ACT Teams and CIT: Improving Diversion for People with Severe Mental Illness

1. ACT Teams and CIT: Improving Diversion for People with Severe Mental Illness DR. STEVEN LAMBERTI Co-Founder, Community Forensic Interventions LLC and Professor of Psychiatry URMC DR. CATHERINE COSTIGAN • Professor of Psychology, University of Victoria • DR. ERICA WOODIN • Associate Professor of Psychology, University of Victoria • KIM HENDRICKSON (moderator) • Project Manager, City of Poulsbo’s 4-city police co-response program 2019 CIT International Conference, Seattle, WA - August 26, 2019

2. CIT TRAINING AND LUCY’S FOOTBALL CORE ELEMENTS OF CIT: DIVERTING PEOPLE WITH MENTAL/BEHAVIORAL HEALTH DISORDERS TO TREATMENT CREATING PARTNERSHIPS WITH SERVICE PROVIDERS In practice…. Limited options for people who need help Limited efficacy of partnerships Lack on ongoing collaboration/consultation Lack of accountability Officers trained to divertand lack options for diversion; officers trained to partner and lack opportunity to collaborate.

3. POLICE PERSPECTIVE:CHALLENGE OF ASSISTING INDIVIDUALS WITH SEVERE MENTAL ILLNESS (SMI) • Complexity, acuity, co-morbidity, chronic conditions • Impaired awareness of illness (anosognosia) • Treatment fragmentary and short term • Lack of support after stabilization • Lack of communication with providers • Cycling through ERs, courts, and jail: “what’s the use”

4. Panel Goals Participants will be able to explain why many criminal justice diversion programs do not work for individuals with severe mental illness-and what services are needed to improve diversion efforts. Participants will be able to list the central features of the assertive community treatment model-and how FACT builds on ACT. Participants will be able to explain how ACT/FACT compliment CIT.

5. University of Rochester Medical center

7. CIT and ACT: Better Together J. Steven Lamberti, MD Professor of Psychiatry Academic Chief, Community Division Chair, Research Subject Review Board for Behavioral and Social Sciences University of Rochester Medical Center

8. Declaration of Interest • Dr. Lamberti is co-founder of Community Forensic Interventions, LLC

9. Severe Mental Illness Schizophrenia Schizoaffective Disorder Bipolar Disorder Other

10. Severe Mental IllnessAssociated Problems Homelessness Drug and alcohol use Anosognosia

11. Severe Mental IllnessEngagement Strategies Outreach Addressing basic needs Overcoming cultural/language barriers Using motivational interviewing Ensuring trauma-informed care

12. “There is no compliance without a therapeutic alliance”

13. THE PROBLEM People with severe mental illness sometimes remain unable or unwilling to engage in treatment despite optimal care.

16. CIT Crisis Intervention Teams ACT Assertive Community Treatment

19. What Is Assertive Community Treatment?

22. Assertive Community Treatment • Mobile – 80% of visits are in the community • Available – On call 24/7 • Multidisciplinary – • Pharmacotherapists • Addiction treatment specialists • Housing specialists • Employment specialists • Other

23. ACT:Risk And Responsivity Factors • Psychosis/Mania Medications • Homelessness Housing Support • Substance Use IDDT • Unemployment Supported Employment • Family Problems Family Psychoeducation

24. ACT Effectiveness ACT is very effective at reducing hospitalization and homelessness ACT hasn’t been proven effective at reducing criminal recidivism Some clients continue to refuse even ACT

27. The Rochester FACT Model A high-fidelity ACT team Identification and targeting of criminogenic risk and responsivity factors Mental health and criminal justice collaboration

28. Mental Health – Criminal Justice Collaboration Use of legal authority to promote engagement (“respectful guidance towards compliance”) Therapeutic alternatives to punishment Use of rewards and graduated sanctions Shared problem solving

29. Mental Health-Criminal Justice Collaboration Potential ACT Partners Courts (esp. Mental Health Courts) Probation (esp. Specialty Probation) Parole (esp. Specialty Parole) Police (esp. CIT)

30. CIT:Challenges and Opportunities CIT has the briefest contact CIT is on the front lines ACT is on the front lines too!

33. INTEGRATING POLICE OFFICERS ON ACT TEAMS: BENEFITS AND DRAWBACKS Erica Woodin, PhD., R.Psych & Catherine L. Costigan, PhD., R.Psych CIT International, August 2019

34. Spectrum of Care for Serious Mental Illness in Victoria Crisis ACT STEP Response Program Program

35. The Police-Integrated Victoria ACT Model • Officer(s) integrated on Victoria ACT teams since 2007 • In the beginning: one officer on a forensics-only team (FACT model) • Problems with staff burnout and demand for support from other teams • Currently: three officers on four teams with ~80 recipients per team • Mix of criminally and non-criminally involved recipients • Benefits of sharing load and reducing stigma of police involvement

36. Roles of Officers on Victoria ACT Teams • Coordinate with ACT staff members regarding options for intervention • Escort ACT staff in risky outreach activities • Support medication compliance • Do home wellbeing checks • Provide support to victims of crime • Advocate for housing and other resources • Communicate about recipients to the police department and integrated court • Conduct involuntary hospitalizations under the BC Mental Health Act • Arrest if warranted

37. Concerns from Members of the Victoria Community • Cost of police versus other health professionals • Risk of criminalizing serious mental illness • Giving police more power in the community

38. The Integrating Municipal Police on ACT Teams (IMPACT) Study • Overarching Goal • A qualitative evaluation of the integration of police officers onto ACT Teams in Victoria, BC

39. Participants • 21 recipients of ACT services • Diversity in age, gender, indigeneity, immigrant status, length of time on team, extensiveness of interaction with police, barriers experienced • 22 ACT staff • Diversity in age, gender, role, length of time on team • 13 affiliated staff • Social services, criminal justice, emergency health care • 8 police officers • Mix of ACT and uniformed officers • 4 members of the STEP program • Former ACT recipients who graduated to a more minimal level of care • 9 Advisory Board Members • ACT recipients and family members, social service providers

40. Sample open-ended interview questions • Universal question • From your perspective, what are some of the key benefits and drawbacks of having an ACT Team Officer involved with your ACT team? • ACT recipients • Is your relationship with your ACT Team Officer different than any interactions you’ve had with other police officers? • Staff members • Does police involvement on the ACT team affect the way your service operates?

41. Relationships - Empathic connections - Practical support Benefits • Embeddedness • Integrated planning • Specialized knowledge Improving Safety - In ACT offices - For vulnerable recipients Recipients and staff were both generally quite positive about police integration on ACT teams, and provided many examples of helpful interactions with ACT Officers. • Preventing Harm • - Identify problems • Maintain stability • Authority • Limit-setting • De-escalation 

42. “I’m a big believer that relationships are everything, so to develop the relationship with the client is the key to successful future contacts.” – Officer “Let’s just say I got in trouble with the law…[the ACT Officer would] be someone you could talk to and find out what was going on and all that…Someone that would treat you with respect.” – Recipient “They have a great rapport with our clients…because they often know our clients better than we do because they’ve come into contact with them on a daily basis.” – Staff Relationships Relationships - Empathic connections - Practical support

43. “[The ACT office] is not an easy place to walk into at times. There’s very difficult people that are very, very ill, whether that’s drug-induced or not... And they’re not reasonable at times, and without that safety net of the police officers … it would be worse for everybody.” – Recipient “If I did not have… officers on the team, and I had to rely on… peer support… for safety, or to help me work with a situation of conflict… I would probably quit. I would not feel safe anymore.” – Staff “We’re also here as a safety component. A lot of our clientele… have some pretty serious mental health issues, at times can be unhappy and can get agitated or aggressive, so we’re here to make sure not only that the team members are safe but also the clients as well.” – Officer Improving Safety - In ACT offices - For vulnerable recipients Improving Safety

44. “They all seem to be of the same mindset, so they’re all working as one… they’re just one great, good team. It would be a terrible day if that ever got broken up.” – Recipient “Being able to have them contact whoever they might need to within their agency for additional support or information makes a huge difference, and it makes a massive difference to what the client’s experience is, as well.” – Staff “We’re here to support [ACT staff] because before they would have clients who maybe had some criminal stuff or were going through the judicial system, and they didn’t really understand what this meant…and we’re able to be there to help educate them and support them.” – Officer • Embeddedness • Integrated planning • Specialized knowledge Embeddedness

45. “[The ACT Officers] are looking for a solution. They’re like, ‘you’re homeless, what are we going to do?’ rather than ‘get the hell out of here now.’” – Recipient “We try to get to them and talk to them and head them off before they start committing criminal offenses. So we’re not necessarily an enforcement tool, we’re more of a proactive and a preemptive tool.” – Officer “We’re able to get people up to the hospital more quickly when they’re decompensating because we have police officers here. …The difference is between me waiting an hour for police to come… if I have to wait an hour, something bad is going to happen.” – Staff • Preventing Harm • - Identify problems • Maintain stability Preventing Harm

46. “With the officers it’s pretty straight and cut and dried, and so, after having a few dealings, the client knows, ‘OK, well this is how it’s gotta go.’” – Staff “You gotta have those boundaries, too. So if you have to arrest them, it’s not punitive, it’s ‘Well we had no choice. We had this discussion before.’ You do it in a way that is not obviously judgmental and you do it in a respectful way.” – Officer “There might be… a crisis or right before it gets to a 911 call or something… [ACT officers] have training that none of us have, so that’s extremely valuable.” – Staff • Authority • Limit-setting • De-escalation  Authority

47. Perceived Risk of Consequences Drawbacks Police Stigma Change Nature of ACT Teams A number of participants did not report any drawbacks to police integration. Recipients were more likely than others to have concerns. Not Available Enough Re-Triggering Trauma

48. “[Other clients] are not very happy with the fact that… ACT teams are working with police involvement, because… now they don’t have any safety. They’re always at risk of being arrested. They’re always at risk of being put in jail, put on probation.” – Recipient “A couple [ACT officers] have said ‘Oh, we’ve heard about you from the team’… that kind of made me feel uncomfortable because people were sharing information about me.” – Recipient Perceived Risk of Consequences

49. “People start seeing me talking to [an ACT officer] at McDonald’s and … it brought me problems because people thought I was a rat because I was talking to a cop.” – Recipient “I don’t think that we’re criminalizing clients with mental health issues, but it does send for some a message that ‘maybe you’re dangerous’ when the client’s maybe not dangerous… I worry a little bit that… we now have police officers… that we’re giving the message to the public, well, ‘you better watch out.’” – Staff Police Stigma

50. “I think some people who have had extensive negative experience with the police may be very hesitant to open up with a police officer present… There’s a lot of hatred. If you’ve been beaten up, like, 10 times, you’re not going to be like, ‘oh, yay,’ right?” – Recipient “There are some clients who don’t necessarily like us on the teams. Where we’ve tried to kind of bridge that gap for them, but for whatever reason, whatever previous experience they’ve had with police, we just can’t seem to kind of get to that ‘I like you and you like me’ kind of situation.” – Officer “Certainly police can maybe have an inflammatory effect on certain interactions. They can be a trigger for negative behaviors from some of our clients who may have had negative interactions with police.” – Staff Re-Triggering Trauma