960s, nationwide deinstitutionalization returned a large
population of people with mental illness to their communities with the intention of
referring them to community-based mental health resources and services (Abramson,
1972; Baillargeon et al., 2009; Teplin, 1984; Vickers, 2000).
2
While well intended, the money saved by closing the mental health institutions
was not used to fund community based mental health services, which left many former
patients without access to mental health treatment (Perez, Leifman & Estrada, 2003;
Vickers, 2000). Without treatment, people with mental illness often decompensate, or
begin experiencing and exhibiting symptoms of their mental illness, and more likely to go
into crisis and act out in unpredictable and/or violent ways (Lamb, Weinberger &
DeCuir, 2002). Without access to treatment, people with mental illness are also more
likely self medicate using illegal drugs, and they are also a vulnerable population who
often end up homeless and victimized (Baillargeon et al., 2009; Greenberg & Rosenheck,
2008; Lamb et al., 2002; Vickers, 2000). These are several factors that contribute to the
higher number of encounters between law enforcement and people with mental illness,
whether during an informal street encounter, or upon citizen request to take control of a
situation involving a person in crisis (Hodges, 2010; Lord, Bjerregaard, Blevins &
Whisman, 2011).
When people go into crisis, their behavior can become unpredictable, bizarre,
confrontational and violent, causing the people around them to fear for their safety
(Abramson, 1972; Morabito et al., 2012; Teplin, 1984). It is at this crisis point when law
enforcement is usually requested to intervene and take control of the situation (Franz &
Borum, 2011; Lamb et al., 2002; Teplin, 1984: Vecchi, Van Hasselt & Romano, 2005).
According to the Crisis Theory, a person can go into crisis when faced with a problem
that exceeds his or her coping abilities, whether suffering from mental illness, dealing
with situational factors or a combination of both (Golan, 1978; McMains & Mullins,
3
2006). People with mental illness are often called mental health consumers, or
consumers, a term that can apply to anyone who uses mental health services, regardless
of whether they have been diagnosed with a mental illness (Dooley, 2010; Vickers,
2000).
Law enforcement officers are not generally trained to recognize signs of mental
illness, or de-escalation and communication techniques that can help the officer gain
compliance from a consumer in crisis without physical intervention (Ruiz & Miller,
2004). Officers find it difficult to handle calls involving consumers because they do not
feel adequately trained to deal with them, in addition to their perception of the danger
being higher in these encounters, as opposed to encounters with non-consumers (Lord et
al., 2011; Morabito et al., 2012; Ruiz & Miller, 2004). Also, the presence of a law
enforcement officer may also instill fear in the consumer, which could escalate the
situation (Ruiz & Miller, 2004). Any encounter that requires the officer to respond with
force to gain compliance increases the chances of injuries, or even death, to the
consumer, the officer, and/or any bystander (Ruiz & Miller, 2004; Strauss et al., 2005;
Watson, Morabito, Draine & Ottati, 2008).
Another reason law enforcement may be requested for a person in crisis is simply
because they are available around the clock to respond to emergencies, while many
mental health services are not (Borum et al., 1998; Lamb et al., 2002). If the responding
officer determines the consumer needs to be taken in for an emergency mental health
evaluation and/or treatment, the admittance process can be very daunting, frustrating, and
time consuming (Morabito et al., 2012). In some cases, the mental health agency may
4
consider the consumer too violent, or question the officer’s judgment and reject the
consumer (Lamb et al., 2002; Teplin, 1984). With limited or no mental health resource
options, and in the interest of time and efficiency, these encounters often end in mercy
bookings. Mercy bookings occur when responding officers are left with no other options
to resolve the situation other than arrest and take the consumer to jail, whether or not the
consumer committed a crime prompting an arrest (Abramson, 1972; Franz & Borum,
2011; Lamb et al., 2002; Teplin, 1984; Watson et al., 2008).
The significantly higher number of consumers involved in the criminal justice
system is often referred to as the criminalization of mental illness (Abramson, 1972;
Teplin, 1984). This is an ongoing and somewhat cyclical problem, as recidivism rates are
also much higher among consumers as well (Baillargeon et al., 2009; McGuire & Bond,
2006). The factors that contribute to this problem are the lack of training for responding
law enforcement officers and limited mental health resources available to the officer to
help place the consumer into the mental health system as opposed to the criminal justice
system (Abramson, 1972; Lamb, 2009; Ruiz & Miller, 2004).
The Crisis Intervention Team (CIT) concept was developed in Memphis,
Tennessee, in response to the need for better ways for law enforcement to handle calls
involving people with mental illness (Dooley, 2010; Dupont, Cochran & Pillsbury, 2007;
Morabito et al., 2012). Since its inception in 1988, the “Memphis Model” of CIT has
been implemented in hundreds of law enforcement agencies nationwide, and has shown
to be very effective in accomplishing its ultimate goal of more positive outcomes in
5
encounters between law enforcement and consumers (Compton, Bahora, Watson &
Oliva, 2008; Dupont et al., 2007).
The original goal of the CIT program was to reduce the likelihood of injury
during a law enforcement encounter with a consumer in crisis (Morabito et al., 2012;
Watson et al., 2008). CIT members are trained to recognize signs of mental illness and
use techniques other than force to gain and maintain control of the situation (Franz &
Borum, 2011; Morabito et al., 2012; Watson et al., 2008). CIT members also use these
encounters as opportunities to help connect the consumer with treatment and resources.
This became the second, but equally important goal of CIT (Morabito et al., 2012;
Watson et al., 2008). CIT officers often report they feel more prepared and confident
when dealing with consumers than they did prior to their CIT training (Watson et al.,
2008).
The ideal outcome of any law enforcement encounter with a consumer is placing
the consumer into the mental health system instead of the criminal justice system (Lamb,
2009). The effectiveness of CITs is largely dependent on the resources and support they
receive from their department and the communities they serve. In partnership with
NAMI, and various community mental health agencies, CITs are a pre-booking diversion
designed to treat mental illness as a disease, not a crime (Lord et al., 2011). Although
CITs have helped to reduce the number of arrests of consumers stemming from law
enforcement encounters (Compton et al., 2008; Franz & Borum, 2011; Strauss et al.,
2005), custody staff for jails and prisons still must deal with a large population of inmate
consumers (Adler, 1986; Dooley, 2010). Additionally, incarceration may cause an
6
inmate to go into crisis and become a consumer, rather than a crisis event causing a
consumer to become an inmate (Edwards & Potter, 2004; Liebling, 1999).
Although CIT is a patrol-based intervention, the model can be adapted to the
custody setting to address the population of inmate consumers. The main goals of CITs
would be the same in a custody setting as they are on patrol; reducing the likelihood of
injuries during an encounter between law enforcement and a consumer and providing him
or her with mental health resources. Establishing a CIT in the custody setting could
accomplish these same goals when dealing with inmates in crisis, whether the inmates are
simply unable to cope with their current situation, or a part of the increasing population
of consumers entering the criminal justice system. In addition to reducing the likelihood
of injuries, the partnership between the CIT and the jail psychiatric staff can help provide
the inmate consumer better access to psychiatric treatment and services as well as access
to other resources, which may, in turn, help reduce recidivism.
The purpose of this project is to examine the structure and core elements of the
Memphis Model of the CIT, and how the model can be adapted to the custody setting.
This project will then establish the structure and operation of a Custody CIT at the Rio
Cosumnes Correctional Center (RCCC), one of the two county jails in Sacramento, CA.
Evaluation procedures will be outlined to help improve the program and determine the
effectiveness in accomplishing its goals. This model can then be applied to the Main Jail
(MJ), the other jail facility in Sacramento County, to establish consistency in how issues
involving consumer inmates are handled in both Sacramento County jail facilities.
7
Benefits of a Custody CIT include the decreased likelihood of injuries to inmates,
jail staff and/or any involved parties in an encounter with an inmate consumer, decreased
chances of civil and financial liability to the agency, more positive public perception of
the agency and law enforcement in general, specialized training for CIT officers that can
be beneficial in other job assignments, improved communication with jail psychiatric
services (JPS) staff, and improved mental health services to inmate consumers. Overall,
the core goal of the Custody CIT is the same as in patrol: more positive outcomes
resulting from encounters between law enforcement and consumers.
8
Chapter 2
Literature Review
People with mental illness, or consumers, frequently come in contact with law
enforcement in a variety of circumstances. In most of these interactions, in order to
achieve law enforcement’s primary goal of restoring and maintaining order, the officer
determines that the consumer needs to be removed from the situation (Engel & Silver,
2001). Lack of available mental health resources, however, often leaves the officer with
no alternative but to take the consumer to jail (Franz & Borum, 2011; Watson et al.,
2008). Most non-violent offenders with mental illness do not belong within the
punishment model of the criminal justice system. Jails are not equipped or intended to
handle this population of inmate consumers, and subsequently, inmate consumers often
do not get the appropriate care they would receive from the therapeutic model of the
mental health system (Human Rights Watch, 2003; Laberge & Morin, 1995).
The resulting increase in the number of consumers in the criminal justice system
is often referred to as Criminalization of Mental Illness Cycle, and has caused concern
over policies regarding how issues involving consumers are handled within the criminal
justice system (Abramson, 1972; Watson et al., 2008). Various pre and post-booking jail
diversion programs have been implemented in agencies across the United States to
address this problem (Baillargeon et al., 2009; Watson et al., 2008). An example of a
post-booking diversion is the use of mental health courts, which divert non-violent
mentally ill offenders from incarceration to closely supervised mental health programs
and services (Baillargeon et al., 2009).
9
An example of a pre-booking diversion is a Crisis Intervention Team (CIT). This
program has shown to be very effective in accomplishing one of its main goals of
reducing arrests of consumers, and instead connecting them with mental health services
(Compton et al., 2008; Franz & Borum, 2011). Although CITs are considered a prebooking diversion designed for the patrol setting, the elements and goals can be easily
applied to the custody setting to help improve the interactions between consumer inmates
and custody staff (Dooley, 2010). Since each CIT is adapted to the agency and
community it serves, adapting the CIT to the custody setting would be a similar process.
Law Enforcement and Consumers
Interactions with consumers and people in crisis are considered a regular part of
police duties (Engel & Silver, 2001) and account for about 7-10% of law enforcement
encounters (Franz & Borum, 2011). That number increases to as much as 20% when
including incidents involving people under the influence of alcohol or other drugs (Franz
& Borum, 2011; Lord et al., 2011; Watson et al., 2008). Law enforcement officers
frequently interact with consumers as suspects, as witnesses, and during informal street
encounters (Hodges, 2010; Lord et al., 2011), although the impetus for the law
enforcement encounter is usually when the person is in crisis and experiencing acute
symptoms, feeling out of control, frightened, agitated, or threatened. If the person’s
behavior becomes unpredictable and violent, making them a danger to self or others, law
enforcement is requested to intervene and gain control of the situation (Franz & Borum,
2011; Morabito et al., 2012; Strauss et al., 2005; Vecchi et al., 2005).
10
A higher percentage of these encounters also end in the arrest of the person,
usually for something minor, compared to the percentage of arrests stemming from
encounters with people who do not exhibit signs of mental illness (Strauss et al., 2005;
Teplin, 1984). In addition to the high number of law enforcement encounters with
consumers, and their disproportionately higher arrest and incarceration rates, studies have
shown an increase in recidivism among consumers as well (Baillargeon et al., 2009;
Compton & Kotwicki, 2007).
This over representation of consumers in the criminal justice system, often
referred to as the criminalization of mental illness, has become a significant problem
(Abramson, 1972; Lamb, 2009; McGuire & Bond, 2011). Not only is it a burden on the
criminal justice system, it stigmatizes the consumers as criminals (Lamb, 2009).
According to the Labeling Theory, once a person is labeled a criminal, any future
behavior or actions by that person may be perceived as criminal, when those same
behaviors or actions may not be perceived as criminal when exhibited by someone else.
The labeling theory further posits that others may begin to expect the labeled person to
engage in criminal behavior. These expectations and reactions can also make the person
feel like a criminal, which could cause them to begin to engage in criminal activity as a
self-fulfilling prophecy (Compton & Kotwicki, 2007; Miller, Schreck & Tewksbury,
2008).
The fact that people with mental illness are more frequently caught up in the
criminal justice system also contributes to the myth that they are more dangerous than
those who do not have mental illness. Ruiz & Miller (2004) identify two prevalent
11
misconceptions that people with mental illness are “incapable of reasoning and they are
all violent” (p. 361). People with mental illness are often caught up in the penal system,
not because they are more dangerous, but because they have mental health needs that are
not being met (Compton & Kotwicki, 2007). With the Labeling Theory in mind, this can
lead to the perception that people with mental illness are all violent criminals. If law
enforcement officers encounter people with mental illness with nothing but these
misperceptions, they respond as they would a violent criminal, further criminalizing the
mentally ill.
Several factors have contributed to the criminalization of mental illness
phenomenon, but the closing of mental health institutions in the early1960s, or
deinstitutionalization, and the subsequent failure to provide mental health services to
former patients upon return to their communities, is often cited as the main catalyst
(Abramson, 1972; Baillargeon et al., 2009; Perez et al., 2003; Vickers, 2000). Prior to
deinstitutionalization, mental health care was available to consumers from public mental
health hospitals. The closing down of these the hospitals was intended to return patients
to the communities and direct the funding to more outpatient resources for them. At that
time there were many people who just needed outpatient treatment, as opposed to being
“stored” in a mental health facility (Perez et al., 2003). In 1972, with Wyatt v. Hickney,
the federal court reinforced deinstitutionalization by asserting that “people with mental
illness have a constitutional right to treatment” (Perez et al., 2003, p. 62). Several laws
were also enacted, creating more stringent requirements for admittance to mental health
12
hospitals in an effort to provide people with mental illness the rights and dignity of living
within their communities (Perez et al., 2003; Teplin, 1984).
Unfortunately, the money saved was not spent to provide community mental
health services as intended, leaving a population of mentally ill people with no or very
limited mental health treatment and resources. Without treatment, they are more likely to
decompensate and engage in activities likely to elicit law enforcement intervention, such
as committing minor criminal offenses, or exhibiting unusual, unpredictable and/or
violent behavior resulting from their untreated mental illness (Baillargeon et al., 2009;
Human Rights Watch, 2003; Perez et al., 2003; Teplin, 1984; Vickers, 2000).
During the 1970s, while the effects of deinstitutionalization were beginning to be
seen, there was a significant paradigm shift in the United States from support for the
rehabilitation approach, to a more punitive approach in dealing with crime and offenders
(Farabee, 2005; Ross, 2008). This growing perception that rehabilitation was not
working is marked by Martinson’s 1974 analysis, “What Works?” which, although never
stated in the report, created the “nothing works” sentiment among the general public and
policy makers (Cullen & Gendreau, 2001; Farabee, 2005; Martinson, 1974; Miller et al.,
2008).
This sentiment led to the creation of more punitive measures such as determinate
sentencing, which prescribed fixed sentence lengths for certain crimes. This made
incarceration the punishment, with little or no consideration for other factors such as
mental illness, and caused a significant increase in the jail inmate populations (Ross,
2008). In addition to the establishment of more punitive measures for dealing with crime,
13
the war on drugs began in the 1980s, which resulted in more drug related arrests, causing
an even more significant increase in jail populations (Ballargeon et al., 2009). Since a
significant number of people with mental illness have co-occurring substance abuse
problems, they were more likely to be swept up into this jail population increase
(Compton & Kotwicki, 2007; Morabito et al., 2012; Ritter, Teller, Marcussen, Munetz &
Teasdale, 2011).
Law enforcement officers often report that they feel that they have inadequate
training and are unprepared for dealing with people with mental illness (Franz & Borum,
2011; Lamb et al., 2002; Morabito et al., 2012). Without training and education about
mental illness, the responding officer may have this misconception of the consumer and
respond accordingly. Additionally, the consumer may fear the responding officer or law
enforcement in general. These perceptions can cause the situation to escalate and
increase the chances of injury and/or death to the consumer, officer or any other involved
party (Morabito et al., 2012; Ruiz & Miller, 2004).
Responding officers also have limited options when dealing with consumers who
are in need of mental health care, rather than law enforcement involvement. Officers
often report that the process for admitting consumers to mental health institutions is often
a very time consuming, complicated, and daunting process (Franz & Borum, 2011; Lamb
et al., 2002; Morabito et al., 2012). Many of these complicated procedures are in
response to the limiting laws established during deinstitutionalization, which makes it
more difficult to admit someone on an involuntary basis (Finn, 1989; Teplin, 1984).
14
Mental health facilities can also refuse admittance if the person is deemed too
dangerous, under the influence of alcohol or drugs, or if the facility has no room (Lamb et
al., 2002; Teplin, 1984). These circumstances often leave mercy booking as the only
option for law enforcement. Placing the consumer under arrest and taking them to jail is
often more reliable and less time consuming than the often cumbersome procedure to
admit them to a mental health facility (Lord et al., 2011; Teplin, 1984; Watson et al.,
2008).
Closing down mental health hospitals and failing to provide adequate community
mental health care for consumers in crisis has resulted in trans-institutionalization instead
of the goal of deinstitutionalization (Fay, 2013). Perez (2003) describes this as the
“unintended reinstitutionalization of this population [of consumers] into our state and
local jails” (p. 62). According to Teplin (1984) “jails and prisons may have become the
long term repository for mentally ill individuals who, in a previous era, would have been
institutionalized within a psychiatric facility” (p. 795). Jail is only a temporary solution
and people with mental illness are not provided any follow up care upon release. This
can result in increased recidivism rates and demonstrates a clear need for alternatives to
incarceration for consumers before they are caught up in the criminal justice cycle
(Lamb, 2009; Lord et al., 2011).
Law enforcement officers are sometimes regarded as gatekeepers and have a high
degree of influence on whether the consumers in these encounters enter the mental health
system or the criminal justice system (Engel & Silver, 2001; Lamb et al., 2002). The
disposition of their encounters with consumers is ultimately based on the responding
15
officers’ recognition and perception of mental illness, their training in how to manage a
call involving a consumer, and their knowledge of available mental health resources for
the consumer.
Crisis, Intervention, and Crisis Theory
The recognition of crisis events and the effects they can have on a person can be
traced back as far as 400 BC, when Hippocrates defined a crisis as a “sudden state that
gravely endangers life” (Roberts, 2005, p. 15). It was not until the mid-20th century,
however, that a cohesive theory or approach to managing crisis events was developed
(Roberts, 2005). In the 1940s Erich Lindemann, known as the “Father of Crisis
Intervention” introduced the concepts of crisis intervention when dealing with the
survivors and families of victims of a nightclub fire in Boston that killed almost 500
people (Roberts, 2005; Smith, 1975).
Lindemann recognized the need for a person to go through an adjustment process,
such as grief work, following a crisis event in order for life to return to normal (as cited in
Roberts, 2005). Lindemann (1944) described grief work as the “emancipation from the
bondage to the deceased, readjustment to the environment in which the deceased is
missing, and the formation of new relationships” (Lindemann, 1944, p. 143). In order to
successfully do the grief work and readjust to a new environment, the grieving person
must first face the distress connected with the precipitating event, then express the
necessary emotions as a result. The role of the psychiatrist is to assist in this catharsis, or
expression of feelings about an event, and help shorten the duration of the person’s grief
reaction (Lindemann, 1944).
16
Lindemann’s colleague, Gerald Caplan, expanded Lindemann’s work and was the
first to introduce the concept of homeostasis to crisis intervention (as cited in Roberts,
2005). According to Caplan (1964), a crisis event is an upset to the steady state of an
individual. He summarized the characteristics of a crisis in four phases. Phase One is the
initial rise in tension caused by an event, or stimulus, that threatens a person’s
homeostasis, which evokes that person’s habitual coping and problem solving strategies.
Phase Two is the continued tension due to the ineffectiveness of the person’s coping
strategies to remove the stimulus. Phase Three describes the further rise in tension
leading the person to scramble for new coping strategies and ways of perceiving or
redefining the problem. Phase Four is reached when the problem continues and tension
rises to the person’s breaking point, leading to “[m]ajor disorganization of the individual
with drastic results” (Caplan, 1964, p. 41). According to Caplan, it is during this crisis
event that intervention and mental health care strategies are most effective for the
person’s mental health (Caplan, 1964).
Roberts (2005) asserted that Lindemann and Caplan laid the foundation for
further research and development of the Crisis Theory and management of crisis events.
According to the Crisis Theory, an individual person strives to maintain homeostasis
within themselves, as well as within groups, family, community, etc. A hazardous event,
or obstacle toward attainment of an important life goal, can occur at any time, and any
number of times to the person throughout his or her lifespan (Golan, 1978). The event
becomes a crisis event when it disrupts the person’s homeostatic balance and tension
rises. When the person’s normal coping strategies do not resolve the problem, the tension
17
peaks and the person enters into state of disequilibrium or “crisis point” (Golan, 1978;
McMains & Mullins, 2006; Roberts, 2005). This period of disorganization can then lead
to a “cataclysm of emotions” such as fear, panic, anger, rage and mental confusion
(McMains & Mullins, 2006, p. 75).
Through the Crisis Theory lens, a crisis event can be seen as a chance for personal
growth, or as dangerous and possibly life threatening (Hoff, 2001). When someone
reaches a crisis point, he or she will most likely reach out to resources such as police,
hospital emergency rooms, emergency psychiatric services, suicide hotlines, etc. where
responders are available around the clock (Roberts, 2005). Crisis intervention techniques
focus on immediate short term crisis resolution to alleviate the impact of the crisis on a
person. They stabilize, then mobilize the person toward further, more long term
resources, if needed, to reach the goal of restored equilibrium and development of new
coping methods (Hoff, 2001; Roberts, 2005).
The Crisis Theory is similar to Freud’s Psychoanalytic Theory in terms of the
concepts of equilibrium, or what Caplan referred to as homeostasis (Hoff, 2001; Smith,
1975). The Psychoanalytic Theory posits that there are three parts of the personality, the
id, ego, and superego, and a well-adjusted person is able to keep the three in balance. An
imbalance of any of these manifests itself in anti-social behavior, including criminal
behavior, or acting out in response to increasing internal pressure, similar to what would
be considered a “crisis event” (Hoff, 2001; Miller et al., 2008). Another similarity
between the two theories is the importance of catharsis, such as Lindemann’s grief work,
in the healing process (Golan, 1978; Hoff, 2001).
18
The differences between the two theories is that the Crisis Theory is based on
healthy individuals while the Psychoanalytic Theory is based on illness (Hoff, 2001).
Psychoanalysis, which is based on the Psychoanalytic Theory, is also long term, as
opposed to the short-term focus of crisis intervention, which is based on the Crisis
Theory (Hoff, 2001; Smith, 1975).
The foundations of the Crisis Theory and crisis intervention began to emerge in
the 1960s during the mental health movement that led to deinstitutionalization. This was
around the time the suicide prevention movement took hold in the United States. Care
for people in crisis relied on the immediate, short-term resolution nature of crisis
intervention (Hoff, 2001; Roberts, 2005).
Crisis Intervention in Law Enforcement
When dealing with people in crisis, the response options for law enforcement
officers are similar to any other law enforcement encounter; do nothing, handle
informally, arrest, or seek another resolution (Watson et al., 2008). By the time law
enforcement is requested for this type of situation, the person is usually in a crisis state,
posing a threat to safety, and doing nothing is not an option (Lamb et al., 2002). Prior to
the 1970s, law enforcement resolution of these types of encounters relied on the verbal
skills of the individual responding officer, or by amassing manpower and demanding the
subject(s) to comply, with the threat of force if they refused. An example of amassing
manpower in these situations was the use of Special Weapons and Tactics (SWAT) teams
(McMains & Mullins, 2006; Russell & Beigel, 1990). Very little, if any, time or effort
was spent in training officers to recognize signs of mental illness in these types of out of
19
control situations. Officers were trained to respond with force, which increased the
likelihood of injuries and/or death in these confrontations (Hatcher, Mohandie, Turner &
Gelles, 1998).
Hostage vs. Crisis and Negotiation vs. Intervention. In the mid-70s, incidents
involving hostages, or hostage incidents (McMains & Mullins, 2006), were the main
focus of concern in the United States, particularly on the west coast (Hatcher et al.,
1998). Due to the often high number of casualties, the utilization of force, such as
SWAT teams, to resolve these incidents began to fall under intense scrutiny (Hatcher et
al., 1998; Vickers, 2000). With the growth of psychological services and input from
several psychologists, hostage negotiation teams were developed in the New York Police
Department, the San Francisco Police Department, and the Los Angeles Police
Department (Hatcher et al., 1998; McMains & Mullins, 2006).
During this time, similar changes to procedures for handling law enforcement
encounters with people in crisis were occurring in other countries as well (Hatcher et al.,
1998). The goal of these hostage negotiation teams was to use specific communication
techniques with the hostage taker to negotiate a peaceful resolution to a hostage incident.
The ideal resolution was the release of hostages, and the hostage taker being taken into
custody, while avoiding injury or death to any involved party (McMains & Mullins,
2006).
The training for these hostage negotiation teams was focused more on dealing
with geopolitical events, such as plane hijackings, terrorist acts, and politically motivated
incidents (Hatcher et al., 1998; McMains & Mullins, 2006). As the name of this type of
20
team indicates, the incidents also involved a hostage, a person held against his or her will
for fulfillment of demands by the hostage taker(s). Demands made are reasonable, goal
oriented and the hostage is used as leverage as opposed to being the target. In contrast,
non-hostage incidents are more fueled by emotion and people being held against their
will are considered “victims” as opposed to hostages. Demands made by the subject(s)
holding the victims are unreasonable, not goal oriented and they are usually expressing
hurt, frustration, and/or disillusionment over a situation they are facing (McMains &
Mullins, 1998; Noesner, 1999; Vecchi et al., 2005).
During the 1980s, the transition from hostage negotiation to crisis negotiation
started to emerge. Law enforcement agencies became more concerned with incidents
involving people in crisis, and away from the larger scale hostage and terrorist acts which
were becoming more rare occurrences (Hatcher et al., 1998). The tactics for dealing with
these incidents shifted emphasis from negotiating demands and bargaining techniques to
using crisis negotiation techniques and active listening skills (McMains & Mullins, 2006;
Vecchi et al., 2005).
Since many mental health resources for mentally ill and people in crisis are not
available after hours or on weekends, responses to these incidents are often left to law
enforcement (Roberts, 2005). The potential for violence is higher in an encounter with a
consumer in crisis, and timely intervention can help prevent the situation from escalating
to a violent confrontation (Engel & Silver, 2001). Since timely intervention is a key to a
successful resolution of these encounters, the term crisis intervention emerged and is
21
often used interchangeably with crisis negotiation (Hatcher et al., 1998, Vecchi et al.,
2005).
Crisis Intervention Team (CIT): The Memphis Model
In 1987, the Memphis Police Department responded to a call for service regarding
a suicidal man, with a history of mental illness, cutting himself with a knife. When the
responding officers demanded he drop the knife, the man ran toward them. Fearing for
their safety, the officers shot and killed the man. This was not the only time that a law
enforcement encounter with a consumer ended in injury to a person or people involved,
but this incident was the catalyst for the development of a Crisis Intervention Team (CIT)
in Memphis, Tennessee1 (Dooley, 2010; Vickers, 2000).
After the CIT became operational in May of 1988, it quickly gained recognition
throughout the United States (Dupont et al., 2007; Vickers, 2000). According to Dupont,
et al. (2007) the basic goals of CITs are to “improve officer safety” and “redirect
individuals from the judicial system to the health care system” (p. 3). Achieving these
goals involves training officers in more effective ways to deal with consumers during law
enforcement encounters, and developing and fostering partnerships between the law
enforcement agencies, community mental health agencies and any other affected people
1
Credit for the creation of CIT in 1987 is given to Lt. Col. Sam Cochran and Dr.
Randolph Dupont. Among many articles written by them either in partnership or
separately about CIT, their article Crisis Intervention Team Core Elements (2007) is
being used as the foundation of the Memphis Model for this project.
22
or organizations, which are referred to as stakeholders (Reuland, Draper & Norton,
2010).
A Crisis Intervention Team is comprised of patrol officers from each shift who
volunteer to be a part of the team, and are chosen based on their compassion and desire to
improve law enforcement interactions with consumers (Vickers, 2000; Watson et al.,
2008). Once selected, the officers are specifically trained in techniques for dealing with
people with mental illness. The 40-hour CIT course includes information about mental
illness and how to recognize their signs and symptoms, and verbal de-escalation
techniques to help manage a situation involving a consumer in crisis, without the use of
force. Officers also learn about local mental health services, accessing mental health
resources, and various laws pertaining to consumers. The training is conducted by the
instructor through lecture, role playing, and guest speaker presentations. The guest
speakers include consumers, family members of consumers, and representatives from
mental health agencies (Dupont et al., 2007, Lord et al., 2011; Morabito et al., 2012).
Upon completion of the training, the CIT officers conduct their regular patrol
duties, but are dispatched to calls involving consumers. Successful CITs have about 2025% of their patrol officers trained as CIT members, but the number of CIT officers
needed per shift is ultimately based on the needs and structure of the agency and
community it serves (Dupont et al., 2007). One of the benefits of CITs is the very
minimal financial impact on the agency budget. CIT members are not paid extra to be on
the team. The only real expense to the agency is the initial and periodic training for the
team members (Vickers, 2000).
23
A very important aspect of CIT is that it is not just simply training officers to
recognize and handle incidents involving people with mental illness (Compton et al.,
2008; Watson et al., 2008). CIT is an ongoing and constantly evolving partnership
between law enforcement, mental health agencies and various stakeholders. CIT
members act as liaisons to help streamline access to mental health services, and help
resolve issues that might create barriers between consumers and mental health agencies.
Having more mental health resources available can lead to fewer crisis events, which can
lead to less law enforcement encounters with consumers, helping to stop the
criminalization of mental illness cycle (Morabito et al., 2012; Watson et al., 2008).
The goal of any law enforcement encounter is to gain control of an out of control
situation (Morabito et al., 2012). In response to a consumer in crisis, CITs provide more
effective ways to deal with consumers by training officers to recognize bizarre, nonresponsive, defiant and/or hostile behavior as possible signs of mental illness (Morabito
et al., 2012). While the original goal of CITs was to reduce likelihood of violence or
injury resulting from a law enforcement encounter with a consumer, providing mental
health resources to consumers emerged as equally important (Watson et al., 2008;
Morabito et al., 2012). Vickers (2000) summarized that the “the goals of the CIT are to
provide immediate response to and management of situations where the mentally ill are
in a state of crisis; prevent, reduce, or eliminate injury to both the consumer and the
responding police officer; find appropriate care for the consumer; and establish a
treatment program that reduces recidivism” (p. 2). CITs have shown to be very effective
24
in accomplishing these goals (Franz & Borum, 2011; Morabito et al., 2009; Ritter et al.,
2011).
Police Director Walter Crews was in charge of hostage negotiations for the
Memphis Police Department when the CIT was established. In the year 2000, he
reported a significant decrease in consumer or police injuries in his department since the
CIT program was established in 1988. He added that CITs almost completely replaced
the department’s hostage negotiations team (Vickers, 2000). CIT officers report they feel
more confident in handling calls involving consumers than they did prior to their CIT
training. If an officer determined the consumer needed to be admitted to a mental health
facility, CITs increased the number of voluntary commitments, helping to avoid the time
consuming and complicated admittance procedure for involuntary commitments. CITs
have become associated with lower arrest rates and more incidents being resolved onscene (Compton et al., 2008; Franz & Borum, 2011; Vickers, 2000). Overall, CITs have
helped to remove the stigma often attached to mental illness, and improved officers’
responses and attitudes towards consumers (Morabito et al., 2012; Vickers, 2000).
Each CIT is adapted to the unique needs and structure of the agency and the
community it serves (Lord et al., 2011). All successful CITs are built around the same
core elements established in the Memphis Model. Three core elements of this model are
Ongoing, Operational, and Sustaining Elements, based on Dupont et al. (2007). In their
report, they identify and describe several aspects of each element. Their report is
outlined in Appendix A. While not all elements in the outline may apply to each agency,
they are things for the agency to take into consideration when establishing a CIT.
25
Ongoing Elements identify the structure of the team, the organizations and people
involved, and their roles in the CIT program. Significant importance is placed on
establishing partnerships between law enforcement, stakeholders, and mental health
providers. This element category also outlines the importance of community
involvement in planning, implementation and networking of the program. Finally, the
ongoing elements category stresses the importance of establishing policies and
procedures for the law enforcement and mental health agencies. Consideration of
existing agency policies and procedures is important when establishing guidelines for the
CIT training, and the structure and deployment of the team.
Operational Elements identify the personnel that primarily comprise the CIT
program (officer, dispatcher and coordinator) and outline their roles and functions. The
CIT officer position is voluntary and officers should go through a selection process to
become CIT members. The selected officers are then CIT trained to perform the role of
CIT team members, in addition to maintaining their existing role as patrol officers. The
40-hour comprehensive CIT training for the officers includes lectures, guest speakers,
scenarios, as well as on-site visits and exposure to people with mental illness.
Dispatchers receive specialized CIT training as well, to be familiar with the structure and
deployment of the team, and to be able to recognize if a patrol call for service is a CIT
crisis event.
CIT coordinators are important from each involved agency, mainly the law
enforcement and mental health agencies, along with various other related agencies. Law
enforcement CIT coordinators are the main point of contact and involved in the planning,
26
implementation and evaluation of the CIT program. As liaisons for the law enforcement
agency, they are responsible for establishing and maintaining relationships between
mental health agencies, involved community members and agencies, and various other
stakeholders. They are also responsible for arranging the training for the CIT members.
Coordinators for mental health and various other agencies can be more informal
positions. They are points of contact for their respective agencies to help maintain
communication, and should all work toward accomplishing the goals of CITs.
Sustaining Elements include establishing guidelines for evaluation and research,
on-going CIT training, recognition of CIT officers, and further development, expansion
and community outreach. This element is important for maintaining and improving the
CIT program.
Adapting the Memphis Model to the Custody Setting
The number of incarcerated adults with mental illness is overrepresented in the
jail and prison systems (Compton & Kotwicki, 2007; Human Rights Watch, 2003).
Anywhere from 15-25% of the incarcerated adult population in the United States is
affected by serious mental illness, such as major depressive disorder, bi-polar disorders,
schizophrenia, post-traumatic stress disorder and anxiety disorders, as compared to only
6% of the US adult population (Baillargeon et al., 2009; Human Rights Watch, 2003;
James & Glaze, 2005; National Commission, 2002). Inmates suffering from serious
mental illness were found to be much more likely to violate facility rules, four times as
likely to be charged with verbally or physically assaulting staff or other inmates, and
much more likely to be injured in a fight while incarcerated (James & Glaze, 2005). The
27
goals and benefits of establishing a CIT in the custody setting would be the same as CITs
in patrol: to decrease the likelihood of physical altercations that can stem from dealing
with inmates in crisis, and forming partnerships with jail psychiatric services staff (JPS)
to better serve inmate consumers.
The priority of corrections is to maintain order, not provide mental health services
(Lamb et al., 2009). Jail facilities are not intended or equipped to handle the increasing
number of incarcerated consumers who require on-going and/or emergency psychiatric
care (Human Rights Watch, 2003; Lord et al., 2011; Perez et al., 2003). Just as in the
patrol setting, custody staff are not trained to recognize signs of mental illness or how to
manage people in crisis. Rather, they are trained to respond to an out of control situation
with force, which increases the likelihood of injuries or death to inmates, officers,
bystanders or any involved party (Human Rights Watch, 2003; Kaminski, DiGiovanni &
Downs, 2004; Ruiz & Miller, 2004).
Issues resulting from a physical altercation can be very costly for the agency in
terms of medical expenses for injuries, hiring staff to backfill for injured officers, and
possible lawsuits, as well as any damage to county property caused by the inmate, or as a
result of an altercation (Dooley, 2010). These circumstances can also contribute to
negative public opinion of the agency, as well as law enforcement, in general. Jail
psychiatric services (JPS) for the facilities are also burdened with handling a high
caseload of patients with often limited funding and resources (Human Rights Watch,
2003; Perez et al., 2003). Injuries to custody staff and subsequent short staffing, and
higher caseloads for jail psychiatric staff can also cause stress and burn-out for
28
employees. Additionally, inmate consumers may not receive the type of treatment that
would help prevent the situation from occurring again (Lord et al., 2011).
While in custody, crisis situations that may require some kind of intervention
occur when inmates become a danger to self or others. These situations can be based on
already existing mental illness, stressful circumstances an inmate must face after being
incarcerated that exceed his or her coping abilities, or a combination of both pre-existing
mental illness and custody related stressors (Liebling, 1999; Edwards & Potter, 2004).
Inmates with no history of mental illness can also go into crisis for various reasons
related to their incarceration, such as living conditions, recent sentencing, relationship
problems, issues that come up outside of incarceration they no longer have control over
such as job loss, evictions, loss of a family member, etc. Alcohol/drug withdrawal and
flashbacks from past use of hallucinogens are also significant issues in the custody setting
(Human Rights Watch, 2003).
Although CITs are considered a pre-booking diversion, originally designed for
patrol, the core elements of the Memphis Model of CIT can be adapted to the custody
setting to address the large number of already incarcerated consumers (Dooley, 2010).
The transition to the custody setting would be similar to adapting the Memphis Model to
another law enforcement agency. Adapting the CIT to the custody setting involves more
adjustments in some areas, considering the nature of the custody setting as opposed to the
patrol setting.
One of the biggest adjustments would be to the dispatch element. Since custody
staff supervises the target population, rather than responding to them when requested
29
through a call for service, the responsibility of recognizing a crisis event falls on the
supervising custody staff. The decision to have the Custody CIT respond would then fall
on custody staff and/or the supervisors. Another consideration, in terms of procedures,
would be if an inmate needs emergency psychiatric care. If the agency has JPS, the
inmate may not be taken out of custody to a community mental health facility like they
would in a patrol setting. Instead, JPS would respond to the inmate in accordance with
their policies and procedures.
In terms of training, Custody CIT members would receive the initial CIT training
and learn how to recognize signs of mental illness and/or an inmate in crisis, along with
crisis intervention and de-escalation techniques. They should then receive custody
specific training, focused on custody specific issues and their role in the custody setting.
After that, Custody CIT members should attend periodic training as arranged by the CIT
coordinator, based on current issues and feedback received through the evaluation
process. Training can be provided by JPS staff, NAMI, various Sheriff’s Deparment
personnel, etc.
More importantly, this program is not just about training. Custody CITs would
also act as liaisons between JPS and the inmate consumer, to facilitate and/or expedite
proper psychiatric evaluation and treatment, as well as work with JPS staff to help
alleviate some of their workload. A CIT in the custody setting can also help improve
communications between JPS and all custody staff, including jail administration and
supervisors. An added benefit of being a Custody CIT member is receiving additional
30
specialized training that can be useful in many other aspects of the member’s current job
assignment, as well as in future job assignments.
The goals of implementing a Custody CIT would be the same as in patrol, just
adjusted for the custody setting. The main goal being better outcomes when dealing with
an inmate consumer, whether they are in crisis due to existing mental illness, the stress of
incarceration, or a combination of both. One advantage of the custody setting is that the
officers may already know the mental health and behavior background of the inmate they
are dealing with, or the information is readily accessible. Since the inmate consumer is
already in custody, the pre-booking diversion role of the Custody CIT would not apply,
but Custody CIT members can help JPS with discharge planning for inmate consumers,
to help connect them to community services upon release, and decrease the chances of
them recidivating (Baillargeon et al., 2009; Human Rights Watch). If there is a CIT
already established in the patrol setting, Custody CIT should work in close partnership as
well, to accomplish the same ultimate goals.
While over 1,000 agencies, nationwide, have implemented CITs for their patrol
divisions (Lord et al., 2011), few agencies have adapted the CIT to the custody setting.
In 2010, Shelby County Sheriff’s Department in Tennessee provided the CIT training for
its jail staff. In his article about it, Dooley (2010) describes the transition of CIT to the
custody setting as “logical because officers in corrections…are first responders to many
crisis situations involving those with mental illness” (p.70).
31
Legal Considerations
Among the laws and programs that have been implemented in California over the
years to address the various issues involving untreated consumers in the community, such
as the Mental Health Services Act (MHSA) enacted in 2009, there are specific laws that
pertain to law enforcement interactions with consumers as well. An important California
code established in 1967 is the Welfare and Institutions Code 5150 (W&I 5150), also
known as the Lanterman-Petris-Short Act (LPS). W&I 5150 establishes criteria for a
person to be involuntarily commitment to a mental health facility. The code also
authorizes law enforcement officers and specifically designated psychiatric or clinical
staff, to be able to determine if the person meets the criteria. The person must exhibit at
least one of the following to be admitted; danger to self, danger to others, or gravely
disabled (unable to accomplish basic life functions) (California Penal Code, 2013). This
type of involuntary commitment is often referred to as a 5150 hold because the person is
held for 72 hours for evaluation and to determine the future course of action.
Consumers who have been placed on a 5150 hold by patrol officers are usually
brought into the mental health facility. In the custody setting, these cases are usually
referred to JPS by custody staff. Incidents of self-harm, such as self-mutilation, suicide
attempts and suicides are very common among inmates. This can be attributed to the
high numbers of inmates with mental illness, and inadequate mental health treatment
available for them in the jails (Human Rights Watch, 2003). In 1976, in the case of
Estelle v. Gamble (42 U.S.C. §1983), the US Supreme Court established the standard of
deliberate indifference which places liability on custody staff if they ignore any facts that
32
would lead them to believe that an inmate is at risk of self-harm (Human Rights Watch,
2003). Subsequent case law established requirements for correctional facilities to
improve their intake screening to assess suicide potential, provide training for custody
staff in suicidal ideation recognition and prevention, and establish specific protocol for
handling inmates who express suicidal ideations (Lee, 2002).
Consumer Inmates
Most of the chronic cases of mental illness in the custody setting are inmates with
schizophrenia, bipolar disorder, delusional disorder, major depressive disorder, borderline
personality disorder, paranoid personality disorder, and schizoaffective disorder
(Sokolov, 2004). Problematic inmates in the jails are non-compliant with medication,
malingering inmates who often fake mental illness, and chronic self-injurious inmates.
Most of these inmates are seen on an outpatient basis by JPS and do not meet the criteria
for inpatient, acute care housing, where JPS licensed staff is available around the clock
for admitted inmates and emergency evaluations and treatment (Compton & Kotwicki,
2007; Sokolov, 2004). Outpatient inmate consumers are generally housed with the
general population, or in designated housing units for inmate consumers who are not able
to be housed with general population inmates.
Most incidents that elicit an emergency psychiatric evaluation of an inmate, fall
into one of four areas of concern; suicide potential, violent behaviors, psychotic
decompensation, and mood disturbances (Sokolov, 2004). These inmates are usually
referred to JPS by custody staff in response to a crisis event. After the inmate is
33
evaluated, JPS staff determines if the inmate is cleared to return to his or her original
housing location, or if the inmate meets the criteria for inpatient, acute care housing.
An inmate who goes into crisis may feel suicidal and/or act out and refuse to
follow custody directives.
Combative inmates may act out due to an existing mental
illness not being adequately or appropriately managed by medication, the inmate’s
defiant and uncooperative personality, or a combination of both (Compton & Kotwicki,
2007). Reasons for an inmate to be deemed a danger to self or others include statements
made by the inmate, or behavior that indicates intent or desire to cause harm, usually in
response to stressors related to their confinement. If the stress of incarceration exceeds
an inmate’s normal coping abilities, he or she may become depressed and feel like
hurting him or herself and/or act out physically (Sokolov, 2004). In these instances,
custody staff must intervene to bring the situation under control, then request JPS respond
for an emergency evaluation and treatment.
Safety Cell Placement
If JPS staff is not available for an emergency evaluation of an inmate in crisis,
precautions must be taken to ensure the safety of the inmate. Inmates displaying selfinjurious and/or aggressive and confrontational behavior may be restrained using
handcuffs, leg shackles, or fully restrained in a pro-straint chair, which is a chair
intended to completely immobilize and prevent the inmate from self-harm, harm to
others, and/or to prevent the inmate from causing damage to property. The inmate is then
placed in the safety cell, a completely empty space to be monitored at all times by
custody staff. This accomplishes the short-term goal of gaining physical compliance,
34
which is the priority of custody staff. This procedure does not involve trying to
determine what caused the inmate to go into crisis, and there is very little focus or
importance placed on follow-up to avoid the situation from recurring (Lord et al., 2011).
This can be a burden on custody staff, who must constantly supervise these inmates in
addition to their regular duties, as well as a burden on medical staff, who must medically
clear them periodically for further placement until JPS is available to evaluate them.
One problem with the use of the safety cell is the high number of unnecessary
placements. If an inmate is depressed, they may say they feel like hurting themselves,
but have no intent to follow through. There are also many inmates who claim they feel
like hurting themselves in order to manipulate the system for a secondary gain and to
further their own agenda (Compton & Kotwicki, 2007). These malingering inmates tend
to make these claims in response to denied requests such as bunk or housing changes, etc.
Regardless of the legitimacy of the claim, custody staff must consider the inmate a
danger to self or others and place the inmate under observation until they can be
evaluated and cleared by JPS staff. The procedure for placing an inmate in a safety cell
involves removing the inmate’s clothes to dress in a safety suit, then placing the inmate in
an empty cell with nothing else to be under constant observation. The safety cell
placement procedure can be humiliating and often exacerbate the inmate’s already
negative mind set (Human Rights Watch, 2003). Having the CIT present during
placement can help de-escalate the situation if these circumstances escalate the crisis
reaction of the inmate.
35
RCCC Specific Issues
Although they are both Sacramento County jail facilities and therefore have many
similarities in terms of purpose and function, Main Jail (MJ) and Rio Cosumnes
Correctional Center (RCCC) have some very distinct differences, as well as their own
unique issues. The following are some RCCC specific issues that a CIT can help
alleviate.
Type of RCCC inmate. In Sacramento County, once inmates are sentenced,
most of them are sent to RCCC to serve their sentence, while MJ handles more pretrial
and fresh arrests. A majority of inmates sent to RCCC are recently sentenced to county
time of one to three years. Edwards and Potter (2004) concluded that inmates who are
sentenced to shorter lengths of time are more “vulnerable to significant psychological
distress” (p. 130), which could lead to a crisis reaction.
Limited JPS availability. There is one acute care inpatient unit (2P) at the MJ
for inmates from both jail facilities, where JPS licensed staff is available around the clock
for admitted inmates and emergency evaluations. Between 2000 and 2004, the average
number of inmates admitted to 2P on a daily basis increased from 9 to 16 (Sokolov,
2004). Currently, a maximum of 18 patients may be housed on 2P, which is almost
always filled to capacity. Not only is 2P almost always full, there is often a waiting list
for inmates who need to be admitted from both facilities (A. Javist, personal
communication, August 30, 2013).
Although RCCC has psychiatric staff on site, they are only available during the
day on weekdays. If an inmate goes into crisis at night or on the weekends, and needs to
36
be placed in the safety cell, there may be a significant delay before the inmate can be
evaluated When an inmate at RCCC is placed into the safety cell, JPS is notified. If JPS
is not available at RCCC, the JPS staff at MJ is advised, but unless the inmate can be
transported to MJ to be evaluated and cleared, the inmate remains in the safety cell until
RCCC JPS staff becomes available.
The number of inmates placed in the safety cell and the length of time they must
wait for an evaluation and/or admittance to 2P are significant issues. Although some
aspects of these issues are not just RCCC specific (i.e., no room on 2P), they become
compounded problems when more than one inmate needs to be placed in a safety cell.
There is only one designated safety cell for male inmates and one for female inmates.
Two inmates cannot share the safety cell while on observation so other holding areas are
used as safety cells until the designated cell becomes available.
Inmates who do not meet the criteria to be housed on 2P are seen on an outpatient
basis and housed with general population inmates, or in designated pods for mentally ill
inmates who are not able to house with the general population, but do not meet the
requirements to be housed in the acute unit. Both RCCC and MJ have designated
housing for male inmates who meet this criteria and these housing units are also almost
always filled to capacity. JPS determines the acuity level of the inmate and works with
custody classification to determine appropriate housing (A. Javist & J. Roof, personal
communication, October 1, 2013). The Sheriff’s Department contracts with UC Davis
Department of Psychiatry for inmate psychiatric services (JPS) for both RCCC and MJ.
JPS is supervised by a medical director who is mainly responsible for inpatient services,
37
and a clinical director who is mainly responsible for outpatient services for the inmates.
Andrea Javist, LCSW, is the program director for outpatient services and Jason Roof,
MD is the inpatient unit supervisor at MJ, and both are directly supervised by the medical
director.
Older Housing Facilities. One consideration in terms of financial burden on the
agency is damage to the facility or agency property. RCCC is an old facility with
construction dating back to the 1950s. Within the last year at RCCC, two maximum
security cells in the women’s facility (SLF, one of the older facilities within RCCC)
alone, have sustained significant damage from inmates in crisis. In one incident, an
inmate kicked the cell door until it broke in half and the bottom half fell off the hinges
completely. The other cell was damaged when the residing inmate slammed a food tray
at the window hard enough to break the window. When an inmate goes into a crisis and
becomes violent and confrontational, custody staff responds with force to gain control of
the situation. When an inmate is becoming confrontational or violent, de-escalation and
crisis intervention techniques can help prevent damage to county property.
Here and Now
California is no exception when it comes to a large number of non-violent
offenders who are caught in the criminal justice system, as opposed to the mental health
system where they would be much better served. In 2009, the Mental Health Services
Act (MHSA) was established in California to address the problem of the increasing
population of people who have ended up homeless and incapable of caring for themselves
as a result of severe mental illness. The MHSA promotes prevention and early detection
38
of mental illness, and tasks state and local agencies with creating innovative programs to
help connect this population with mental health services, to help prevent them from
decompensating due to their mental illness. According to the MHSA, the side effects of
untreated mental illness in the communities of California have cost state and county
governments billions dollars every year. This is related to several factors including
emergency and long term medical care, housing and unemployment, and criminal justice
intervention (Mental Health Services Act, 2009).
A program recently established as part of the Stop Stigma Sacramento campaign,
is the Mental Illness: It's not always what you think project. This program is aimed at
ending the stigma often attached to mental illness, and ending the subsequent
discrimination against people with mental illness that often occurs as a result of the
stigma. The program was initiated by the Sacramento County Department of Health and
Human Services/ Division of Behavioral Health Services (DHHS/DBHS) in response to
the MHSA. According to their website, the ultimate goal of the program is to “eliminate
the barriers [for people with mental illness] to achieving full inclusion in society and
increase access to mental health resources to support individuals and families” (Stop
Stigma Sacramento, n.d.). Other organizations in Sacramento, including the Sacramento
chapter of NAMI also have programs in place to improve care for people with mental
illness in Sacramento and help meet the goals of the MHSA.
Over the last few decades, as interactions with people with mental illness has
become accepted as part of law enforcement in California, there has been a shift in
attention as to how agencies prepare their officers for dealing with these encounters.
39
According to the California Commission on Peace Officer Standards and Training
(POST), Penal Code 13515.25 was enacted in 2000 requiring them to “develop a law
enforcement training course on mental and developmental disabilities” (p. 3) and report
back to the Legislature. For their report, the Commission examined various law
enforcement agencies in California, including two who had established CITs, to get an
idea of the various ways law enforcement agencies in the state handle interactions
involving people with mental illness. The Commission then created an eight-hour POST
course to provide some basic and standardized training for all peace officers in California
(California Commission).
In response to negative outcomes of recent incidents involving people with mental
illness and local law enforcement in Sacramento County, the Sheriff, Scott Jones, has
recently taken a more specific interest in promoting more positive interactions between
law enforcement and people with mental illness in Sacramento County. A brief CIT
component was recently added to the curriculum for the Sheriff’s Department Advanced
Officer Training, which included some basic information about mental illness and
techniques in dealing with consumers. Additionally, the department is currently working
in partnership with several other law enforcement agencies in Sacramento County to
implement a CIT in patrol. Jones is hoping to expand this type of training to all Sheriff’s
Department employees, and eventually make it a part of the Sheriff’s Department
academy curriculum (Ramos, 2013).
Whether or not a CIT is established in patrol, the jails will still have to deal with a
population of inmates with mental illness. Even if all non-violent consumers are
40
successfully diverted to mental health agencies as opposed to being subjected to mercy
bookings, there will still be consumers who commit crimes affecting an arrest and
inmates with no documented history of mental illness who succumb to the stresses of the
custody environment. Establishing a CIT in each jail will not only help the large
population of consumer inmates incarcerated in Sacramento County, it can also help
support the establishment of a CIT in patrol. This can help significantly improve
communication between the patrol and corrections divisions, as well as among all local
law enforcement agencies in regard to their response to mental health issues within the
county. These partnerships can also help provide better services for consumers in and out
of jail, and help to accomplish the goal of reducing recidivism among people with mental
illness in Sacramento County.
41
Chapter 3
Project Process
The purpose of this project was to research and examine the Memphis Model of
the Crisis Intervention Team (CIT), a patrol based program, and adapt it to the custody
setting, such as a jail. Since its inception in 1988, the Memphis Model of CIT has been
implemented in the patrol divisions of hundreds of law enforcement agencies,
nationwide, to improve encounters between law enforcement and people with mental
illness in the community. Each CIT is adapted to the unique needs and characteristics of
the agencies and communities they serve. Since it is a patrol-based, pre-booking
diversion, designed to help prevent the incarceration of people with mental illness, or
consumers, very few agencies have adapted the program for the custody setting.
Whether or not a CIT or similar intervention program is in place in patrol, not all
consumers can be diverted from incarceration. The elements of the CIT program can be
adapted to the custody setting in much the same way as the elements are adapted to
different patrol agencies, to address similar issues involving inmate consumers, and help
to accomplish some of the same ultimate goals as a CIT in patrol. After adapting the
Memphis Model to the custody setting, the structure of a Custody CIT was established
for the Rio Cosumnes Correctional Center (RCCC) in Sacramento, California.
All Custody CIT members need to attend the initial CIT training to learn how to
recognize mental illness in a law enforcement encounter. Through this training, they will
also learn techniques for dealing with consumers in crisis to help prevent the situation
from escalating to a physical confrontation, as well as ways to help connect the consumer
42
to resources and treatment and minimize law enforcement involvement. For this project,
in addition to establishing the structure of a Custody CIT (CCIT), the information
collected about the program, inmate consumers, and various custody and RCCC specific
issues was organized into an orientation manual for the team members to augment their
CIT training.
There are two jails in Sacramento County, the Main Jail (MJ) and Rio Cosumnes
Correctional Center (RCCC) and are run by the Sacramento County Sheriff’s
Department. Both facilities face the same problem of dealing with a high population of
inmates with mental illness, and would benefit from a CCIT. Once established at RCCC,
this model can then be used to establish a CCIT at MJ. Overall, it is important for CCIT
members to be aware of the issues and how to handle situations involving consumer
inmates. Members should be familiar with not only policy and procedures that apply to
them, but the facility Jail Psychiatric Services (JPS) policy and procedures as well and
how to work collaboratively for the benefit of the consumer inmate.
What was Done
For this project, information and articles about a variety of aspects of CIT were
gathered to establish a thorough understanding of its design, goals, and how it is
implemented in a patrol setting. Information about the interactions between law
enforcement and consumers was also gathered to more fully understand the problems and
issues that CIT is intended to address. Finally, in order to apply the elements of the
Memphis Model of CIT in the custody setting, information was gathered about custody
specific problems and issues involving mental illness and inmate consumers. This
43
included identifying the common mental illnesses among incarcerated individuals,
reasons inmates might go into crisis that are unique to the custody setting, and policies
and procedures in place for custody staff and JPS responses to inmate consumers.
The structure and deployment of the team in the custody setting is similar to a
CIT in patrol with some adjustments. In the custody setting, the term community refers to
the population of inmates already being supervised by law enforcement (custody staff).
Instead of being dispatched to a call for service, CCIT would respond to an inmate in
crisis when requested by other custody staff. JPS would then respond to the inmate upon
custody staff request, as opposed to the inmate being taken to mental health services
outside of the facility. The goals of the CCIT are the same as CIT in patrol, which are
decreasing the likelihood of injuries when dealing with consumers in crisis and
improving access to mental health services for the consumers.
The next step in establishing the CIT in a custody setting was recognizing and
incorporating agency specific considerations. These include laws pertaining to law
enforcement and consumers, the agency policies and procedures already established for
dealing with inmate consumers and inmates in crisis, and identifying the pertinent mental
health resources such as JPS, and the policies and procedures for accessing them. Also
identified were various tasks involving inmate consumers and various mental health
issues in the custody setting that need to be completed by custody or JPS staff that can be
assigned to CCIT members. After identifying and taking into consideration the various
aspects of dealing with consumers unique to the custody setting, and the agency specific
policies and procedures, then applying the pertinent elements of the Memphis Model of
44
the CIT, the basic design and structure of a CCIT was established. A summary of the
following is provided in Appendix B.
Structure and Deployment. The CCIT consists of deputies from each shift who
are assigned to supervise inmates. Team members are provided CIT training and agree to
participate in subsequent periodic training, in addition to any training done on their
respective shifts. The team members continue to work in their regular capacity, but may
be requested at any time during their shift to respond to any situation that may benefit
from a crisis intervention response. The Custody CIT can be requested alone or along
with the Custody Emergency Response Team (CERT) for violent or confrontational
inmates. If responding with CERT, the CCIT would be the initial responder in an attempt
to gain compliance and de-escalate the situation, possibly avoiding physical intervention.
The CCIT will also help improve communications between custody staff and JPS
staff to help improve services for inmate consumers. Although CCIT members will not
be trained to be, or considered to be JPS staff, there are several things CCIT members can
do to help JPS as well as the consumer inmates. Since JPS is often not aware of when
inmates are released, JPS may make a notation in certain inmate patient files requesting
custody staff to contact JPS before the inmate is released. This notation is made for a
variety of reasons, which may include simple tasks that anyone can be trained in, or be
shown how to handle. Having CCIT members handle these tasks can help to ensure
consistency across all shifts and help alleviate some of the JPS workload.
The CCIT members will also help ensure consistency across shifts in how custody
staff handles issues involving inmate consumers. An instance where CCIT can be
45
utilized for consistency across shifts is during safety cell placement. Since CCIT
members should be familiar with the safety cell placement process through their training,
they can help custody staff who have questions about the procedures for placement. CCIT
members can also oversee any safety cell placement to be sure certain appropriate
documentations are being made for future statistical evaluation and analysis by jail and
JPS staff. Also, since placement can also be stressful for an inmate already in a crisis
state, having the CCIT present during placement can help prevent the situation from
escalating to a physical confrontation if the inmate begins to act out.
The deployment and use of CCIT members can change over time based on often
changing inmate populations. For example, a recent and significant policy change in
California, Prison Realignment (AB109), has shifted a large number of state prison
inmates to the county jails. Prison inmates bring with them a different mentality and tend
to be serving longer sentences. RCCC has also recently entered into a contract with the
Federal Government to house Immigration and Customs Enforcement (ICE) detainees.
This will also add a new dynamic to the inmate population as they are subject to custody
requirements and entitlements that differ from the rest of the inmate population at RCCC.
These ICE inmates are also from different countries and backgrounds which may
contribute to misunderstandings due to culture differences and language barriers.
The CCIT program should be evaluated periodically in terms of its usefulness,
effectiveness and areas for improvement. Along with collecting quantitative data about
how often CIT is deployed and the types of incidents they respond to, qualitative
46
feedback from the CIT members, jail staff and JPS staff will be taken into consideration
in the evaluation process.
Team Members. Custody CIT members will be deputies, either self-selected or
chosen based on their compassion and desire to help improve the relationship between
law enforcement and consumer inmates. Team members will initially be CIT trained,
then given custody specific orientation and training. After that, they will be expected to
attend subsequent training three to four times a year as a team (with members from all
shifts). Training may also be done anytime on shift, ideally along with CERT. Team
members continue to work in their regular capacity, but may be requested anytime during
their shift to respond to any situation that may benefit from a crisis intervention response.
They do not receive extra pay, but are distinguished as CCIT members. As liaisons
between JPS and custody staff, CCIT will also be requested to handle miscellaneous
duties related to JPS, but within the scope of their law enforcement duties. RCCC and
MJ requires custody staff receive a certain amount of inmate suicide prevention training
each year and CCIT members can assist in providing the information to their shift.
Training. Each member will be CIT trained and will learn basic information
about consumers, mental illness and various communication and de-escalation techniques
to use when interacting with consumers in a law enforcement capacity. After receiving
the CIT training, Custody CIT members will then receive more jail facility specific
training and information, which can be reviewed while on shift and referenced when
needed.
47
The information will be presented in the form of a manual, included in Appendix
C, which consists of information about consumer inmates and various issues specific to
them, and the role of the CCIT member and team. The manual will also include
information about custody staff and JPS response to disruptive inmates, or inmates in
crisis, and how incidents involving inmate consumers are handled within the procedural
guidelines established by various Sheriff’s Department Operations Orders, internal
agency documents that outline the department rules and policies.
The manual was designed based on guidelines and suggestions offered in
Lanigan (2010) for creating a manual to be used as a “self study” tool. Since it is the
CCIT members’ main source of information, and does not require instructor led training,
CCIT members can review the manual during downtime on their shift and have it for
future reference if needed. This saves time and money by not requiring an instructor, and
not requiring the members to attend additional training outside their regular work
schedule.
Ongoing training as a team is a very important aspect of being a CCIT member.
Team members will be encouraged to train along with CERT on their respective shifts.
All CCIT members should attend training three to four times a year as a refresher about
mental illness and communication techniques. This is also an opportunity for the team to
receive updates and new information pertinent to their position as CCIT members. The
training will include, but will not be limited to: Inmate consumer and/or facility specific
issues, information about JPS and functions within the facility, current community and/or
legal issues regarding inmate consumers, mental illness refresher, communication
48
techniques refresher, visits to 2P to observe clinician rounds with patients, and training
with the Sheriff’s Department Critical Incident Negotiations Team (CINT).
These ongoing training sessions will be provided by any combination of the
following people: CCIT Coordinator, JPS Supervisor and/or JPS Staff, representatives
from NAMI and other community mental health agencies, and members of the Sheriff’s
Department. The training will be based on the current issues and needs of the department
and issues that are brought to light through the ongoing evaluation of the program.
CCIT Coordinator. The CCIT coordinator is responsible for planning ongoing
training for all CCIT members. The coordinator is the primary point of contact for all
team members from all shifts, jail administration and supervisors, as well as JPS staff.
The coordinator will also develop and foster relationships with mental health agencies in
the community, as well as other divisions within the agency. The coordinator is
responsible for collecting information in order to evaluate the use and effectiveness of the
CCIT over time and address issues as they arise, as well as collecting pertinent data for
future evaluation and analysis.
Program Evaluation. Approximately one year after the CCIT is established, the
evaluation procedures should address the following: How often, and in what capacities
the CIT was used, if the implementation of the CCIT helped meet the program’s two
main goals of decreasing physical confrontations with consumers in crisis, and how the
team members feel about their involvement. These evaluation criteria are outlined in
Appendix C. For RCCC, this evaluation criteria can be used to work out any problems or
issues that may arise, as well as help to improve the program. This program can then be
49
used as a model to establish a CCIT at MJ, in order to promote consistency between the
two facilities in how incidents involving consumer inmates are handled in both
Sacramento County jail facilities.
Custody CIT (CCIT) – Benefits and Implementation
Most of the elements of the CCIT are similar to the patrol setting. CCIT officers
can be utilized in an attempt to verbally resolve an out of control situation involving a
consumer inmate in crisis, by using listening and using other de-escalation techniques.
This helps reduce the likelihood of the situation escalating to a physical confrontation,
and reduces the chance of injuries and/or damage to county property. Reducing the
chances of physical altercations with inmates, and providing more care for consumer
inmates can help improve public perception of the jail and law enforcement in general.
In terms of custody specific issues, CCIT officers can also help mitigate the
number of safety cell placements, reducing the burden on custody, medical and JPS staff,
as well as help alleviate the problem of limited housing for consumer inmates who cannot
be housed with general population inmates. A benefit to the inmate consumer is that the
team members also act as liaisons between them and psychiatric services, streamlining
access to psychiatric care, and possibly reducing the chances and/or occurrences of the
inmate going back into crisis. By implementing the CIT in the custody setting,
partnerships will also be established with JPS and other stakeholders, in and outside of
the custody setting, which can benefit the inmate consumer in the longer term as well.
Sacramento County will benefit financially by reduced chances of injuries and
damage to county property, reducing associated costs. CIT members are also not paid
50
extra to be a part of the team. The only cost would be the initial CIT training, the cost for
ongoing refresher training as a team, and the cost to backfill the members’ positions
while they are in training. CCIT members also benefit from receiving specialized
training that can be useful in various other aspects of their job within the jail. As
seniority permits, deputies assigned to MJ or RCCC eventually move on to patrol, and
these skills can also be beneficial when dealing with a consumer in a call for service, or
for a possible future involvement in the CIT currently being implemented in the patrol
setting for the Sacramento County Sheriff’s Department.
51
Chapter 4
Conclusions and Recommendations
Over the last few decades, several inter-related factors in the United States have
contributed to the over-representation of people with mental illness in jails and prisons.
One of the initial factors included deinstitutionalization, which involved the mass closing
of mental health hospitals, releasing a large population of people with mental illness,
known as consumers, to the community without mental health resources and/or treatment.
Without resources or treatment, these consumers are likely to decompensate and go into
crisis.
A person in crisis, whether it be due to an existing mental health problem,
stressors that exceed the person’s coping abilities, or a combination of both, may act out
in bizarre, aggressive, dangerous and/or unpredictable ways. This behavior may cause
people around them to fear for their safety and request law enforcement intervention. If
no mental health resources are available, law enforcement may also be the only available
option to resolve the situation. Law enforcement officers are provided very little training
in recognizing signs of mental illness. They often also feel inadequately prepared for
dealing with consumers in crisis and tend to respond to unpredictable or aggressive
behavior based on their training, by using force to bring the situation under control.
As the number of interactions between consumers and law enforcement increased
over the last several decades since deinstitutionalization, the chances of injuries during an
encounter has increased due to the likelihood of it escalating to a physical confrontation.
Injuries sustained by any involved party can be costly to the law enforcement agency in
52
the form of lawsuits, medical costs, and backfilling for injured officers. Additionally, the
number of consumers arrested and taken to jail as a result of these encounters has
increased due to the officer either having no other options, or not being aware of other
options to resolve the situation. These arrests, often referred to as mercy bookings, are
usually for something minor, and may have only resulted in a warning or citation under
different circumstances.
The increase in injuries and arrests stemming from law enforcement encounters
with consumers in crisis is a nationwide problem. In 1987, the Crisis Intervention Team
(CIT) concept was introduced in Memphis, Tennessee as a solution to help alleviate these
problems. Selected Memphis Police Patrol Officers were provided specialized training in
recognizing signs of mental illness, de-escalation techniques and ways to deal with
consumers and people in crisis, and provided with information about available mental
health resources and alternatives to mercy bookings. These officers were then designated
CIT members who continue to perform their regular patrol duties, but are specifically
dispatched to calls involving consumers.
There are two main goals of what is referred to as the “Memphis Model” of CIT.
The first is reducing the chances of injuries to consumers, officers, and/or any other
involved party during law enforcement encounters with consumers. The second, but
equally important goal, is working with mental health agencies to help provide mental
health resources to people in crisis, up to and including more efficient admissions
procedures for admitting consumers to a mental health facility if they are a danger to
themselves or others, or gravely disabled and unable to care for themselves. Improved
53
flow of information and communication not only benefits the law enforcement agencies
and mental health providers, but the consumers as well. The Memphis Model of CIT was
very successful in accomplishing these goals. The success of the program quickly spread
nationwide with hundreds of other agencies adopting and implementing the model for
their law enforcement agencies.
Even with a reduction in the number of arrests and incarceration of consumers,
there is and will always be consumers and people with mental illness in jails and prisons.
They may have committed a crime that elicits an arrest or go into crisis as a result of
incarceration or a combination of both. Regardless of the reason, implementing a CIT
based on the Memphis Model in the custody setting would be beneficial for the
consumer, the agency, staff and any other stakeholder. The Memphis Model of CIT is a
patrol based pre-booking intervention but can be adapted to the custody setting.
Various elements, such as the main goal of improving interactions between law
enforcement and consumers in crisis would remain the same. A Custody CIT (CCIT)
would serve the same purpose of reducing the likelihood of injuries during these
encounters, reducing possible financial impact on the agency, as well as help provide
consumers with better access to mental health resources. In addition to receiving custody
specific training, CCIT officers would receive the initial CIT training which can be useful
for other aspects of their current and future job assignments.
Although many of the basic aspects of the structure of the team would remain the
same as in patrol, such as having a CCIT Coordinator and designated CCIT members
from each shift, there are some adjustments that need to be made for the custody setting.
54
One of the biggest differences from patrol is that there is no dispatch involved. Instead,
CCIT response is upon request of custody staff if they observe an inmate in crisis.
Additionally, in most cases, Jail Psychiatric Staff (JPS) would be requested to respond to
the inmate, as opposed to bringing the inmate to a community mental health clinic or
hospital. JPS and custody staff would then work together to determine appropriate
housing for the inmate based on the JPS evaluation.
Once the CIT structure is adapted to custody specific issues, it must also take into
consideration the agency specific policies and procedures. This project was intended to
implement a CCIT at the Rio Cosumnes Correctional Center (RCCC) in Sacramento, CA,
so it needed to take into account the policies and procedures established by the
Sacramento County Sheriff’s Department, the agency that runs RCCC, as well as any
local, state and federal laws that may apply.
Just the planning for the implementation of the CCIT at RCCC has already
improved communication between JPS and custody staff, which is one of its main goals.
Using CCIT members as liaisons between JPS and other custody staff helps increase
consistency in how crisis events are handled facility-wide. The CCIT Coordinator also
acts as a liaison to further establish consistency between RCCC and MJ, as well as within
the department. Although the plan for this project was to implement a CCIT at RCCC
first, then apply it to MJ, RCCC has recently requested that MJ be included in the initial
implementation.
Mental health issues and the increase in interactions between law enforcement
and consumers is a nationwide problem. Several major tragedies, such as several
55
shootings over the last decade have brought considerable national attention to the
problem of untreated mental illness in our communities. Sacramento County has had its
share of law enforcement encounters with consumers which resulted in death and/or
injury to any involved parties. These events were a catalyst for Sheriff Scott Jones to
direct the creation and implementation of a countywide CIT for all law enforcement
agencies in Sacramento County.
While the ideal goal of CIT would be to keep all consumers out of jail, a
reduction in the number of incarcerated consumers is a good start. A CCIT is beneficial
for the consumers who could not be diverted from jail either because they committed a
crime requiring arrest, develop a mental illness while in custody or any other reason. In
partnership with JPS and CIT in patrol, having a CCIT in the jails can help work toward
an ultimate ideal goal for all involved stakeholders, of keeping consumers out of jails and
providing them the resources they need to live productive lives within our communities.
56
Appendix A
Memphis Model CIT Core Elements Outline
Outline: Dupont, R., Cochran, S., & Pillsbury, S. (2007). Crisis Intervention Team Core
Elements. Memphis, TN: University of Memphis.
Ongoing Elements
1.
Partnerships: Law Enforcement, Advocacy, Mental Health
a. Law Enforcement Community
i.
ii.
iii.
b.
Advocacy Community
i.
ii.
iii.
c.
Providers, Educators, Practitioners, and Trainers
1. Professionals
2. Public, Non-Profit, & Private Agencies, Institutions, & Universities
3. Trainers
Community Ownership: Planning, Implementation and Networking
a. Planning Groups
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
b.
c.
Advocates
Citizens
Consumers/Individuals with a Mental Illness
Family Members
Government
Judiciary
Law Enforcement Community
Mental Health Community
Implementation
i.
ii.
Leadership from Law Enforcement,, Mental Health, and Advocacy Community
Training Curriculum
Networking
i.
ii.
3.
Consumers /Individuals with a Mental Illness
Family Members
Advocacy Groups – National Alliance on Mental Illness (NAMI), National Mental Health
Association (NMHA) and miscellaneous other mental health groups and organizations
Mental Health Community
i.
2.
Law Enforcement: CIT Operational Component
1. Police Department
2. Sheriff’s Department
Law Enforcement: Criminal Justice Partnership Component
1. Corrections
2. Judiciary – Public Defender, State Attorney, Judges, Probation/Parole
3. Crime Commission/Public Safety Commission
Law Enforcement: Policy Development Component
1. Law Enforcement Command Staff
2. Training and Standards
Feedback
Problem Solving
Policies and Procedures
a. CIT Training
i.
ii.
b.
Law Enforcement Policies and Procedures
i.
ii.
c.
Inter-Agency Agreements
Size and Scope
Dispatch Policies and Procedures
Patrol Policies and Procedures
Mental Health Emergency Policy and Procedures
i. Law Enforcement Referral Policies
57
Operational Elements
4.
CIT: Officer, Dispatcher, Coordinator
a. CIT Officer
i.
ii.
iii.
iv.
v.
vi.
b.
Dispatch
i.
ii.
iii.
iv.
v.
vi.
c.
d.
e.
f.
5.
CIT Training
Familiarity with CIT
Recognize Call as CIT Crisis Event
Ask Caller Appropriate Questions
Dispatch Nearest CIT Officer
Additional/Advanced In-Service Training
CIT Law Enforcement Coordinator
Mental Health Coordinator
Advocacy Coordinator
Program Coordinator (Multi-jurisdictional)
Curriculum: CIT Training
a. Patrol Officer: 40-Hour Comprehensive Training
i.
ii.
iii.
b.
Didactics and Lectures/Specialized Knowledge
On-Site Visits and Exposure
Practical Skill training/Scenario Based
Dispatch Training
i.
ii.
iii.
iv.
6.
Voluntary
Selection Process
Patrol Role
CIT Role
CIT Training and CIT Skills
Safety Skills
Recognition and Assessment of a CIT Crisis Event
Appropriate Questions to ask Caller
Identify Nearest CIT Officer
Policies and Procedures
Mental Health Receiving Facility: Emergency Services
a. Specialized Mental Health Emergency Care
i.
ii.
iii.
iv.
v.
vi.
Single Source of Entry (or well-coordinated multiple sources)
On-Demand Access: Twenty-Four Hours/Seven Days a Week Availability
No Clinical Barriers to Care
Minimal Law Enforcement Turnaround Time
Access to Wide Range of Disposition Options
Community Interface (Feedback and Problem Solving Capacity)
Sustaining Elements
7.
Evaluation and Research
a.
b.
8.
In-service Training
a.
9.
Program Evaluation and Research
Development Research Issues
Extended and Advanced Training
Recognition and Honors
i. Examples: Awards, Certificate of Recognition, Annual Banquet
10. Outreach: Developing CIT in Other Communities
a. Outreach Efforts
i.
ii.
iii.
iv.
Local Communities/Agency Development
Regional Community/Agency Development
Statewide CIT Development
Legislative Development
58
Appendix B
RCCC CCIT Program Outline
Basic Structure and Deployment
Team Members
Must be Deputies assigned to one of the four shifts, and can be CERT members if the
team structure allows for it. They must have the desire and interest in improving
relationships between custody staff and inmate consumers. Must have at least one year
of experience in working in a custody setting and ideally an educational background in a
related field such as psychology or social work. They need to be available on a call-out
type basis during their shift if needed for an inmate consumer in crisis.
59
CCIT Member Training
-
CIT Training Course
-
Custody Specific Orientation
-
Ongoing additional training and presentations with JPS, other mental health
agencies and representatives, NAMI, etc. as arranged by the CCIT Coordinator
CCIT Coordinator
Must be assigned to RCCC and have the desire to facilitate improved relationships
between law enforcement and consumers in the custody setting by working with custody
staff and supervisors, as well as jail psychiatric staff. Must be CIT trained and ideally
have experience working in a custody setting and with consumer inmates, and an
educational background in a related field such as psychology or social work.
Responsibilities
-
Supervises all members from all shifts
-
Maintains a team roster and recruits new members
-
Coordinates ongoing training for all members
-
Works with JPS and other mental health agencies to improve services for inmate
consumers
-
Works as a liaison between JPS staff, custody staff, supervisors and other
pertinent Sheriff’s Department personnel
-
Maintains records for program evaluation, improvement, and reporting to
supervisors
60
Program Evaluation
Once implemented, the CCIT Coordinator will collect information from various sources
such as incident reports, watch summary logs and interviews with CCIT members and
JPS staff for evaluation purposes and as well as to provide to supervisors and/or other
Sheriff’s Department Personnel if requested.
-
Are CCIT goals being met?
-
Is staffing sufficient?
-
Is training sufficient?
-
How does staff feel about their involvement?
On a yearly basis, the following information can be collected from the safety cell logs for
quantitative analysis to evaluate CCIT effectiveness in meeting its goals:
-
Time/date of placement into safety cell and duration of placement
-
Reason for placement (danger to self/others; disruptive/combative)
-
Gender of inmate
-
Whether CCIT and/or CERT was requested/responded
-
Injuries and/or damage to property?
-
Response time for Jail Psychiatric Services once advised
-
Disposition
Feedback from various involved staff members, such as CCIT members, JPS staff, other
RCCC staff and supervisors, can be gathered on an on-going basis by the CCIT
coordinator who can then adjust the program accordingly.
61
Appendix C
RCCC CCIT Orientation Manual
Rio Cosumnes
Correctional
Center
Custody Crisis
Intervention
Team (CCIT)
Reference
Manual
62
The problem:
High number of inmates with mental illness are incarcerated in Sacramento
County jails, as well as in correctional facilities nationwide. Jail facilities
and jail staff are not intended or equipped to deal with this type of inmate
population. If an inmate begins exhibiting unpredictable or dangerous
behavior due to a mental illness, custody staff is more likely to physically
intervene to gain control of the situation.
People in the community who utilize mental health resources are often
referred to as consumers. For inmate consumers at Rio Cosumnes
Correctional Center (RCCC) and Main Jail (MJ), the term “patient” will
refer to any inmate who receives treatment by Jail Psychiatric Services
(JPS), whether it is ongoing for an existing mental illness or treatment for a
mental health crisis.
Mental Health Services Act (MHSA): Recently established in California to
address the problem of the increasing population of people who have ended
up homeless and incapable of caring for themselves as a result of severe
mental illness. The act promotes prevention and early detection of mental
illness, and tasks state and local agencies with creating innovative programs
to help connect this population to mental health services, to help prevent
them from decompensating due to their mental illness. According to the
MHSA, untreated mental illness has cost state and county governments in
California “billions of dollars each year in emergency medical care, longterm nursing home care, unemployment, housing, and law enforcement,
including juvenile justice, jail and prison costs” (Mental Health Services
Act).
Legal Considerations:
California Welfare and Institutions Code (W&I) 5150 / the LantermanPetris-Short Act (LPS): Establishes criteria for a person to be involuntarily
admitted to a mental health facility for 72 hours for evaluation and
treatment. The code also authorizes law enforcement officers and designated
mental health professionals to determine if the person meets one or more of
the following criteria; Danger to Self, Danger to Others, or Gravely Disabled
(unable to accomplish basic life functions)
Estelle v. Gamble (42 U.S.C. §1983): In 1976, the US Supreme Court
established the standard of deliberate indifference which places liability on
custody staff if they ignore any facts that lead them to believe that an inmate
is at risk of self harm (Human Rights Watch, 2003). Subsequent case law
established requirements for correctional facilities to improve their intake
screening to assess suicide potential, provide training for custody staff in
suicidal ideation recognition and prevention, and establish specific protocol
for handling inmates who express suicidal ideations (Lee, 2002).
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The main goals of the Custody CIT at
RCCC:
- Increase officer safety when responding to an
-
-
inmate consumer in crisis by decreasing the
likelihood of the incident escalating to a
physical confrontation
Establish and foster relationships with Jail
Psychiatric Services (JPS) to help improve
access to mental health resources for inmate
consumer incarcerated at RCCC
Improve communication with various patrol
divisions in Sacramento County and their CITs
if established, other community resources and
stakeholders to help reduce recidivism and keep
consumers out of jail.
CCIT Members:
-
-
-
Deputies assigned to one of the four shifts (can be
CERT members if the team structure allows for it)
Have the desire and interest in improving
relationships between custody staff and inmate
consumers
Have at least one year of experience in working in a
custody setting and ideally an educational
background in a related field such as psychology or
social work
Available on a call-out type basis during their shift
as needed for an inmate consumer in crisis
Attend the POST approved 24-hour CIT training to
become CIT certified (offered by the Sacramento
County Sheriff’s Department) and attend on-going
training/presentations as arranged by the CCIT
Coordinator
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Why inmates go into crisis in the
custody setting:
Mental health issues
- Refusing to comply with mental health
treatment
- Not yet receiving mental health treatment
- Undiagnosed/undocumented mental
illness
-
Stressors of incarceration
Bad news (i.e. death in the family, etc.)
Recent drug/alcohol use/withdrawal
Recent arrest/sentencing
No support system
Living conditions in the jail
Problems with other inmates
Combination of both – Incarceration often
leads to high levels of stress on all inmates,
especially on those with mental illness.
Stressors of incarceration can also bring out
undiagnosed/undocumented mental illnesses in
inmates.
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Types of crises:
Disruptive: Combative inmates who refuse to comply with
directives given by custody staff, and may be acting out
physically. If the inmate is acting out as a result of a mental
illness, they may not understand what is going on, they could be
paranoid, or responding to internal stimuli. This type of
behavior could also be the result of the inmate’s uncooperative,
defiant personality.
CCIT involvement in handling disruptive inmates:
- First responder to try to verbally de-escalate the
situation
- Stay involved for relocation/rehousing and or prostraint chair placement to help prevent escalation
- Point of contact for safety any questions regarding
safety cell placement
- Assure all proper documentation and notifications
(JPS, medical, etc.) are made
Suicidal/Danger to Self: Inmates who make statements or
behavior that indicates their intent or desire to kill and/or hurt
themselves. Periods of high risk include inmates within the first
8-24 hours of incarceration, inmates in isolation cell housing,
their first time in jail, drug/alcohol withdrawal, inmates waiting
for/going through trial, recent sentencing, impending release
when the inmate has no support system, holidays/personal
anniversaries, past suicide attempts.
CCIT involvement in handling suicidal inmates:
- Point of contact for any questions regarding safety
cell placement
- Assure all proper documentation and notifications
(JPS, medical, etc.) are made
66
RCCC Observation/Safety Cell
Housing Packet
Required Documentation:
- COMPLETED OBSERVATION/SAFETY
CELL LOGSHEET
- COPY OF FACILITY LOGBOOK
ENTRIES (all facilities involved)
- PRINTOUT OF INMATE’S PF2 AND PF4
SCREENS
- PRINTOUT OF INMATE’S PF10
INFORMATIONAL REPORT
Optional Documentation: (include when used)
- COPY OF AFR REPORT –
CRIME/INCIDENT/CASUALTY
- COMPLETED 647 P.C. EVALUATION
FORM
- PRINTOUT OF PF7, PF11, AND/OR ANY
OTHER INCIDENT RELATED REPORTS
Packets are completed when the inmate is cleared by
JPS to either return to regular custody housing or
admitted to 2P.
Completed packets are submitted to RCCC
Administration by the Deputies on duty when inmate
is cleared to be removed from observation/safety cell.
67
JPS and Inmate Patients
Sacramento County contracts with UC Davis Department of
Psychiatry and Behavioral Sciences to provide psychiatric
services for both RCCC and MJ.
Inpatient Services for Inmates:
There is one 24-hour acute care, inpatient unit at MJ (2P) for
patients from both jail facilities where JPS licensed staff is
available around the clock for emergency evaluations and
admitted patients who require acute, on-going and/or immediate
psychiatric care.
The criteria for admitting patients to 2P is based on the criteria
established in W&I 5150, whether the inmate is a danger to
him/herself, a danger to others, or gravely disabled. Since their
basic needs (clothing, food, and shelter) are provided, the bar
for deeming an inmate gravely disabled is different in the
custody setting than in patrol. The determination is based on
whether or not the patient is able to receive the services
provided, to meet their basic needs, and whether they are able to
program in the custody setting.
Outpatient Services for Inmates:
Inmates who are seen on an outpatient basis and do not meet the
criteria for acute inpatient treatment.
Inmates who may have a chronic mental illness managed by
medication and treatment are seen on an outpatient basis. They
may either be housed in general population based on custody
classification, or they may need to be housed in CBF 600 pod
for male inmates/Ramona Wing for female inmates. These are
the designated housing units at RCCC for patients who require
specialized psychiatric housing, but do not meet the
requirements to be housed on 2P.
68
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