Far too many youth with mental illness are landing in the juvenile justice system. Research shows that 70 percent of youth in the juvenile justice system have one or more psychiatric disorders. At least 20 percent of these youth have a serious mental illness, including those who are suicidal, struggling with psychotic disorders, and experiencing symptoms that significantly interfere with their day‐to‐day functioning.

Many of these youth are incarcerated for minor, non‐violent offenses, while others have not been charged with a crime. Schools and families are often forced to involve police when a child is experiencing a psychiatric crisis because alternatives do not exist. The police are accustomed to handcuffing and transporting these youth to the juvenile justice system. This is known as the school to prison pipeline. It disproportionably impacts youth with mental health treatment needs.

Yet, with more than 52 million students in schools in the U.S., schools are in a unique and key position to identify mental health concerns early and to link students with appropriate services. Goal 4 of the President’s New Freedom Commission Report on Mental Health, issued in July 2003, calls for schools to play a larger role in the early identification of mental health treatment needs in children and to link them to appropriate services. Engaging schools in identifying children and adolescents with mental health treatment needs promises to help reduce the lag time, often eight to ten years, from when an individual first experiences the symptoms of mental illness to when they first seek and receive treatment. Children and adolescents with mental illness are not faring well in many communities across the country. This is true for a number of reasons. Mental health services for children are fragmented and may be available in multiple systems, including mental health, education, child welfare, juvenile justice, and primary care. The fragmentation of services and lack of cross‐ Table 1. Positive Behavioral Interventions and Supports13 Positive Behavioral Interventions and Supports (PBIS) s a school‐based practice model that emphasizes school‐wide systems of support with proactive strategies to create a positive school environment and address students’ challenging behaviors . PBIS focuses on first understanding the underlying cause of a student’s negative behavior and then developing a positive intervention plan that uses a collaborative team approach to address the student’s individual needs. The PBIS approach is data‐driven and has produced the following results:

• Research conducted over the past 15 years has shown that PBIS is effective in promoting positive behavior in students and schools.
• Schools report increased time engaged in academic activities and improved academic performance.
• Schools indicate reductions in office discipline referrals of 20 to 60 percent.
• PBIS leads to dramatic improvements that have long‐term effects on the lifestyle, communication skills, and problem behavior in individuals with disabilities.
• PBIS makes it easier to identify students who need intensive interventions and works collaboratively with other service systems.

Systems collaboration has often led to a lack of accountability. It has also led to many families being forced to act as case managers for their children. There is also a lack of capacity in the home and community‐based services available for youth. All of these factors have led to extremely poor outcomes for youth with mental illness, as outlined in Table 2. Research shows that 10 percent of youth have a serious mental illness.15 However, only 20 to 30 percent of these youth receive any mental health services; leaving over 70 percent of children and adolescents with a diagnosable mental illness without services.16 Meanwhile, other child‐serving systems like juvenile justice and child welfare must provide the mental health treatment needs of youth, often without the training or personnel to do so. Research shows that youth with mental illness fail more classes, earn lower grade point averages, miss more days of school, and are retained more often at grade level than other students with disabilities.14 School personnel and administrators have expressed frustration with poor academic performance and disruptive behaviors of groups of students, including those with serious mental health treatment needs. Law enforcement personnel express concern that they are often used as the “big stick” in schools and communities when addressing youth with mental illness. They are repeatedly contacted about the same individuals who are not linked to mental health services and supports, resulting in repeated confrontations that often lead to the unnecessary, costly incarceration of these youth in the juvenile justice system. Community members become outraged when law enforcement personnel unnecessarily injure or kill an individual who was acting out because of a mental illness and needed mental health services. This situation can create great community unrest. Families are frustrated that they are left with few alternatives other than to call the police when their children are experiencing a psychiatric crisis. They are often not informed of other Table 2. Negative Outcomes for Youth with Mental Illness 10% of children and adolescents in the U.S. live with a serious mental illness that causes significant impairment in their dayto‐ day lives, yet only 20% of them are identified and receive mental health services.17

• 50% of students with a mental illness age 14 and older drop out of high school—the highest dropout rate of any disability group.18 73% of those who drop out are arrested within five years.19
• Children with mental illness are more than three times as likely to be arrested before leaving school as other students.20
• Children with mental illness fail more courses, earn lower grade point averages, miss more days of school, and are retained at grade level more often that other students with disabilities.21
• Suicide is the third leading cause of death in youth aged 10 to 24.22 90% of people who die by suicide have a diagnosable and treatable mental illness at the time of their death.23
• 70% of youth involved in state and local juvenile justice systems have a serious mental illness, with at least 20% experiencing symptoms so severe that their ability to function is significantly impaired.24

Children with mental illness are twice as likely to be living in a correctional facility, halfway house, drug treatment center, or “on the street” after leaving school compared to students with other disabilities.

Resources or services that are designed to meet the needs of their children during a crisis. These frustrations and the negative outcomes for youth with untreated mental illness underline the critical importance of law enforcement, schools, communities, and families embracing effective crisis intervention programs. These programs provide law enforcement personnel and other first responders with the tools they need to respond compassionately and effectively to youth in psychiatric crisis. They also promise to help break the steady flow of youth with mental illness into the juvenile justice system. They will also lead to safer outcomes when law enforcement must get involved. Children’s mental health advocates play an important role in building the momentum and interest in crisis intervention programs for youth and in bringing together the stakeholders needed to ensure the effective implementation and sustainability of these programs.

The Crisis Intervention Team (CIT) model is designed to improve the outcomes of interactions between law enforcement personnel and individuals with mental illness. When individuals with mental illness are experiencing a psychiatric crisis or are acting out as a result of a mental illness, CIT works by diverting them to appropriate mental health services and supports rather than to the criminal justice system. CIT provides training to law enforcement personnel on preventing psychiatric crises and deescalating a crisis when it occurs, without the unnecessary use of physical force. However, CIT is not just a training program.

CIT programs are only effective when law enforcement personnel, the community mental health system, consumer and family advocates, and other stakeholders collaborate to help ensure that when officers divert an individual, the treatment system is willing and able to provide appropriate services. Until recently, CIT training focused primarily on addressing the needs of adults, although trained officers have also long responded to calls involving youth in psychiatric crises. Adult CIT has three key components:

• A community collaboration between mental health providers, law enforcement personnel, family and consumer advocates, and other stakeholders. Representatives from these stakeholder groups form a steering committee or advisory group. They examine local systems to determine their community’s needs, agree on strategies for meeting those needs, and organize training for law enforcement personnel. This committee also determines the best way to transfer people with mental illness from police custody to the community mental health system and ensures that there are adequate services for triage.
• A 40‐hour training program for law enforcement personnel that includes basic information about mental illness, information about the local mental health system and local policies, interaction with consumers and family members to learn about their experiences, verbal de‐escalation techniques and strategies, and role‐playing.
• Consumer and family involvement in steering and advisory committees, coordinating training sessions, and leading training sessions.

The first CIT program was established in Memphis in 1988 after a police officer shot and killed a man with a serious mental illness. This tragedy prompted a collaborative effort between the police, NAMI Memphis, the University of Tennessee Medical School, and the University of Memphis to improve police training and procedures in response to calls involving individuals with mental illness. The Memphis CIT program has achieved remarkable success, in large part because it has remained a true community partnership.

Today, the so‐called “Memphis Model” CIT has been adopted by hundreds of communities in more than 40 states, and is being implemented statewide in several states. Building on the success of CIT programs for adults, several communities have started to adapt CIT programs for youth. Some of these communities are spotlighted in the next section and are utilized as case studies throughout this paper.

The crisis intervention programs for youth briefly described below were chosen as case studies for this paper because they are comprehensive and follow the overarching guidelines set for adult CIT programs. These programs are described and compared in further detail in subsequent sections of this paper. Children in Crisis (CIC) Denver, Colorado CIC levels the playing field so everyone is working from the same sheet of music…everyone wins! I cannot imagine law enforcement not wanting this; it goes a long way with kids.

‐ Sgt. Jon VanZandt, Adams County Sheriff’s Office Children in Crisis (CIC) is a regionally‐based program designed to divert youth with mental illness from the juvenile justice system by using appropriate crisis intervention responses and services. One of the components of this CIT‐based program is training for law enforcement personnel, including school resource officers (SROs), and school administrators. This program is designed to improve crisis intervention responses with youth and in schools by training officers on mental health issues, de‐escalation and problem solving techniques, and methods for connecting to child and adolescent resources. As with any CIT‐based program, a key component of the program is the development of local partnerships between stakeholder groups. CIC was developed by a CIT stakeholder group, including a number of local law enforcement agencies and juvenile justice professionals, under the Colorado Regional Community Policing 10 Institute (CRCPI). The program was piloted in 2006.The program is available to be implemented in other communities, however, the community partnerships described above must be in place before program implementation. The program is currently being revised as part of a national Models for Change multi‐state project, funded by the MacArthur Foundation.The updated and revised program will be named CIT for Youth. For more information about CIC, please visit www.dcj.state.co.us/crcpi (Click “CIT”). Children’s Crisis Intervention Training (CCIT) San Antonio, Texas If you can bridge the gap between school districts and police departments and youth with mental illness, that makes all the difference. Safety is the first thing on a school administrator’s mind, so it is important to emphasize that the program is in tune with those concerns.

‐ Terri Mabrito, Youth Diversion Facilitator, The Center for Health Care Services The Children’s Crisis Intervention Training (CCIT) program focuses on training school campus officers and school resource officers (SROs) to respond to children and youth in psychiatric crises and divert them to mental health treatment. This provider‐driven, community‐based program involves various community organizations, youth, and families in implementing the program and developing community partnerships for sustainability. The program was developed by youth‐focused community partners and stakeholders with leadership and coordination by the Center for Health Care Services in Bexar County. The program was piloted in 2008. The program is available to be implemented in other communities. Fine tuning will help the program fit the uniqueness of any community, particularly with respect to the unique needs and resources of school districts and their police departments. For more information, contact Terri Mabrito, Community Liaison, Youth Diversion Facilitator, The Center for Health Care Services, at tmabrito@chcsbc.org. Crisis Intervention Team (CIT) for Youth Chicago, Illinois The officers at school are at the front entrance to the juvenile justice system. They need more support. They should not just be used as the ‘bad guys.’

‐ Lt. Jeffry Murphy, Chicago Police Department Chicago’s CIT for Youth program, which is still in development, will focus on diverting youth from the juvenile justice system to mental health treatment. The program will target schoolbased police officers and will work closely to develop a hand‐in‐hand partnership with schools. The program includes the promotion and delivery of supplemental programs that educate school professionals on mental illness. CIT for Youth is being developed by the Chicago Police Department and is expected to be available for dissemination in 2009. However, it will likely require adaptations to successfully meet the needs of diverse communities. For more information, contact Officer Kurt Gawrisch, Crisis Intervention Team, Chicago Police Department, at: kurt.gawrisch@chicagopolice.org.

Developed by faculty from the Dartmouth Medical School
Available from Hazelden Publishing, September 2008

An integrated system of mental health and addiction services that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems.
– Co-occurring Center for Excellence (SAMSHA)

In recent studies, researchers estimate that about half of the people treated in mental health settings have at least one substance use problem in their lifetime, if not within the past year. Approximately 25 to 33 percent of the people treated in mental health settings have experienced substance use problems either currently or within the past year. In addiction treatment settings, these estimates are similar if not higher. As many as 50 to 75 percent of people in addiction treatment centers also suffer from a psychiatric disorder, some with chronic disorders.

As the above quote from SAMSHA’s Overview Paper #3: Overarching Principals to Address the Needs of Persons with Co-occurring Disorders affirms, over 20 years of research has settled the old question of which of these disorders should be treated as primary by demonstrating that integrated treatment, which treats both disorders concurrently, offers the best possible outcomes for clients and client’s families. The Co-occurring Disorders Program, to be published by Hazelden in September 2008, offers a comprehensive, manualized system that supports evidence-based, integrated treatment for these disorders.

The Dartmouth Psychiatric Research Center developed and tested the Integrated Dual Disorder Treatment (IDDT) model, which is now an established evidence-based practice designed for people with severe mental illness (SMI). Drawing upon the numerous randomized controlled trials testing the IDDT model, as well as the rapidly accumulating evidence for practices with co-occurring substance use and non-SMI disorders, the Co-occurring Disorders Program represents the state-of-the-science in treatment approaches for people in addiction treatment settings. Since the evidence base for co-occurring disorders in addiction treatment exists on a continuum, each component of this Program will describe the scientific status of the various treatment approaches, from investigative to promising to established practices. In some components, careful adaptations of evidence-based approaches, for example the family education approach, are made in order to be relevant for the non-SMI client in an addiction treatment program.

The therapeutic interventions documented in this Program are primarily drawn from current best practices in cognitive-behavioral therapy, motivational interviewing, and Twelve Step facilitation. These materials have been developed within the context of addiction treatment programs treating clients either individually or in groups, but are equally useful when applied in a mental health program that would like to offer integrated treatment for co-occurring disorders. The package includes all the support tools necessary to implement an integrated treatment program to fulfill the needs of administrators, clinicians, patients, family members, team members, and other stakeholders.

The seven components of the Co-occurring Disorders Program  are designed for use with adult patients, as well as their family members, who are participating in a residential or outpatient treatment and/or mental health program for substance use and non-severe mental health disorders. The program components listed below, include a manual, five 3-ring binder curricula with CD-ROMs, and a DVD.

Program Manual: Clinical Administrator’s Guidebook

This perfect-bound manual contains complete instructions for implementing the Co-occurring Disorders Program. The guidebook is for a mental health or addiction treatment organization’s director, board of directors, CEO, CFO, and other key agency leaders. This guidebook offers all the tools a clinical administrator needs to assess the seven key areas of organizational effectiveness, including the policy, practice, and workforce benchmarks needed to deliver the best possible services to persons with co-occurring disorders. The Clinical Administrator’s Guidebook also contains a valuable organizational assessment guide, which outlines the steps needed to assess and improve services offered to patients with co-occurring disorders. Links to resources about co-occurring disorders, a sample charter agreement and DDCAT implementation plan, and other materials are included on the accompanying CD-ROM.

Curriculum One: Screening and Assessment

The first of the five curriculum components is a must-use tool that helps clinicians evaluate patients with an effective, protocol-driven method so that appropriate treatment options can be addressed with regard to each patient’s symptoms, history, and motivation to change. Included are specific measures for screening, assessment, differential diagnostics, and stage of motivation to address and treat both addiction and psychiatric problems in patients. Screening and Assessment comes with a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Two: Cognitive-Behavioral Therapy 

The second curriculum utilizes cognitive-behavioral therapy (CBT) principles to address the most common psychiatric problems in addiction settings: depression, anxiety disorders, bipolar disorder, social phobia, and post-traumatic stress disorder (PTSD). Adaptations of CBT are an evidence-based practice for treating substance use disorders and most psychiatric disorders. Research shows that CBT is useful for treating non-severe co-occurring psychiatric disorders in an addiction treatment setting. Psychosocial treatments, particularly CBT, are equally, if not more, effective for the psychiatric disorders that most commonly occur with substance use disorders.  Research with CBT for persons with co-occurring disorders has been highly specialized by the specific co-occurring disorder. Until now, providers had no one manual or practice to implement in real-world settings where patients have a variety of these disorders. Cognitive-Behavioral Therapy includes a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Three: Integrating Combined Therapies

The third curriculum utilizes a combination of motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and Twelve Step facilitation (TSF) therapy. Each of these models of therapy has been proven successful when used in community addiction treatment programs. There is a growing consensus that these practices are effective if delivered singularly to patients, but are even more effective if rationally combined based on stage of motivation, problem pattern and severity, and patient preference. We can think of MET as serving the role to engage change, CBT working to assist change, and TSF as a proven model to sustain change and elaborate upon it.  Each of these evidence-based practices is described here with appropriate modifications for persons with co-occurring disorders. This curriculum will enable a clinician to successfully deliver these evidence-based substance dependence treatment therapies to patients with co-occurring disorders, resulting in greater positive outcomes for clients. Integrating Combined Therapies comes with a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Four: Medication Management

The fourth curriculum is a valuable resource for medical directors and clinicians. It contains vital, current information about the complex issues of medication management, including medication compliance and other psychological concerns of the patient. Issues of differential diagnosis, timing, indications, monitoring, dosage, tolerance and withdrawal, and other topics are considered in this component. Current evidence and consensus-based practices are provided to enable providers to make clinical decisions about medications and their prescription. While many people in peer support groups take psychotropic medication, stigma can still cause some to hide their medication use from others. These issues, and information about the benefits and risks of medications, are also addressed for the patient. Medication Management comes with clinician’s instructions and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Five: Family Program

The fifth curriculum helps clinicians involve patients with co-occurring disorders and their family members in an integrated treatment approach.First, family members, including the patient,meet to learn about the patient’s specific psychiatric disorder andhowit interacts withthe substance use disorder. Then, the family joins other families in a 12-week program of education on such topics as managing cravings, effective communication, using medications, and preventing relapses. The Family Program component includes a bound clinician’smanualand a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Program Video: Hope and Healing for Co-occurring Disorder Patients and their Families

This 90-minute DVD educates patients and families on the treatment of co-occurring disorders. It provides an educational overview of co-occurring disorders, offers interviews from people who have them, and discusses ways that patients can participate in treatment to better manage their recovery from both disorders. Included are dramatic vignettes as well as professional narration to show a comprehensive look at all the issues of recovery. Clinicians can use this DVD when implementing all seven components of the Co-occurring Disorders Program or as a stand-alone with the Family Program.

Implementation training developed by Hazelden and the faculty of Dartmouth Psychiatric Research Center to help treatment and mental health centers develop greater capacity, skills, and processes to treat non-severe mental health patients with substance use disorders will be available when the Program is released in September 2008. 

Pricing and ordering information for Co-occurring Disorders Program and the implementation training will be announced in April 2008.

About the Authors

Mark McGovern is an associate professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School. Dr. McGovern specializes in the treatment of co-occurring substance use and psychiatric disorders and practices through the Department of Psychiatry at Dartmouth-Hitchcock Medical Center. In July of 2004, he received a five-year career development award from the National Institute on Drug Abuse. The overarching goal of this award involves developing, testing, and transferring evidence-based treatments to community settings for persons with co-occurring substance use and psychiatric disorders.

Robert E. Drake, M.D., Ph.D., is the Andrew Thomson Professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School and the director of the Dartmouth Psychiatric Research Center and is currently vice chair and director of research in the department of Psychiatry. He works as a community mental health doctor and researcher. His research focuses on co-occurring disorders, vocational rehabilitation, health services research, and evidence-based practices. He directs four national studies of quality improvement, and he has written fifteen books and over 360 papers.

Matthew Merrens, Ph.D.,< is codirector of Dartmouth Evidence-Based Practices Center and visiting professor of Psychiatry at Dartmouth Medical School. He received his Ph.D. in clinical psychology at the University of Montana and was formerly on the faculty and chair of the Psychology Department at the State University of New York–Plattsburgh. He has extensive experience in clinical psychology and community mental health and has authored and edited textbooks in the psychology of personality, introductory psychology, the psychology of development, and social psychology. He recently published a book on evidence-based mental health practice.

Kim T. Mueser, Ph.D., is a licensed clinical psychologist and a professor in the Department of Psychiatry and the Department of Community and Family Medicine at the Dartmouth Medical School . Dr. Mueser’s clinical and research interests include integrated treatment for co-occurring psychiatric and substance use disorders, rehabilitation for persons with severe mental illnesses, and the treatment of post-traumatic stress disorder. He has published several hundred journal articles and has coauthored or edited ten books.

Mary F. Brunette, M.D., is an associate professor of Psychiatry at Dartmouth Medical School. She conducts research on services and medications for people with co-occurring substance abuse and serious mental illness at Dartmouth Medical School. She also is medical director of the Bureau of Behavioral Health in the New Hampshire Department of Health and Human Services. She has published over thirty articles in peer-reviewed journals, many related to medication treatment for people with co-occurring disorders. She speaks nationally on this topic.

Richard Hendrick, who produced the DVD, is a television writer, producer, and director and an educator. He has created award-winning productions for PBS, Turner Broadcasting, and A&E, among others. He taught for many years at Dartmouth College, including courses in developmental psychology, educational technology, and television and children, and has also lectured at Harvard Graduate School of Education, Columbia University, Bank Street College, and the University of Siena in Italy.

The Adult Mental Health Division provided grants to the Adult Mental Health Initiatives in July 2008 to implement or enhance Crisis Intervention Teams (CIT) in their regions. Crisis intervention team training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses.

Developing CIT is critically important since officers are often first-line responders to emergency calls involving individuals with mental illnesses. CIT was first developed in 1988 by the Memphis Police Department in partnership with the Memphis chapter of the National Alliance on Mental Illness, the University of Memphis, and the University of Tennessee. CIT programs, through de-escalation training and education about mental illnesses, have been successful in reducing unnecessary arrests and use of force, while increasing referral rates to emergency health care. Studies also show that compared with non-CIT officers from the same police department, CIT officers are significantly more likely to feel well prepared in handling crises involving people with mental illnesses.

Grants have been awarded for one or more of the following core components of CIT to nine of the Adult Mental Health Initiatives in Minnesota:

1. Introduction to CIT through CIT Orientation meetings.

2. CIT Planning, Implementation & Networking facilitated meetings. Community collaborations and partnerships are essential to succesful implementation of CIT.

3. Dispatch training sessions to provide training for emergency dispatchers such as call takers, dispatchers, and 911 operators.

4. Law Enforcement Officer Trainings. The 40-hour comprehensive training emphasizes mental health-related topics, crisis resolution skills, de-escalation training, and access to community-based services.

The Adult Mental Health Initiatives participating in developing CIT components with grants through June 2009 are:

1. NW8 – Polk County Host (& Kittson, Roseau, Marshall, Pennington, Red Lake, Norman, Mahnomen).

2. Region 2 – Hubbard County Host (& Lake of the Woods, Beltrami, Clearwater).

3. BCOW and 4 South –Grant County. Host (& Becker, Clay, Otter Tail, Wilkin, Traverse, Douglas, Stevens, Pope).

4. Region 7 East – Isanti County Host (& Mille Lacs, Kanabec, Pine, Chisago).

5. CommUNITY- Benton County Host (& Stearns, Benton, Sherburne, Wright)

6. Ramsey County.

7. South Central Community Based – Blue Earth County (& Sibley, Nicollet, Brown, LeSueur, Rice, Watonwan, Faribault/Martin, Freeborn).

8. SW 18 – Cottonwood County Host (& Big Stone, Swift, Kandiyohi, Meeker, Lac qui Parle, Chippewa, Renville, McLeod, Yellow Medicine, Lincoln, Lyon, Murray, Redwood, Pipestone, Rock, Nobles, Jackson).

9. CREST – Olmsted County Host (& Goodhue, Wabasha, Winona, Houston, Waseca, Steele, Dodge, Mower, and Fillmore).

Article Courtesey of NAMI-MN

Mental Health Services are key to CIT success

A rigorous study of the Crisis Intervention Team in Chicago indicates the importance of “responsive and effective” mental health services to the success of CIT, a widely adopted, award-winning community policing program that has been shown to prevent injuries to police officers as well as civilians. The study, by researchers at the University of Illinois, Chicago (funded by the National Institute of Mental Health), found that “[c]ompared to their non-CIT trained peers, CIT trained patrol officers were resolving a greater proportion of calls by transporting or otherwise directing adults with mental illnesses to mental health services.” However, the researchers say that, unless the mental health services that receive officer referrals are “responsive and effective” and there are accessible supportive services, such as housing, employment, and medical care, “it is possible that officers (CIT trained or not) eventually may become disillusioned and stop making the effort to link people.” A policy brief about the study was published by the Rutgers University Center for Behavioral Health Services & Criminal Justice Research.

Source: http://www.cbhs-cjr.rutgers.edu/pdfs/Policy%20Brief%202%2009%20(2).pdf

Combination of factors drive up danger, researchers say

By Carla K. Johnson, Associated Press
In the Pioneer Press, St Paul Minnesota

CHICAGO — A new large study challenges the idea that mental illness alone is a leading cause of violence.
Researchers instead blame a combination of factors, specifically substance abuse and a history of violent acts, that drives up the danger when combined with mental illness in what they call an “intricate link.”

People with serious mental illness, without other big risk factors, are no more violent than most people, according to the study of more than 34,000 U.S. adults. The research was released Monday in Archives of General Psychiatry.
“Mental illness can provide the knee-jerk explanation for the Virginia Tech shootings,” but it’s not a strong predictor of violence by itself, said lead author Eric Elbogen of the University of North Carolina at Chapel Hill School of Medicine.

Elbogen compiled a “top 10” list of things that predict violent behavior, based on the analysis.

Youth topped the list. History of violence came next, followed by male gender, history of juvenile detention, divorce or separation in the past year, history of physical abuse, parental criminal history and unemployment in the past year. Rounding out the list were severe mental illness with substance abuse and being a crime victim in the past year.
After the 2007 Virginia Tech killings by a student ordered to get psychiatric treatment, some states considered laws adding mental health questions to background checks for gun buyers or denying weapons to people who’ve been involuntarily committed for mental health treatment.

The new research, which bolsters other similar findings, raises questions about such laws, experts said. Such legislation may be both ineffective and discourage people who need help from getting treatment.

“We are being misled by our own fears,” said Columbia University psychiatry professor Dr. Paul Appelbaum, who wasn’t involved in the new study. “We ought to be concerned about providing good treatment and helping people lead fulfilling lives, not obsessed with protecting ourselves from phantom threats that appear to be unrelated to mental illness.”
U.S. systems to treat mental illness and substance abuse are separate, uncoordinated and could do a better job treating people with both problems, Appelbaum said.

For the new study, the researchers analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions. The original survey in 2001-2002 involved more than 43,000 face-to-face interviews with a representative sample of American adults. Three years later, many of the same people, more than 34,000, were interviewed again.
From the responses, the researchers determined what elements raised the risk of violent behavior.

There were 3,089 people deemed to have severe mental illness — schizophrenia, bipolar disorder and major depression — but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10. The relationship between mental illness and violence is there, “but it’s not as strong as people think,” Elbogen said.

Council on Crime and Justice’s 50th Anniversary Forum
October 10, 2007, Minneapolis Convention Center
By: Mark Anderson and Lynda Cannova

Mark Anderson, founding Executive Director of the Barbara Schneider Foundation, was Senior Policy Advisor on mental health and related issues for Wellstone’s 12 years in the U.S. Senatae. 1989-1990, Director of Board and Commission Appointments in the Office of Governor Rudy Perpich. He has an MA, in Liberal Studies, HamlineUniversity. Lynda Cannova is the mother of two grown sons with schizophrenia. She has worked with Barbara Schneider Foundation on policy development and outreach for three years. She has an MSW from the University of Minnesota School of Social Work.

In the last 50 years there have been dramatic changes in systems of care for those with mental illness, and in how this care is financed. There have been exciting advances in the science of the brain that helps us understand what mental illness really is and how we can respond to it. But even with all the improvements in what we know and what we do, the lives of those with a mental illness have not improved nearly as much as they could have. We know much more now than we did fifty years ago, but our society’s institutions have not kept up so we continue to fall short. Where our health care systems have failed, our criminal justice system has taken on the burden with problematic consequences.

According to the Surgeon General’s Report on Mental Illness, it is estimated that in an average one-year period, 22 to 23 percent of the U.S. adult population—or 44 million people—have diagnosable mental disorders. About 28 to 30 percent of the population has either a mental or addictive disorder. It is estimated that 9 percent of all U.S. adults have mental disorders experience some significant functional impairment. Five percent of adults are considered to have a “serious” mental illness. About half of those (or 2.6 percent of all adults) were identified as being even more seriously affected, that is, by having “severe and persistent” mental illness. This category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder. Today, only 60% of severely mentally ill persons receive treatment in a given year, leaving approximately 2.2 million severely mentally ill persons untreated (Torrey, 1997).

In 1957 mental health treatment was typically provided in large state hospitals and other institutions. This was the era when pharmaceutical treatment of mental illness was just beginning and an affordable community based mental health system did not exist. Patients were sent to these institutions for care and often spent many years there. Families could care for their family members in their own home, as had been done since time immemorial but, in an increasingly urbanized society, that style of care was less possible for many. These state run institutions were seen as humane alternatives to incarceration or homelessness.

According to the groundbreaking first Surgeon General’s Report on Mental Health, “In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as “mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior.”

With the invention of new pharmaceuticals, that made it possible to moderate the extreme behavior of many who lived in these institutions, it was thought that allowing patients to leave and be treated in the community would be more humane.

President John Kennedy supported the Community Mental Health Act of 1963 which provided federal financing to states to develop community mental health centers. These community mental health centers developed as an important part of our mental health system, and formed an important core of a growing community mental health movement. But they were never adequately funded and so were never able to provide community based mental health care for all those who had been deinstitutionalized. Deinstitutionalization reduced the population of state and county mental hospitals from a high of about 560,000 in 1955 to well below 100,000 by the 1990s. De-institutionalization has eliminated over 90% of former state psychiatric hospital beds (Sigurdson, 2000). But an adequate community based mental health system has even today not been created.

On July 30, 1965 Medicare, a federal single payer system for those over 65 and, after 1972 for those with a disability, was created. Its companion program Medicaid was also created to cover long term care for the elderly and others and care for mothers and children who met income guidelines. Unfortunately Medicare, to this day, discriminates against mental health coverage, charging a 50% co-pay for mental health care and a 20% co-pay for medical and surgical care. In addition, there was no Medicare coverage for pharmaceutical care outside the hospital setting for the first 4 decades of the program. And Medicaid is moving to a managed care model that has not worked well with this population.

The development of a wide variety of pharmaceuticals lead to an increased reliance on pharmaceutical care rather than hospital care for mental health as well as medical and surgical care. After the failed 1992 national health care reform effort, managed care became the standard way to organize care including mental health care. This business model of mental health treatment helped further medicalize mental health care by disconnecting it from support services. The rise in reliance on pharmaceutical care, combined with managed care led to a decrease in talk therapy and a failure to provide needed support services to those who were de-institutionalized. In fact it would not be an understatement to say that pharmaceutical companies took on a growing role in defining care options. In mental health this lead to the colloquialism, “off his meds,” to refer to someone who was exhibiting symptoms of psychiatric illness.

In speeches to medical societies in the 1940s and 1950s, Bill W., the founder of Alcoholics Anonymous, noted the important role played by leading psychiatrists in the development of AA. And yet there developed a split between the treatment of mental illness and the treatment of substance abuse and addiction. The varying stigma associated with these two sets of disorders and the public’s and the health care community’s failure to understand their inter-relationship lead to a situation where patients with co-occuring mental illness and substance abuse or addiction we bounced back and forth between these systems because neither system was fully able to treat both disorders. This is now changing due to the new brain science that is clarifying the underlying disease processes at work and making possible the identification of effective dual-diagnosis treatments.

After the Vietnam War, military veterans fought for years to gain the recognition of the diagnosis of post traumatic stress disorder, PTSD, as a diagnosable and treatable mental health disorder. Later it was recognized that other sufferers of trauma, sexual assault, torture, children who witness violence, and others, could also be affected by PTSD. During the current conflicts in Iraq and Afghanistan, it is being recognized that combat and operational stress are treatable disorders and that their immediate treatment can lower rates of PTSD in warriors who experience the stress of life in the combat zone. In addition, military health care providers are seeing the importance of traumatic brain injury, TBI, and this is leading to the recognition of the importance of treatment of this disorder throughout the health care system.

Consumer movements like those that lead to the recognition of PTSD have also grown up with a number of other mental health disorders. Consumer organizations, and organizations of family members of those with mental illness, have played an important role in recent years in raising awareness among policy maker and health care leaders in the need to treat mental illness.

Beginning in the 1960s, the feminist movement helped re-define women’s mental health.

Communities of color pressed for respect for cultural differences in mental health care and began to insist on cultural competence by mental health providers so that providers would have the ability to develop rapport and a healing relationship with their patients and clients.

As society changed its view of mental illness, the courts became more understanding of mental health related issues. Civil commitment proceedings were reformed and criminal mental health courts created.

There was a growing understanding of the relationship between children’s and adult mental health. School districts have become much more aware of the barriers to success in education that mental illnesses create for children. And yet schools are not health care institutions and their failure to adequately respond to the needs of children with a mental illness has contributed to the overwhelming majority of children in our juvenile justice system having a diagnosed mental health disorder.

The American’s with Disabilities Act, ADA, which took effect on July 26, 1992, supported parents and consumers’ insistence on an appropriate response to mental illness in the workplace and public accommodations.

Particularly since 1990, advances in brain science, brain scans, growing understanding in brain biochemistry, advances in psychological therapy, electrical brain stimulation, and the role of the genome in brain development and functioning are bringing important new understandings to health care providers, policy makers and the public.

There is an increased understanding that the mind/body split that 18th century philosophers detailed is a fiction. The brain is a real part of the body and the brain and other organs of the body interact in numerous ways so that a health care system that does not treat the brain with the body is outmoded. This new understanding is reflected in the Mental Health Parity Act of 1996 which broke down some of the discrimination against mental health care. So called full parity between mental health, substance abuse treatment and medical and surgical treatment has been under consideration by congress since the mid 1990s and appears closer than ever to passage this year. And at the state level, 1997 saw passage of uniform mental health benefits in all the major public health care program benefit sets. Mental health parity has already been the law in Minnesota since the 1990s.

Today there is an overwhelming need to update all health care, public safety, criminal justice and social service institutions to utilize the new insights that science provides. These systems, which in many cases are based on models that are centuries old, must be updated based on this new knowledge.

In spite of all the progress made in the mental health system in the last 50 years, our current mental health system reflects a social and political mental health injustice. Mental health care providers report that our capacity for emergency psychiatric care is regressing to a time 40 years ago when providers had to accompany patients to the emergency room and wait with them for care. Criminal justice professionals report that 60-75% of those in some of our jails have a mental illness. There are more persons with mental illness in jails and prisons than in all state hospitals combined. Many have identified this situation as the criminalization of the mentally ill.

Due to the decreasing number of inpatient beds and the lack of needed community based mental health providers, many people struggling with severe mental illness find themselves repeatedly and unnecessarily in mental health crisis. Many of them will end up committing suicide, as crime victims, and encountering the police. Clearly reform is needed. There is a need for comprehensive and effective long-term care environment for this high risk population. People with severe mental illness are frequently turned away from treatment facilities and often wind up in jail or are homeless due to lack of treatment. These individuals often have to go through the criminal justice system to get the treatment they need.

In the current situation a large percentage, estimated at 30%, of the population in the criminal justice system is on psychotropic medications to treat severe mental illness; the historic and continuing decline in inpatient beds in mental health hospitals and hospital psychiatric wards; the lack of community based programs to provide long term support to people with severe mental illness needed to avoid repeated hospitalizations, homelessness, suicide, and the number of people who die each year because of the inadequacy of our prevention systems make this proposal profoundly important. Besides these disastrous results our current view of mental health as a social welfare and public safety issue promotes actual loss of liberty when someone who is mentally ill but untreated commits a crime and ends up incarcerated, often being forced into treatment that could easily have been given on a preventive basis in the community.

Research has proven that mental illness is a biological brain disease and not a lifestyle choice. When someone is sick, whether from disease that can be seen under a microscope or from one that strikes the mind invisibly, treatment is required. Unfortunately the current system for providing treatment for those with psychiatric disorders remains dangerously troubled. There is inequity in laws concerning the mentally ill in that they are not guaranteed the right to high quality treatment given to people with other organic but not behavioral illnesses. To be equitable, the mentally ill should have the same right to get treatment as people with any other debilitating disease or disorder. If mental illnesses are not understood as medical conditions, then equity is not a feature of laws and services. People with severe heart conditions or diabetes and cancer can access treatment by going to a doctor’s office or hospital, while the mentally ill are often turned away from treatment facilities. Appropriate response to this population can help save lives, save law enforcement, court, incarceration and health care costs, reduce homelessness, and improve the lives of people with severe mental illness and the lives of their loved ones.

Since the 1970s police departments across the country have seen a sharp increase in calls involving persons with mental illness (Torrey, 1997). It is estimated that between 7-10% of law enforcement contacts involve persons with mental illness (Bailey 2001, Hails & Borum, 2003). Research also indicates that in police encounters, persons with mental illness are more likely to be arrested than those who are not (Teplin, 2000). This high rate of law enforcement contact with persons with mental illness has led to incidents that have resulted in injury or death for the mentally ill. For example in Los Angeles, over a six-year period confrontations with the mentally ill ended in 25 fatal shootings by police (Bailey 2001). One study in a large law enforcement agency found that “suicide by cop” accounted for 11% of all officer-involved shootings (Lamb, Weinberger, DeCuir, 2002).

Recent strides by science in the understanding brain and biological factors that contribute to mental illnesses make these illnesses diagnosable and successfully treatable. This progress has not been matched by public policy in guiding our response to mental illness. Law enforcement response to mental health crisis involves a great deal of discretion in determining the outcome. Police decisions at a scene often determine whether a person will enter the mental health or the criminal justice system; yet officers often have very little training in identifying and working with persons exhibiting mental illness.

Police officers are called on to respond to mental health crisis situations while ensuring officer safety, public safety and on scene resolution or transport to the mental health system. Police need specialized response programs to respond appropriately and effectively.

Persons with mental illness face many risk factors which impact their chances of encounters with law enforcement and for incarceration, including dual-diagnosis with chemical dependency, homelessness, and treatment non-compliance (Munetz, Grande & Chambers, 2001). It is estimated that between 20-30% of the adult homeless population suffers from a severe mental illness (Sigurdson, 2000). In addition 80-90% of mentally ill offenders are estimated to have co-occuring substance abuse problems (Sigurdson, 2000). Disordered thinking and paranoid delusions can lead to nuisances as perceived by the public and even criminal, sometimes dangerous, behavior.

Along with the reports of increased police involvement, reports of large numbers of mentally ill persons in U.S. jails and prisons began appearing in the 1970s (Lamb & Weinberg 1998, Torrey, 1997). Approximately 685,000 persons with severe mental illness are admitted to U.S. jails every year and between 6-15% of jail inmates have a severe mental illness (Hails & Borum, 2003; Lamb & Weinberg, 1998). The U.S. Department of Justice estimates that in 1998 there were 283,800 mentally ill offenders in U.S. prisons and jails, representing 16% of state prison inmates, 7% of federal inmates, and 16% of those in local jails (Ditton, 1999). The incarceration of persons with mental illness has become so rampant that professionals in the field claim that jails and prisons have become mental health facilities (Faust 2003, Howd 1998, Torrey 1997). This has major implications for criminal justice funding, for the cost of imprisonment often exceeds the cost of appropriate mental health care in the community (Sigurdson 2000). Mentally ill offenders are considered to have the highest rate of recidivism of any group of offenders (Sigurdson 2000).

Law enforcement has a professional responsibility to respond to persons with mental illness who are experiencing crises. There are two common law principles that create the opportunity for police officers to become involved with persons with mental illness. The first is that the police have the authority and responsibility to ensure public safety. Secondly, officers have a parens patriae obligation to protect persons with disabilities who cannot care for themselves (Lamb et al., 2002). Police have the authority to initiate a psychiatric emergency apprehension when a person poses a danger to themselves or others or if unable to provide for his or her own basic physical needs necessary to protect oneself from harm (Teplin, 2000). Police officers are often the first responders to people in crisis, but often lack the training necessary to respond appropriately (Patch & Arrigo, 1999).

Police officers typically have three options when encountering a person with mental illness who is creating a disturbance or is in crisis: 1) resolve the situation informally at the scene; 2) transport the person to a mental hospital; or 3) arrest the person (Teplin, 2000). Law enforcement response to persons who are apparently mentally ill involves a lot of discretion in determining the outcome (Patch & Arrigo, 1999). The decisions that police make at a scene involving a person exhibiting mental illness often determine whether a person will enter the mental health system or the criminal justice system. Depending on other community resources, police officers are often the only responders to situations involving persons with mental illness who are experiencing crisis. This is why police officers are often referred to as “street-corner psychiatrists” (Teplin, 2000) or gatekeepers (Patch & Arrigo, 1999).

This role that police officers take on as “street-corner psychiatrists” can be problematic because they often have very little training in identifying and working with persons exhibiting mental illness. Sometimes police do not have the training necessary to distinguish between whether someone’s behavior is a manifestation of mental illness or it is unlawful behavior (Hails & Borum, 2003). When asked, police officers will often identify that they feel unprepared to respond to such situations (Hails & Borum, 2003) and identify that they would like to receive training in how to recognize mental illness, how to respond to situations, and what community resources are available for persons with mental illness (Lamb et al., 2002). Also, research indicates that police interactions with persons exhibiting mental illness are different from interactions with persons who are not apparently mentally ill. Teplin conducted a study in 1980 in which it was found that persons with mental illness have a 67% greater chance to be arrested than those who apparently were not mentally ill (2000).

There is also a concern regarding the use of excessive force with persons with mental illness. As discussed above, interactions between police and persons with mental illness have unfortunately led to death and injury for both persons with mental illness and involved police officers. Although more research is needed, national data indicates that force is more likely to be used with persons with mental illness. Police training in the use of interpersonal skills for de-escalation, the use of less lethal weapons, such as tasers, and other tactics are all issues that impact the use of force by police officers.

When police officers do try to initiate a psychiatric response, by transporting a person for emergency apprehension, they often face barriers. Due to the cuts in funding experienced by the mental health system, many hospitals have a limited number of psychiatric beds. Some programs also have regulations on whom they will accept, such as not accepting persons who are considered dangerous or if they have a co-occurring substance abuse problem (Teplin, 2000). Sometimes officers will transport a person for hospitalization or psychiatric evaluation, just to have the person back on the streets with in hours–creating a revolving door for criminal justice response. In addition, when officers transport a person to the hospital, they sometimes will face a long wait to transfer the individual, which takes the officer away from their patrol duties. In addition, psychiatric care may be more available in the jails than in the community system. Given the barriers officers often face when trying to initiate a psychiatric hospitalization, sometimes arrest is viewed as a simpler and more reliable way to resolve some situations (Teplin, 2000). This is often referred to as “mercy bookings” and is used both when officers do not feel like they have any other realistic choice and also when they believe that it is in the person‘s best interest, for they will receive shelter and possibly mental health services provided by the system (Sigurdson, 2000; Torrey, 1997).

There is growing evidence that formal collaboration between law enforcement and the mental health system is critical for the best law enforcement response to persons with mental illness (Klein, 2002; Gentz & Goree 2003; Lamb et al 2002; Sigurdson 2000; Steadman, 2000 & 2001; Teplin, 2000; Thompson 2003). Police-based diversion programs, involving collaboration with the mental health system have emerged. As compared to court-based diversion, police-based diversion happens before booking and the filing of charges and involves police making direct referrals to community-based mental health or substance abuse programs as an alternative to arrest and detention (Steadman, et. al. 2000). Diversion programs have been shown to work in both decreasing subsequent hospitalizations and recidivism (Sigurdson, 2000).

The Barbara Schneider Foundation was born out of a tragedy that occurred on June 12, 2000. Local police, called in on a noise complaint, shot Barbara Schneider to death in her own home. Six police officers entered her Minneapolis apartment when she was having a mental health crisis. The police were untrained to deal with this call as a health care intervention and rather than de-escalating the crisis they confronted her with force. She had a deadly weapon and she did not back down, as is not uncommon with individuals in mental health crisis.

The mental health community responded by building a long term dialogue with law enforcement and they partnered to prevent such tragedies from re-occurring. In fact the crisis of Barbara Schneider’s death has lead to training in for those responding to individuals in crisis for police, jailers, paramedics, nurses, mental health professionals and social service providers by Barbara Schneider Foundation and their partners in the community. There is a growing awareness of the need to improve our response to mental illness and to build collaborations across all the institutions that respond to those at risk for mental health crisis. This growing consumer lead movement is challenging all the systems in health care and criminal justice to make urgently needed changes. It is this growing voice of those who themselves struggle with a mental illness that provides hope that fairness for those with mental illness can prevail over the forces of ignorance, denial, discrimination, greed and stigma.

By Rubén Rosario, St Paul Pioneer Press

I spent a few drama-filled hours in jail last week. A sobbing, suicidal inmate named “Christine” barricaded herself in her cell and refused to come out. Another inmate named “Mandy” did likewise in another cell on the same floor; she requested medical care as she showered jail officers with the kind of crude and sexually tinged language that would make even a street pimp blush. And four floors below in the basement, where the old-but-still-functioning jail operates under the arguably more stately and civil Minneapolis City Hall, a clearly agitated inmate named “Michael” held a physician hostage in a locked room.

“I’m not going to hurt him. I just need new medication,” the hostage taker bellowed to a sweaty-palmed-but-composed jail negotiator on the other side of the locked door. Luckily, this was all theater. The inmates were local professional actors taking part in the role-playing portion of a four-day crisis-intervention team (CIT) training session put on by the Barbara Schneider Foundation. The Twin Cities-based nonprofit is named after a mentally ill woman fatally shot by Minneapolis police during a standoff in her apartment in June 2000. But the best art, in my view, imitates raw reality. In recent decades, America’s jails and prisons have become the largest psychiatric hospitals and the repositories of last resort for mentally ill offenders. Mental illness is a brain disorder and not a crime, but we have chosen, largely because of ignorance and short-term convenience, to arrest and incarcerate this social problem.

According to studies and national statistics, about one of every four inmates in U.S. jails and prisons suffers from a mental illness. The breakdown is roughly the same with Minnesota’s jail and prison populations. Corrections officials struggle to deal with mentally ill inmates amid escalating medical costs and dwindling budgets. Meanwhile, on the streets and inside homes, too many confrontations end up like Schneider’s.

In 1998, just two years earlier, Americans with severe mental disorders were shot and killed by police at a rate nearly four times as great as that of the general population. The fear of harm, from a public-safety and officer-safety point of view, may have been justified: That same year, mentally ill Americans killed law enforcement officers at a rate 5.5 times higher than the general population did. National crisis? No doubt. But what to do?

CHANGING TACTICS

The response in places like Minnesota has been: Raise awareness. Change the mind-set. Cut through the entrenched cultural stigma about the mentally ill without sacrificing officer safety. Embrace de-escalation techniques while toning down the traditional law-and-order use-of-force continuum with this population. Is it working?

Hennepin County Sheriff’s Lt. Randy Carroll, an 18-year veteran and training-session coordinator, says use-of-force incidents — in which officers physically subdue or restrain inmates — have plunged 40 percent in the county jail in the two years since the training was introduced. The jail books nearly 43,000 people annually, by far the most in the state.

About 70 percent of those inmates are repeat offenders, and a “good percentage of them are mentally ill to some degree,” said Hennepin County Sheriff Rich Stanek, the former Minneapolis cop and state legislator who was elected sheriff two years ago.

“We can either serve as just a warehouse or try to do something far more innovative that addresses the root cause of the problem,” said Stanek, adding that the jail has added facilities to house and care for such inmates. “This is absolutely all about de-escalation,” Stanek said. “We are in a place where, to the inmate, there really is no place to run to or go. So there really shouldn’t be a reason, other than an officer-safety or hostage crisis, where we need to use force to solve an issue.”

SPREADING THE WORD

The participants in last week’s training included jail officers from metro and outstate counties. Dave Isais, a Sherburne County jail captain and nearly nine-year veteran, was thrown into the unfolding hostage simulation.

“I’m sure the doctor is pretty scared right now,” Isais told inmate “Michael.” “I know you didn’t mean to do anything,” he added. “Could you let him come over here so we can talk about medication that could help you? Would you be willing to come with me to another room?”

Isais, who shook hands with me and apologized because his was moist from the role-playing encounter, got high marks from Josh Fulwider, a CIT-trained Hennepin County deputy. “The thing I want to stress to you is that in this type of action, there are no limits to what you can say,” Fulwider told him during a break.

“You can say whatever,” Fulwider added. “If it’s something that’s from the training that you received or something you saw in the news, you can use it. Use it to let them understand that you are paying attention and that you care about people.”

In an earlier scenario, Mark Anderson, executive director of the Barbara Schneider Foundation, underscored the hesitancy and fear that jail personnel have about bringing up the issue of mental illness during such incidents. “You are not the first person that has ever asked them this,” Anderson counseled one group. “They are used to talking about it.”

Moments earlier, before Isais was thrust into the mock hostage crisis, a veteran Washington County correctional officer gently tried to coax inmate “Christine” out of a barricaded holding cell. It could have easily been done with force. Roosevelt Collins instead applied verbal judo dripping with empathy and concern.

“You went from ‘(Expletive) you’ to ‘My name is Christine’ to getting her to open up and reveal stuff to you,” said Chris Mays, a CIT-trained Hennepin County deputy monitoring the role-playing segment. “I think you did a really good job. If you had another 20 minutes, I think you would have gotten her.”

“I learned a lot,” Collins told me and others during a break. So did I.

Rubén Rosario can be reached at rrosario@pioneerpress.com or 651-228-5454.

By Rubén Rosario, St Paul Pioneer Press

There is a ton of bad as well as good public servant stories out there. This is one of the really good ones.

Ramsey County Sheriff’s Deputy Mike Casey briefly considered following the routine when 15-year-old Jani Ray of Shoreview was reported as a runaway: Question the parents or legal caretakers. Jot down the basics. File the report. Resume patrol.

Instead, he took the time on an early spring day this year to read a computerized field note, known as an “FI,” that informed him about the runaway youth’s bipolar disorder, depression and other mental afflictions.

It confirmed his gut instinct. Routine just would not do this night.

He found her MySpace account. In it, he read disturbing writings — words that hinted at thoughts of suicide. He combed through her cluttered bedroom with her mother’s permission and found journals her mother never knew existed, journals that expressed similar, dark thoughts.

He spent much of that unusually slow Saturday night looking for her.

On Wednesday, Casey and Jani Ray saw each other for the first time since the runaway episode. Along with her mother, Nancy Ray, the youth presented Casey with a St. Michael the Archangel medallion. St. Michael is the patron saint of cops.

“I would like to see him in person and would love to thank him face to face,” Jani Ray told me a few days before the reunion. “If he wouldn’t have come and got me that night, I don’t even think that I would be alive right now. I owe him my life.” A recap is in order.

Nancy Ray, who works as a financial officer for Ramsey County’s Human Services Department, approached Ramsey County Sheriff’s Deputy Sgt. Kent Mueller, who works in the same government building in downtown St. Paul.

Ray’s daughter was refusing to take her medication, she told the deputy. She was abusing drugs and alcohol. Ray feared the girl would likely run away again. She wondered if there was anything proactive she could do to alert authorities in the event Jani ran away or had a run-in with the law.

Mueller, trained in crisis intervention, serves on the board of the Barbara Schneider Foundation. The nonprofit is named after a Minneapolis woman who was fatally shot by police during a confrontation in her home in 2000. Although two officers were cleared of criminal wrongdoing in the shooting, Minneapolis established a special police crisis unit to respond to calls involving people with mental illness. The group trains first responders, from cops and emergency room staff to homeless and school officials, on how to de-escalate and deal with a mental-health crisis. It had just conducted a three-hour seminar for all Ramsey County sworn personnel.

Mueller suggested writing up a field note with information on Jani Ray’s condition and state of mind. As predicted, Jani Ray ran away several days later.

“It was an option for me,” Ray said now of her writings about suicide. “I truly felt alone. I felt like I had no one. I was willing to go the full hundred yards and end my life because I was very unhappy.”

GETTING HELP

When Casey responded to the runaway call, Nancy Ray suggested he look up the field note on her daughter. Casey pulled it up in his squad car’s computer. He tapped into Jani Ray’s MySpace account and then went back into the home, where he found the journals and a list of cell phone numbers for several of the runaway teen’s friends. He spent roughly two hours calling numbers, pretending to be “Mike,” a friend. He learned that Jani Ray was expected to show up that night at a backyard house party in Shoreview. The girl having the party was a friend of Jani Ray, and she and her father agreed to help lure Ray to the home. When the runaway teen arrived, Casey and a female officer approached her. Playing tough cop at first, he grabbed her arm and told her she was coming with him. “She was very subdued, but she was in a dazed state,” Casey said.

“I’m not going to arrest you. I’m going to take you home. We’re going to get you some help,” he remembered telling the teenager as she sat in the back seat of his car.

Jani Ray’s admission that she had not taken her medication gave Casey the authority to take the teen to a medical facility and place a 72-hour hold on her. But he allowed Nancy Ray as the parent to do that. Jani Ray attended two intensive-treatment facilities from late spring until late August, when she was released in time for the start of classes at Mounds View High School. She confided to schoolmates for the first time about her situation.

“I was completely honest with them, and my peers have been unbelievably supportive of me,” Ray told me during our chat inside the apartment she shares with her mother. “They want for me to be with them, to have a normal high school experience like them.”

GOAL: SHARING INFO

Mueller believes field notes — which are not incident or full-fledged police reports — could be used by the law enforcement community to store critical information provided by relatives or others about the mental state or condition of someone they might come into contact with on the streets. Mental disorders are the leading cause of disability in the U.S. for persons ages 15 to 44, according to the National Institute for Mental health. Roughly one out of four Americans age 18 or older — close to 58 million people — suffers from a diagnosable mental illness in any given year.

“Knowledge is power,” said Mueller, who is in the preliminary stages of finding out whether area police agencies are willing to share such information. Right now, Mueller said, such field notes cannot be shared because of different and incompatible police data computer systems.

Mueller envisions the day when every police agency in the state, if not the country, shares field notes. But the reality is that few police agencies have compatible computer systems to tap and view such data right now. Casey, meanwhile, had no clue about the impact he had that night until I gave him a jingle.

“Wow,” he said. “It sounds cheesy, but I just simply wanted to find her and get her home, just for mom’s sake.” Jani Ray is willing to share her struggles publicly to help lift the stigma of mental illness among youths as well as hopefully to encourage troubled teens to seek help.

“I understand now that I was not alone, that there are caring people out there, my mother and others, who love and support me and that I can go talk to,”” Jani Ray said. “I needed to let this officer know just how much he means to me. There is not a day that goes by that I don’t think about what he did.”

“She can count on me if she ever needs to talk to someone,” Casey said. The guardian angel medallion sounds like an appropriate gift after all.