Can 911 Respond to Mental Health Crises?

22-02 Can 911 Respond to Mental Health Crises?

[00:00:00] Reed Pence: This is Radio Health Journal. I'm Reed Pence. This week: Do 9-1-1, and police respond appropriately to mental health crises?

[00:00:08] Tracy Velazquez: What kind of response you'll get that depends on where you live. About one in five indicates that they didn't know or didn't have crisis trained individuals at all. The difference between treatment, jail, and sometimes death, when Radio Health Journal returns…

[00:00:27] Reed Pence: When someone calls 9-1-1, the response you get depends on the emergency called in. A building fire brings the fire department, a bad car crash brings paramedics, but what happens if a mentally ill neighbor grabs a machete, runs into the yard, and start screaming threats against anyone and everyone? In most places, police get the call, according to Dr. Adam Vaughn, Assistant Professor of Criminal Justice and Criminology at Texas State University.

[00:00:57] Dr. Adam Vaughan: Police are the first -- and in most cases the last service provider -- the only service provider that would attend those types of calls. I think of more remote and rural locations where healthcare service providers just are not plentiful, but everywhere in the U.S. there's a police service. So they end up becoming the de facto, kind of, mental health service providers in those communities.

[00:01:22] Reed Pence: An estimated five to 15% of 9-1-1 calls are for mental health or substance abuse crises. But in many of those cases, officers arriving on the scene, know little or nothing about the person they're responding to, often even whether a mental health crisis is behind the behavior. The problem starts with the 9-1-1 call itself.

[00:01:44] Tracy Velazquez: When someone's in a mental health or substance use crisis, they often can be unable to potentially talk about the issue themselves. Oftentimes, other people will call on their behalf and how 9-1-1 responds can very well influence the outcome of that call.

[00:02:03] Reed Pence: That's Tracy Velasquez, manager of public safety research for The Pew Charitable Trusts, which has just finished a study of how 9-1-1 call centers respond to mental health crises.

[00:02:14] Tracy Velazquez: If a 9-1-1 operator doesn't understand that the person is simply having a psychotic episode, the person may send law enforcement, who may come to believe that that person is a danger. And they may respond, for example, with flashing lights and sirens, which can make a mental health issue even worse. And so, the more that the 9-1-1 operators, the call-takers, and the dispatchers know about the call, the better they are able to send the right response. And the more likely the person will end up with a connection with treatment rather than potentially going to jail.

[00:02:54] Reed Pence: Studies show that 20% of people in jails and 15% in prisons have severe mental illness. Many need treatment rather than jail, but sometimes the outcome of a 9-1-1 call for a mental health crisis is even worse than a misplaced jail term. Studies show that people with mental illness are _16 times_ more likely than those without it to be killed by police.

[00:03:20] Tracy Velazquez: We do know that there's a substantial number of police shootings that do involve people who had a mental illness or a mental health crisis. So, you know, I think that police do the best they can in the situation, and it's hard to know exactly what the circumstances were of all of them. But I think, you know, the lesson here is that the more that we can find out upfront before law enforcement gets dispatched, the better the outcomes can be.

[00:03:48] Reed Pence: The 9-1-1 staffer needs to understand mental health crises and ask the right questions. They need to know what can happen when the wrong type of responder is first on the scene.

[00:03:59] Tracy Velazquez: Will a crisis trained law enforcement officer would be sent -- someone who has been taught how to deescalate a situation -- or will a clinician be sent, either separately or along with a law enforcement officer? So what happens in those first few moments at the 9-1-1 call center can make a big difference in terms of the outcomes for the people involved.

[00:04:19] Reed Pence: But sometimes there's no choice. Velasquez and her team have found that sending a crisis trained officer or a mental health professional to this kind of call can be surprisingly difficult.

[00:04:31] Tracy Velazquez: We've talked with some of those call takers and dispatchers, and they've said it can be difficult, especially if someone is calling on behalf of the person in crisis to know what's going on.

Some 9-1-1 call centers have actually started to put clinicians inside 9-1-1 call centers to help with those calls, to help identify if someone is having a mental health crisis. But most of the folks that we talked to in our survey, they didn't have access to behavioral health clinicians.

This is particularly a problem in rural areas. They had the least opportunity to have clinical expertise available to them to help with these calls. But in some communities, they didn't even have a crisis trained police officer. Out of our questionnaires that we sent out about one in five indicates that they didn't know or didn't have crisis trained individuals at all.

And so this really speaks to a great diversity in terms of what kind of response you'll get -- that depends on where you live.

[00:05:30] Reed Pence: Well, Velazquez has says having a clinician in a dispatch center means that mental health and substance abuse crisis calls can be handled differently.

[00:05:38] Tracy Velazquez: It has to do with really being able to ask questions. So, for example, someone could be under the influence of drugs and the person might think the individual -- they may be calling on their behalf and thinking that they are having some kind of psychotic break. So the clinician can help begin to identify what might be going on. In some places that have crisis lines, what they have found is that having a person who has a crisis training, who's a clinician, on the call in about 80% of the time they're able to stabilize the situation, so no one needs to go out right then. What they can do is they can stabilize the situation and get the person connected with a clinician.

So sometimes if we can get help early, right at the time of the call, we can avoid having to send out first responders at all.

[00:06:35] Reed Pence: Some fortunate cities have multiple service options when they're needed -- crisis intervention and social service people rather than police -- out on the streets to talk down a potentially violent person with a mental health crisis.

But Velasquez says her survey has found that many others, not only don't have those, they haven't equipped 9-1-1 centers with anything approaching what they need to handle such a call.

[00:07:00] Tracy Velazquez: Only about half said that they even had a script that they could use to help guide them through the call. So these scripts would say things like, you know, do you feel like hurting yourself? Questions like that, that would help them understand the nature of the call. And less than a third of them said that their call takers and dispatchers had crisis training and this crisis training, again, could help them identify whether someone was having a mental health or substance use crisis. And then less than half also had access to a clinician who can help them understand and triage a call.

So there is really, what we thought is, most call centers didn't have many of these pieces, and some didn't have any at all.

[00:07:45] Reed Pence: Fortunately, that's starting to turn around. But it's a slow process.

[00:07:49] Tracy Velazquez: Most of the call centers did say that at least they had some of the time law enforcement that had received crisis intervention training. So that was the good news here, is that many of them did have law enforcement that had learned skills like deescalation. But then there were always some that said, well, they're only available some shifts, or there's only one officer who has this training and they might not be available. So, it really varied among the sites.

[00:08:17] Dr. Adam Vaughan: The awareness is there that having additional support services -- such as social workers, such as nurses, such as paramedics, mental health professionals, counselors -- having them either sitting in a dispatch room or being on call or in some cases they will ride around with a police officer and attend calls for service. I think people are aware that this is something that can benefit police, but there are still some significant barriers to getting partnerships up and running.

[00:08:48] Reed Pence: Unfortunately, what's best for the community may run directly into the reality of police departments and 9-1-1 that haven't been constructed this way before. Clinicians in the call center and mental health crisis trained officers would be great, but many communities don't have the resources to go much beyond the basics.

[00:09:08] Dr. Adam Vaughan: We have to recall that if someone's having a mental health problem in the community, it makes sense to send a mental health professionals to that, because they're the ones with the necessary training and education and skillset to best respond to the needs of the patient in the community. It just so happens that because many communities don't have any sort of community mental health services, or at least able to meet the needs of the patients in the community... we tend to send police because they work 24/7. They're always there. And this is a challenge, particularly if a program only works 12 hours of the day.

So it could be a crisis intervention team. It could be a group of nurses and EMS, but if they're only working 12 hours of the day, then who's going to respond in the other 12 hours of the day? Chances are it's going to be your local police service that will do that, sort of, other portion of the day work.

[00:10:05] Reed Pence: So how do we plug the gaps in the most efficient way? Vaughan suggests that training street officers is one place to start.

[00:10:13] Dr. Adam Vaughan: In theory, the idea is that if you have more education and training, that the type of response and the result of that response will be more in line with the needs of the patient in the community. It doesn't mean that they won't go sideways and they can't go wrong. But it's the idea that if you've better educated the responder that, in theory, this is less likely to occur.

[00:10:34] Reed Pence: Velazquez says in years to come, people will be able to call 9-8-8 for mental health and suicide crises rather than calling 9-1-1. The Federal Communications Commission set up the plan about a year and a half ago to be put into effect around the nation.

[00:10:50] Tracy Velazquez: And it would connect with your local suicide hotline or your local crisis response center. We're hoping that this really does change the way that people use 9-1-1 and think about alternatives to the traditional response for someone having a behavioral health crisis.

[00:11:07] Reed Pence: 9-8-8 will put some of the responsibility on callers to do sorting, rather than leaving it only two dispatch centers. And that will help where dispatchers haven't had enough training or where turnover is a problem at the call center.

[00:11:21] Tracy Velazquez: When you lose that expertise, when you lose that experience, if you don't have training, if you don't have clinicians available, then it can really be difficult for them to compensate for that loss of expertise. In terms of potentially having a line that they can shift the call to, like when 9-8-8 comes into operation, that could be a big help. But there will always be cases where people are worried that public safety is involved, that someone is potentially dangerous because as they're in a mental health crisis. And so I think it's important to recognize that 9-1-1 will always play a role and there may always be times when police do need to be involved. So continuing to have them trained is an important component of a more comprehensive crisis system for the country.

[00:12:08] Reed Pence: You can find out more about this issue and about Tracy Velasquez, Dr. Adam Vaughan and all of our guests through links on our website, radiohealthjournal.org. I'm Reed Pence.