crisis intervention team officer dispatch, assessment, and disposition: interactions with...

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Crisis intervention team officer dispatch, assessment, and disposition: Interactionswith individuals with severe mental illness

Christian Ritter a, Jennifer L.S. Teller a,⁎, Kristen Marcussen b, Mark R. Munetz a, Brent Teasdale c

a Northeastern Ohio Universities Colleges of Medicine and Pharmacy, United Statesb Kent State University, United Statesc Georgia State University, United States

a b s t r a c ta r t i c l e i n f o

Available online 7 December 2010

Keywords:CIT modelMental illness crisisOfficers' assessmentsCalls for assistanceDispositions

The Crisis Intervention Team (CIT) model is a specialized police response program for people in a mentalillness crisis. We analyzed 2174 CIT officers' reports from one community, whichwere completed during a fiveyear period. These officers' reports described interactions with people presumed to be in a mental illnesscrisis. We used hierarchical logistic andmultinomial regression analyses to compare transport to treatment toeither transport to jail or no transport by how the calls were dispatched. The results revealed that bothdispatch codes and officers' on-scene assessments influenced transport decisions. Specifically, callsdispatched as suspected suicide were more likely to be transported to treatment than calls dispatched asmental disturbance. Furthermore, calls dispatched as calls for assistance, disturbance, suspicious person,assault, suspicion of a crime, and to meet a citizen were all less likely thanmental disturbance calls to result intransportation to treatment. Officer assessments of the use of substances, being off medications, signs andsymptoms of mental or physical illness, and violence to self or others were associated with the likelihood ofbeing transported to treatment. These results build on previous work that demonstrated differences intransport decisions between CIT trained and non-CIT trained officers.

© 2010 Elsevier Ltd. All rights reserved.

Deinstitutionalization has resulted in a dramatic shift in the locusof care of people with serious mental illness (Grob, 1991, 1994;Mechanic, 1986). While this shift has created opportunities for manypeople with mental disorders to live successfully in our communities,it has also created serious challenges including poverty, unemploy-ment and under-employment, homelessness, and criminal victimiza-tion (Dowdall, 1999; Morrissey, 1999; Urbanoski, Cairney, Adlaf, &Rush, 2007). Additionally, many individuals are at increased risk forsubstance abuse and dependence (Abram & Teplin, 1991; Kessler &Zhao, 1999; Morse et al., 2006; Steadman & Naples, 2005). Thesefactors, as well as difficulty accessing treatment services in afragmented mental health service system (President's New FreedomCommission on Mental Health, 2003), increase the risk of arrests andincarcerations for individuals with serious and persistent mentaldisorders. This phenomenon, often referred to as the criminalizationof the mentally ill, is a national problem (Hiday, 1991, 1999; Munetz,Grande, & Chambers, 2001; Teplin, Abram, McClelland, Dulcan, &Mericle, 2002; Teplin & Pruett, 1992; Torrey et al., 1992).

Police officers are often the first to respond to individuals in amental illness crisis (Lamb & Weinberger, 2001). As such, specialized

programs to assist officers in resolving such crises safely have beenintroduced in an effort to de-criminalize mental illness (Munetz &Griffin, 2006). In this paper, we discuss factors that may influencepolice interactions with people in mental illness crises, focusing on apolice-based mental health response, the Crisis Intervention Team(CIT) model. Specifically, we examine CIT officers' assessments thatare associated with decisions to transport individuals to treatment,rather than transporting them to jail or resolving the encounterinformally (e.g., advising, recommending treatment options, orleaving the individual at the scene). Our purpose is to explore themanner in which officers apply their training in the field (Compton,Bahora, Watson, & Oliva, 2008), and more specifically examine thefactors that might help explain why CIT officers are more likely thannon-CIT trained officers to transport individuals to treatment (Teller,Munetz, Gil, & Ritter, 2006).

1. Officer decision making

Officers have three optionswhen deciding how to handle a call: theycan transport the person to treatment, transport the person to jail, orresolve the situation informally and leave the person at the scene(Green, 1997; Hails & Borum, 2003; Lamb,Weinberger, & DeCuir, 2002;Patch & Arrigo, 1999; Teplin, 2000; Watson, Morabito, Draine, & Ottati,2008). In order to make these decisions, officers must assess thecircumstances of the call (Lamb et al., 2002; Morabito, 2007; Teplin,

International Journal of Law and Psychiatry 34 (2011) 30–38

⁎ Corresponding author. Department of Behavioral and Community Health Sciences,Northeastern Ohio Universities Colleges of Medicine and Pharmacy, 4209 State Route44, Rootstown, OH 44272, United States. Tel.: +1 330 325 6181; fax: +1 330 325 5907.

E-mail address: [email protected] (J.L.S. Teller).

0160-2527/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.ijlp.2010.11.005

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry


1986, 2000). When the interaction involves people in a mental illnesscrisis, officers' assessments of the situation include such factors aswhether the individual exhibited signs of violence, if the individual wastaking prescribed medication, or if the individual had signs andsymptoms of mental illness or substance use (Finn & Stalans, 2002;Lawton, 2007; Skeem & Bibeau, 2008; White, Goldkamp, & Campbell,2006). After making an initial assessment, an officer's decision abouthow to proceed is contingent on the availability of treatment services inthe community and the degree of knowledge that the officer possessesabout options within the mental health treatment system (Bittner,1967; Green, 1997; Henriques, 2002; Morabito, 2007; Patch & Arrigo,1999; Teplin & Pruett, 1992). Officers' assessments may also beinfluenced by the demeanor of the citizen in question, the officer'sown personal characteristics, and the type of offense. In general, there ismore discretion for misdemeanor offenses than for felony offenses.

2. Police training for encounters with individuals in a mentalillness crisis

Given that officers' responses are influenced by the assessmentsthey make during an encounter with individuals in a mental illnesscrisis, a specialized police-based program that is designed specificallyto respond to these individuals should result in improved and moreappropriate outcomes (Hails & Borum, 2003; Lamb et al., 2002; Skeem& Bibeau, 2008; Teplin, 1986;Wells & Schafer, 2006). The CIT programprovides intensive training about mental illness and the local systemof care to volunteer patrol officers who then are available to respondto mental disturbance calls at all times. From the perspective of thepolice and the local mental health system, the decision to transport anindividual in a mental health crisis to treatment is preferable totransporting the individual to jail or leaving the person at the scene.

2.1. A specialized program for police response to mental illness crises

The CITmodel, which began inMemphis in 1988 (Cochran, Deane, &Borum, 2000), represents a partnership between local law enforcementagencies, the public mental health system, and consumers of mentalhealth services and their family members. The goals of the CIT programinclude increasing safety for officers, citizens, and the overall commu-nity by better preparing officers to handle crises involving personswithmental illness (Vermette, Pinals, & Appelbaum, 2005; Watson et al.,2008). An additional goal is to make the mental health system moreunderstandable and more responsive to law enforcement in order tofacilitate referral of individuals in need of treatment (Steadman, Deane,Borum, & Morrissey, 2000). Indeed, studies that have examined CITprograms suggest that trained officers report increased knowledge ofservices available in the community and more comfort interacting withindividuals experiencing a mental illness crisis (Wells & Schafer, 2006),decreased social distance (Compton, Esterberg, McGee, Kotwicki, &Olivia, 2006; Ritter, Teller, Munetz, & Gil, 2005), and more confidenceconcerning how to appropriately deal with calls (Bahora, Hanafi, Chien,& Compton, 2008).

CIT programshave been spreadingnationally,with trainedofficers inmore than 325 law enforcement agencies, including 51 sheriffdepartments and 43 college/university safety forces in Ohio alone(Woody, 2009). Despite the growth of CIT, there are still relatively fewstudies examining the specific components of these programs and howthey might influence outcomes (Compton et al., 2008; Watson et al.,2008). In addition to examining officers' overall perceptions of the CITprogram, as some studies have done, it is important to examine officers'assessments at the scene and the relationship between those assess-ments and the decisions they make when dealing with calls involvingpotential mental illness. Our study contributes to the literature on thistopic.

2.2. Description of the study site of the CIT program

The site of the study was Akron (Summit County) Ohio. The publicmental health system in Akron has attempted to systematicallyaddress the needs of individuals with serious and persistent mentaldisorders in order to minimize inappropriate incarceration (AmericanPsychiatric Association, 2003). As part of these efforts, the AkronPolice Department CIT program began May 2000 (Munetz, Morrison,Krake, Young, & Woody, 2006) and is based on the Memphis CITmodel. At the time of this study, all certified Ohio officers hadcompleted 3 h of training on handling the special needs of thepopulation and 6 h of training in crisis intervention (Ohio PoliceOfficer Training Commission, 2003).1 The CIT program in Akron addsan additional 40 h of training that relates specifically to the needs of,appropriate police responses to, and community resources availableto this population. All officers are volunteers and are screened by theCIT Coordinator to determine their selection into this specializedtraining. The main selection criteria for the program include strongcommunication skills, motivation to improve knowledge aboutmental illness, and willingness to be the primary responder to mentalillness emergencies.

After acceptance to the program, each officer participates in a 40 h,week-long training on mental health and mental illness, including athorough overview of the local mental health system. Officers alsoreceive extensive training in verbal de-escalation skills and engage inrole playing exercises to practice these skills in simulated crises(Teller et al., 2006). As of June 2005, 76 of 355 (21%) patrol officerswere CIT trained, with an additional 16 officers CIT trained but in non-patrol positions (Akron Police Department, 2004).

There are two types of records that document the CIT program inAkron. The first is the computerized dispatch log. CIT officers areidentified to the call dispatchers through the duty roster. When a callis made to the police department, dispatchers assign a code reflectingtheir evaluation of the call (e.g., mental disturbance call, potentialsuicide, fight, drunk, or traffic accident). Once the officers arrive on thescene, they determine the disposition of the call to best serve theneeds of the individual in crisis and of the community. When calls forservice are evaluated as a mental disturbance call and/or potentialsuicide call, the protocol requires dispatchers to send available CITofficer(s).

The second type of record is a report, completed by CIT officers,detailing their encounter with a person suspected of mental illness.These reports typically include the citizen's demographic information,how the call was dispatched, techniques used by the officer, and anarrative describing the call. The reports are generated regardless ofhow the dispatcher evaluated the call and function, in part, to alert themental health system to people who may be in need of attention.Therefore, these reports also include calls that were not dispatched asmental disturbance or potential suicide calls.

3. Current study

In previous research, Teller and colleagues (2006) examined theAkron Police Department's computerized dispatch system to studythe effectiveness of the CIT program. Results of this study indicatedthat, in comparison to non-CIT officers, CIT officers weremore likely totransport individuals with suspected mental illness to treatment. Thecurrent study extends this research to examine the relationshipbetween dispatch code and transport decisions based on analysis ofCIT officers' documentation of encounters that they believed involvedindividuals in a mental illness crisis. Specifically, we were interestedin the relationship between dispatch codes, CIT officers' assessments,

1 In order to be certified in Ohio, officer training on handling the special needspopulation increased to 16 h in 2006 (Michael Woody, personal communication,September 2008).

31C. Ritter et al. / International Journal of Law and Psychiatry 34 (2011) 30–38


and dispositions. In this study we addressed three research questions:(1) is there a relationship between dispatch code and disposition, (2)is there a relationship between CIT officers' assessments anddispositions, and (3) do CIT officers' assessments help account for(or mediate) the relationship between dispatch codes anddisposition?

3.1. Method

Research committees of Summit County Alcohol, Drug Addiction,and Mental Health Services Board, Akron Police Department, KentState University, and Northeastern Ohio Universities Colleges ofMedicine and Pharmacy Institutional Review Boards (IRB) approvedthe research. All research team members successfully completed theNational Institutes of Health “Human Participant Protections Educa-tion for Research Teams.” Due to IRB restrictions the data were limitedto examining those interactions involving people at least 18 years old.

3.2. Participants and sample

The data for this study came from CIT officers' reports of callsinvolving someone they believed had a mental illness. Each reportincluded demographic characteristics of the person in question, thedispatch code, the action officers took, and a narrative about theinteraction. All identifying information concerning the individual wasremoved prior to the research team's analysis of the reports.2 For theperiod June 2000 to May 2005 (60 months), 84 CIT officers submitted2508 reports for incidents involving people aged 18 or older.

The CIT reports were completed in the first five years of the CITprogram. The CIT-trained officers studied in the previous research(Teller et al., 2006) were the majority of the officers studied in thisresearch, as the time periods overlap. We extended the previousresearch to include those calls evaluated in person by the CIT-trainedofficers (instead of by the dispatchers over the phone) as involvingpeople in a mental illness crisis. This allowed us to further explorewhat factors influenced CIT officers to transport individuals totreatment. As completing the reports was voluntary, officers mayhave neglected to document an encounter they had with a potentiallymentally ill individual. However, because trained officers tend to bestrong advocates of the CIT program, we have a reason to believe thatcompliance in documenting encounters was high.

CIT officers provided their assessment of the encounter in anarrative form. Up to four officers were listed on each report;however, the officer listed first on the report provided the narrative.The research team developed an initial coding scheme for thenarratives that included (1) whether the officer believed the personhad been drinking or was on drugs, (2) if the officer thought theperson was off prescribed medications, and (3) officers' observationsas to whether the person was violent to self or to others. In addition tothese three variables, two additional emerged upon further exami-nation of the narratives: (4) the presence of psychotic symptoms and(5) concerns about physical health.

Trained data enterers evaluated the narratives and coded theofficers' assessments of the encounter. Each data enterer was givenstandardized instructions and trained in a one on one session with asenior research team member. Thirty randomly selected codednarratives were examined to assess inter-rater reliability. There wasgreater than 99% agreement on the first three variables across all dataenterers. We coded the last two variables in a similar manner to theinitial coding, with an additional step of independent double codingby three coders. The trained coders each coded two-thirds of thenarratives and were then paired on a third of the packets with one

coder and on another third of the packets with the second coder. Wetabulated differences between coders and three senior teammembersresolved all disagreements by reviewing the narratives where therewere discrepant results. We measured the percentage agreement andcalculated Cohen's kappa, which measures the agreement betweentwo coders rating the same object. For ‘manifestation of psychoticsymptoms,’ the inter-coder agreement was 90.5% (Cohen's kappa.730). Inter-coder agreement for the variable ‘physical healthconcerns’ was 90.0% (Cohen's kappa .560).3

3.3. Measures

The dependent variable for these analyses was the disposition ofthe call. Officers reported four types of decisions: transport totreatment, transport to jail, no transport, or some other type ofdecision (e.g., transport to a family member's home or a homelessshelter).

We examined three types of independent variables: dispatchcodes, officers' assessments, and controls. Dispatch codes were listedin the reports and ranged from minor offenses (such as traffic stop ornon-emergency request for backup) to more serious offenses (such asrape or robbery). We combined the 43 dispatch codes into eightcategories. When classifying the dispatch codes, we made everyattempt to keep most of the codes distinct, and combined theremaining, less frequently occurring, codes in conceptually meaning-ful and distinct categories. The resultant categories were: suspectedmental illness, suspected suicide, assault, meet a citizen, calls forassistance, suspicious person, and suspicion of crime. These categorieswere largely consistent with those suggested by the Akron PoliceDepartment. Only four codes, involving 44 cases, did not fall into oneof these categories. Of these uncategorized cases, 16 cases were trafficrelated and 25 cases were dispatched as an unknown call. Thereforewe eliminated these cases from the sample. See Appendix A for alisting of codes in each of the categories.

Based on the coding scheme briefly described in Section 3.2, weevaluated four categories of officers' assessments: substance use, offprescribed medications, violence, and signs and symptoms. Substanceuse indicated the use of alcohol and/or drugs, including abused butlegally prescribed drugs, and that the officer believed that this usecontributed to the circumstances of the interaction. The officers'assessment that the person was off prescribed medications and thatthis contributed to the interaction was also noted. The third categorywas violence to self or violence to others.

Signs and symptoms were manifestations of pathological condi-tions observed by the officer, represented by two independentvariables: psychotic symptoms and physical health concerns. Mani-festation of psychotic symptoms was coded when the officer notedhallucinations and/or delusions in those specific words, or when itcould be inferred from the narrative that this was what the officer wasobserving (e.g., the person called because she thought others weremoving furniture around, but officers noted they did not find any suchindications of furniture movement or the person complained of a gasleak, but there was no evidence of one). Physical health concernsreferred to aspects of daily living (such as not bathing, eating, ordrinking), confusion of the person (e.g., disorientation in time orspace), or physical signs of other health concerns (i.e., bruising,bleeding). It should be noted that, because officers were not requiredto list all factors, this represented a conservative estimate of officers'assessments that may have influenced the interaction.

2 To determine if the team had all copies of the reports, selected senior members ofthe team confirmed our records/data (including original dispatch codes) with theAkron Police Department database of the encounters.

3 As the sample is large (n=2508) and the proportion of agreement is high, kappacan sometimes be low despite the high agreement because of departures fromsymmetry in the marginal distributions (Cicchetti & Feinstein, 1990; Feinstein &Cicchetti, 1990). As low reliability contributes to error and thus inhibits the ability tofind significant effects, any resulting significant effects are likely robust.

32 C. Ritter et al. / International Journal of Law and Psychiatry 34 (2011) 30–38


3.4. Analysis

WeusedSPSS 15 for thedescriptive analyses. Because the dependentvariables were categorical, we used logistic and multinomial logisticregressions to assess the relationships between dispatch codes, officers'assessments, and dispositions. The nested nature of the data (havingmultiple incidents per officer) introduced the possibility of correlatedresiduals in a single level model. In order to take into account thepossibility of dependence (correlated residuals), we estimated multi-level logistic andmultinomial logistic regressionmodels using Bryk andRaudenbush's HLM (version 6.06) program (Bryk &Raudenbush, 1992).Therewere individualswhohadmultiple encounters in thedatabase. Aswewere examining how officers' assessmentswere associatedwith theinteraction, we nested incidents within officers and included a dummyvariable to control for individuals with multiple police contacts.

We did not include in the analysis individuals who were notuniquely identified (n=101) or reports withmissing data (reports thatlacked individuals' race, gender, or age (n=109), reports thathadeither“other” transport location (n=53) or “other” dispatch codes (n=50),and reports that lacked either the officer ID, call code, or narrative(n=21)). The final sample size for these analyses was 2174 reports.

All dispatch codes were used in the hierarchical binomial logisticregression analyses comparing transport to treatment to no transport.The dispatch code of suspected mental illness was the comparisoncategory. Transport to treatmentwas, as discussed previously, a desiredoutcome for both CIT officers and the local mental health system andwas used as the comparison category for the disposition decision.

We assessed the distribution of dispositions by dispatch code. Sincethere were only three dispatch codes with a reasonable likelihood ofarrest (assaults, suspicion of crime and suspicious person), we used thesedispatch codes in the multinomial analyses examining transport totreatment, no transport, and transport to jail. In the hierarchicalmultinomial regression, we compared calls dispatched for assaults andsuspected crimes to calls dispatched for suspicious persons (the referencecategory).

4. Results

The citizens represented in the sample were 55% male and 65%white, with an average age of 38.5±14.0 years (range 18–94). Therewere 1663 unique individuals in the sample; the average number ofreports per person was 1.31±.864 reports per person (range 1–9).The reports did not include officer descriptors.4 Eighty-two officers5

described the encounters and the average number of reports writtenper officer was 26.5±24.1 (range 1–97).

Table 1 lists the distribution of the dispositions of the calls. Officerstransported individuals to treatment most often (1690 or 77.7%),followed by no transport (366 or 16.8%). Table 1 also shows thedistribution of the calls by dispatch code, that is, how the dispatchersevaluated the callers' problems.6 As mentioned above, the sampleconsists of CIT officers' reports of calls involving someone theybelieved had a mental illness. The majority of the calls weredispatched as one of two categories of mental disturbance calls;dispatchers labeled the calls as involving suspected mental illness(848 or 39.0%) and suspected suicide (474 or 26.8%), as shown in thelast column of Table 1. The least frequent dispatch category wassuspicion of a crime (80 or 3.7%). In Table 2 we present thedistribution of officers' assessments. As shown, no assessment wasmade in about 32% of the narratives. For those in which an assessmentwas mentioned, officers reported psychotic symptoms most frequently(523 or 24.1%) and physical health concerns least frequently (283or 13.0%).

Table 3 presents the results of the hierarchical binomial logisticregression. Model 1 presents the results for the first research questionconcerning the relationship between dispatch code and disposition.Model 2 portrays the second research question concerning therelationship between officers' assessments and disposition. Table 4presents the results of the hierarchical multinomial logistic regres-sion. Models 1 and 2 examine the likelihood of transport to treatmentversus no transport and models 3 and 4 examine the likelihood oftransport to treatment versus transport to jail. Models 1 and 3 presentthe results for the first research question and models 2 and 4 presentthe results for the second research question. Note that althoughpresented in separate columns, the results for Models 1 and 3 wereestimated simultaneously, as were the results for models 2 and 4.

4.1. Hierarchical binomial logistic regression results

The results shown in Table 3 included all categories of officers'assessments. Model 1 indicated that, in comparison to those calls thatwere dispatched as suspected mental illness, calls that weredispatched for suspected suicides were more likely and the othercodeswere less likely to result in transport to treatment than not to betransported. Our first research question concerning the existence of arelationship between dispatch code and disposition was answeredaffirmatively.

Table 1Distribution of disposition by dispatch codes (n=2174).

Notransport

Transport totreatment

Transportto jail

Total

f row % f row % f row % f column %

Suspected mentalillness

135 15.9 687 81.0 26 3.1 848 39.0

Suspected suicide 25 4.3 550 94.3 8 1.4 583 26.8Assault 53 19.6 168 62.0 50 18.5 271 12.5Meet a citizen 66 45.2 76 52.1 4 2.7 146 6.7Calls for assistance 32 24.4 91 69.5 8 6.1 131 6.0Suspicious person 29 25.2 73 63.5 13 11.3 115 5.3Suspicion of crime 26 32.5 45 56.3 9 11.3 80 3.7Total 366 16.8 1690 77.7 118 5.4 2174 100.0

4 In another facet of our research, we administered a questionnaire at all initialtraining sessions to Akron officers in 2000, 2001, 2002, and 2003 (n=70). There, wedid collect demographic data. Most (85.7%) of the CIT-trained officers were male.Almost 83% of the officers were white, with an average age 32.7±6.4, range 25 to 61.The average number of years as a police officer at the time the surveys wereadministered was 5.9±4.8, range 1 to 31 years.

5 Two officers' reports lacked information on the individuals in the encounter andwere therefore not included in these analyses.

6 Officers, on the other hand, evaluated all the calls as involving someone with amental illness and therefore completed the reports documenting the encounter.

Table 2Distribution of officer assessments reported in narratives (n=2174).

Officer assessments Frequency %

No assessment noted 694 31.9Assessment noted 1480 68.1

The assessments notedSubstance use

Alcohol suspected 298 13.7Drugs suspected 279 12.8

Off medications 402 18.5Violence

Violence to self 382 17.6Violence to others 274 12.6

Signs and symptomsPsychotic symptoms 523 24.1Physical health concerns 283 13.0

Assessments are not mutually exclusive. They therefore do total more than 100%. Theseassessments are treated as independent variables in subsequent analyses.



Model 2 of Table 3 indicated that, in comparison to calls dispatchedas suspected mental illness, the relationship between how a call wasdispatched and the likelihood of transport location remained the sameas in Model 1. Suspicions of alcohol, drugs, or being off prescribedmedications multiplied almost two-fold the odds of transport totreatment (OR=1.84, 1.74, and 1.871). Violence to self multiplied theodds of transport to treatmentmore than ten-fold (OR=14.99), whileviolence to others multiplied the odds of transport to treatment incomparison to no transport a little more than 3.35 times. Officers'observations that individuals had physical health concerns more thandoubled the odds of transport to treatment. This finding providessupport for our second research question concerning the effects ofofficer assessments.

When we compared dispatch code coefficients of Models 1 and 2,we noted that the relationships between dispatch code anddisposition remained essentially the same. When including officers'assessments in themodel, the odds of transport to treatment inModel2 relative to Model 1 decreased for all but one of the dispatch codes.Consequently, the relationship between dispatch code and disposi-tion, while remaining significantly different when compared tosuspected mental illness calls, became more similar in transport totreatment by including CIT officers' assessments of the situation in themodel. However when we tested for mediation we did not findevidence for it. Therefore, with regard to the third research questionabout the influence of officers' assessments on the relationshipbetween dispatch code and disposition, we find little evidence.

4.2. Hierarchical multinomial logistic regression results

The hierarchical multinomial regression examined three dispatchcodes, (assault and suspicion of crime compared to suspicious person).InModels 1 and 2, Table 4,we contrasted the dispositions of transport totreatment versus no transport. Model 1 examined the relationshipbetween dispatch codes and disposition and showed that, in compar-

ison to those calls dispatched as suspicious person, calls dispatched forassaults and suspicion of crime were not significantly different fromcalls dispatched as suspicious person. Model 2 included all officers'assessments of the encounter. Violence to self, violence to others, beingsuspected of alcohol use, physical health concerns, and suspicions ofbeing off medications increased the odds (13.533, 3.189, 2.694, 2.213,and 2.101, respectively) of transport to treatment compared to notransport. In both models, women were less likely to be transported totreatment in favor of leaving on the scene than were men. In sum, theresults of the multinomial regression indicated that CIT officers'assessments were associated with the disposition of calls. Officers'assessments that individuals were violent to self and others, hadphysical health concerns, were using alcohol, or were off medicationsincreased the odds of transport to treatment in comparison to notransport.

In the secondmultinomial regression comparison (Models 3 and 4,Table 4), we contrasted the dispositions of transport to treatmentversus transport to jail. Model 1 examined the relationship betweendispatch codes and disposition and showed that, in comparison tothose calls dispatched as suspicious person, calls dispatched for otherreasons (assaults, suspicion of a crime) were no different in transportlocation.

Model 2 included all officers' assessments of the encounter. InModel 2, violence towards others and suspicions of drug usesignificantly decreased transportation to treatment (compared withtransportation to jail). Consistent with Model 1, the dispatch codeswere not significantly different from one another on the transportdecision. In bothmodels, we found that womenweremore likely to betransported to treatment than to jail.

4.3. Variation due to officers

When we estimated a null model in HLM (v. 6.06), each of therandom intercepts (one for each of the comparison categories in the

Table 3Coefficients from the hierarchical logistic regression of selected independent variables on disposition (n=2056).

Likelihood transport to treatment versus no transport

Model 1 Model 2

b SE Odds ratio C.I. b SE Odds ratio C.I.

DemographicsAge (in years) −.017*** .005 .983 .974 .992 −.015** .005 .985 .977 .994Gender (1=female) −.157 .110 .855 .690 1.060 −.130 .116 .877 .699 1.102Race (1=black) −.202 .127 .817 .637 1.048 −.174 .128 .840 .653 1.080More than one report −.017 .152 .983 .729 1.325 −.062 .151 .940 .699 1.264

Dispatch codea

Suspected suicide 1.308*** .211 3.699 2.447 5.592 1.190*** .203 3.286 2.207 4.893Calls for assistance −.513* .248 .599 .368 .973 −.602* .236 .548 .345 .870Suspicious person −.700** .257 .496 .300 .822 −.740** .271 .477 .281 .812Assault −.493** .173 .611 .435 .858 −.513** .167 .599 .431 .831Meet a citizen −1.376*** .181 .253 .177 .360 −1.263*** .194 .282 .194 .413Suspicion of crime −.920*** .260 .399 .239 .664 −1.094*** .274 .335 .196 .573

Officer assessmentsSubstance use

Alcohol suspected .607** .235 1.835 1.158 2.908Drugs suspected .554* .255 1.740 1.056 2.867

Off medications .626** .223 1.871 1.209 2.894Violence

Violent to self 2.661*** .485 14.305 5.533 36.983Violent to others 1.209*** .259 3.351 2.016 5.568

Signs and symptomsPsychotic symptoms .309 .176 1.362 .965 1.922Physical health concerns .752*** .207 2.121 1.413 3.184

Intercept 2.570*** 1.835***μ0 .537 .555

*p≤ .05; **p≤ .01; and ***p≤ .001. aDispatch code reference category: suspected mental illness.



multinomial equation) was significant (data not shown), indicatingthat there was shared error variance across incidents within an officeron the outcome of interest (decision to transport). Because hierar-chical logistic and multinomial logistic regression models do notprovide estimates for r (the individual level variance of the officers), itwas impossible to estimate the proportion of the variance attributableto officers. Consequently, we recoded the outcome as a series ofdichotomous comparisons and estimated null models that treated thedependent variable as continuous, normal. While recoding theoutcome variable in this way violated the assumptions of the model,it allowed us to give some estimate of the proportion of the variance

attributable to officers. Based on these models, we estimated thatapproximately 5% [(μ/μ+r)=.003/(.003+.0605)] of the variance inthe transportation to jail versus treatment model and approximately4% [.007/(.007+.1236)] of the variance in the no transport versustransport to treatment model was due to the officer level.7

Table 4Coefficientsa from the hierarchical multinomial logistic regression of selected independent variables on disposition (n=466).

Likelihood transport to treatment versus no transportb

Model 1 Model 2


DemographicsAge (in years) −.007 .009 .993 .976 1.011 .001 .009 1.001 .984 1.018Gender (1=female) −.694*** .210 .500 .331 .755 −.636** .218 .529 .345 .812Race (1=black) −.069 .255 .933 .565 1.538 −.037 .262 .963 .577 1.610More than one report −.083 .382 .920 .435 1.949 −.223 .407 .800 .360 1.776

Dispatch codec

Assault .335 .230 1.397 .889 2.198 .296 .268 1.344 .794 2.278Suspicion of crime −.166 .261 .847 .508 1.412 −.358 .270 .699 .412 1.188


Alcohol suspected .991* .409 2.694 1.206 6.024Drugs suspected −.058 .422 .944 .413 2.160

Off medications .745* .301 2.107 1.167 3.802Violence

Violent to self 2.605** 1.007 13.533 1.876 100.000Violent to others 1.160* .462 3.189 1.289 7.874

Signs and symptomsPsychotic symptoms .259 .302 1.296 .717 2.342Physical health concerns .794* .315 2.213 1.192 4.115

Intercept 1.656** .711μ0 .809 .720

Likelihood transport to treatment versus transport to jailb

Model 3 Model 4


DemographicsAge (in years) .013 .008 1.013 .997 1.029 .012 .009 1.012 .994 1.031Gender (1=female) 1.142*** .330 3.134 1.664 5.988 1.158*** .315 3.183 1.715 5.917Race (1=black) −.239 .330 .787 .412 1.506 −.188 .356 .829 .412 1.667More than one report −.045 .234 .956 .604 1.513 −.081 .276 .923 .536 1.587

Dispatch codec

Assault −.629 .423 .533 .233 1.224 −.558 .410 .572 .256 1.279Suspicion of crime −.206 .490 .813 .311 2.128 −.348 .522 .706 .254 1.965


Alcohol suspected .657 .347 1.928 .976 3.817Drugs suspected −.727* .355 .483 .241 .970

Off medications .537 .424 1.712 .745 3.937Violence

Violent to self .050 .450 1.051 .435 2.538Violent to others −1.537*** .314 .215 .116 .398

Signs and symptomsPsychotic symptoms .335 .307 1.397 .765 2.551Physical health concerns −.559 .375 .572 .274 1.193

Intercept 1.252* 1.634**μ0 .667 .720

*p≤ .05; **p≤ .01; and ***p≤ .001.a The HLM program sets the reference category (transport to treatment) as “0” such that the odds reported are the odds of either transport to jail or no transport when compared

to transport to treatment. For clarity in discussing the results, we reversed all the signs in this table so that negative coefficients indicate having lower odds of transport to treatmentand positive coefficients indicate having higher odds of transport to treatment than the category to which it is compared.

b Transport reference category: transport to treatment.c Dispatch code reference category: suspicious person.

7 We also examined the degree to which officers always transported to the samelocation. To assess this question we looked at the 69 officers who had submitted atleast five reports. Of these officers, only 5 (7.2%) reported transport to the samelocation on all their reports. The maximum number of transports by these officers wasseven. Therefore, we concluded that this is not an issue of concern.



4.4. Assessments and dispatch codes

In post hoc analyses presented in Table 5, we find that assessmentsvary as a function of dispatch codes. These analyses suggest thatsuspected alcohol use, violence to self, and physical health concernswere most dependent on dispatch codes. As discussed above, each ofthe seven assessments, except psychotic symptoms, had a significanteffect on increasing the likelihood of being transported to treatment.

Focusing on these three assessments, suspected alcohol use variedmost across dispatch codes. Suspected alcohol use is assessed mostoften for calls dispatched as suspicion of crime and least likely to beassessed for suspected mental illness as well as calls to meet a citizen(as shown in Table 5). Violence to self was most likely to be assessedfor suspected suicide and least likely to be assessed for suspiciousperson and meet a person calls. Physical health concerns were mostlikely to be noted in cases dispatched as suspicious person and leastlikely to be mentioned for suspected suicide calls.

5. Discussion and conclusions

In this paper,weuseCIT officers' reports to explore factors associatedwith transport decisions, focusing on call takers' assessment of thesituation (using dispatch codes) and officers' assessments. We utilizeboth quantitative and qualitative information provided by CIT officerson their written summaries of CIT encounters in our research.

With respect to our first research question concerning therelationship between dispatch code and disposition, we found thatthe manner in which the call was dispatched was, in fact, related tothe decisions that officers made at scene. Dispatcher training has beenidentified as one of the core elements of CIT training. However, wealso note that officers' judgments of people as having a mental illnessare not dependent upon how the call was dispatched. Officers reportsuch encounters as interactions with people with a suspected mentalillness even though the calls were dispatched with another code.

We also found that officer assessments were associated withdispositions thereby providing support for our second researchquestion. Specifically, we found that the assessment areas stressedin CIT training (substance abuse, adherence to medication, signs and

symptoms of mental or physical illness, and violence towards self orothers) were associated with increased likelihood of being trans-ported to treatment.

However, we found no support for our third research question. CITofficer assessments did not account for the relationships betweendispatch codes and dispositions. That is, the officers' assessments didnot reduce the relationship between the dispatch code and disposi-tion to non-significance.

Overall, our results indicate that CIT officers identify individuals inneed of treatment regardless of how calls are dispatched. Results alsosuggest that officers' assessments of the individual affect transport totreatment. We speculate that training in the availability of the localtreatment options influences officers to intervene before a crisisnecessitates arrest (Watson et al., 2008), reducing the likelihood ofcriminalizing individuals who had experienced a mental illness crisis.We also found that the small amount of variation that exists in theway encounters are handled does not appear to be attributable to theindividual officers, but rather to characteristics of the encounter itself.Finally, officer assessments do vary across types of calls dispatched.However, officer assessments do not account for the relationshipbetween dispatch codes and dispositions.

There are a number of contributions this research makes to theliterature on CIT programs. First, this study is one of few assessinghow trained CIT officers' assessments on the scene relate to theirdecision making. Presumably, officers who are trained to betterunderstand mental illness will be more likely to consider treatmentoptions over other potential outcomes. Our findings provide prelim-inary support for this assertion. Second, our data are unique in that thereports we use include quantitative and qualitative information, aswell as multiple disposition outcomes. As a result, we were able toexamine different scenarios (transport to treatment compared totransport to jail or no transport). Our results show that theseoutcomes are differentially related to officers' assessments. Finally,because our data include a number of different types of officers'assessments, we can begin to identify which types of assessmentsmatter most, and/or the ways in which they influence outcomes.

The results of this study provide some important informationfor policy makers, mental health workers, police trainers, and police

Table 5Coefficients from the hierarchical logistic regression of independent variables on officer assessmentsa (n=2056).

Officer assessments

Alcohol Drugs Off medications Violent to self

b SE b SE b SE b SE

Dispatch codeb

Suspected suicide .572*** .156 1.564*** .157 −.879*** .141 1.393*** .134Calls for assistance .693** .264 .829** .300 .168 .268 −.276 .352Suspicious person .681*** .207 .642 .395 .179 .255 −1.828* .742Assault .567** .181 .278 .253 −.173 .203 .086 .247Meet a citizen −.554 .401 −.591 .421 −.479* .221 −1.748* .768Suspicion of crime 1.182*** .245 .607 .339 −.153 .337 −.142 .410Intercept −1.843*** −2.055*** −1.081*** −.827***μ0 .388 .464 .430 .074

Violent to others Psychotic symptoms Physical health concerns

b SE b SE b SE

Dispatch codea

Suspected suicide −1.703*** .236 −2.235*** .262 −1.111*** .223Calls for assistance −.050 .280 −.158 .224 −.012 .211Suspicious person −.348 .278 .189 .203 .731*** .200Assault .259 .170 −.334 .187 −.663* .267Meet a citizen −1.020** .379 .642** .199 .276 .192Suspicion of crime −.610 .524 .569* .270 .273 .331Intercept −1.493*** −2.773*** −2.526***μ0 .490 .261 .476

*p≤ .05; **p≤ .01; ***p≤ .001.a Controlling for demographic variables.b Disptach code reference category: suspected mental illness.



personnel. Dispatcher classification of calls has an impact on officerdispositions. This underscores the importance of dispatcher trainingas a part of CIT training. In addition CIT officers' assessments of peoplewith active signs and symptoms of mental illness and knowledge oftreatment options in their particular system appear to increase thelikelihood that individuals will be transported to treatment instead oftransported to jail or left at the scene. Though some law enforcementdecisions are more restricted than others (e.g., domestic violence),even in these cases there is an increase in transport to treatment onceofficers' assessments of substance abuse, violence, and physical healthconcerns are considered.

While this research represents a necessary step forward in empiricalwork assessing CIT programs, there are limitations to our study thatshould be addressed in future work. First, the data do not include acomparison group of reports from non-CIT trained officers. Previousresearch (Teller et al., 2006) indicated that CIT-trained officerstransported to treatment more frequently and left people at the sceneless frequently than non-CIT trained officers. Thoughwewere unable tomake such comparisons in this study, this study examined the effect ofofficer assessments of the same cohort of CIT-trained officers in theirdecision how to handle a call. Second, and related to this issue, thesedata are based on CIT officers' reports documenting an encounter theyhave with a potentially mentally ill individual. In other words, the dataare not based on a random sample of police encounters with thosewhowere in a mental illness crisis, but of a sample of reports of CIT-trainedofficers' encounters. Access to information about all mental illnessencounters (whether reported or not) might provide insight intoadditional factors that influence officers' assessments.

It is also important to note that theAkronMunicipal Court operates aMental Health Court for misdemeanants with serious mental disorders,whichmay complicate the interpretationof ourfindings. TheCIT officersare aware that this structured treatment program is an option forindividualswhoare arrested andwhootherwisemay resist treatment inthe civil treatment system. Officers can request that the court considersuch individuals for the mental health court program. Future studiesshould investigate the interaction betweenmental health courts andCITprograms on decision making by officers.

Related to this point, future research in this area should employmultilevel analysis techniques to examine the influence that communitycontext (e.g., availability of community resources) has on officerdecisions in conjunction with officer characteristics and the character-istics of those in crisis (Watson et al., 2008). It seems likely that theaspects of the community context interact with individual and incidentlevel characteristics when predicting officers' decisions to transportindividuals to jail or treatment versus resolving the matter informally.

Finally, officer assessments may be influenced by the specializedtraining CIT officers receive and subsequent extensive field experienceso that when officers have discretion, they transport individuals withmental illness to treatment instead of leaving these individuals at thescene or transporting them to jail. This study increases our knowledgeabout the potential influence of CIT and points to areas requiring furtherstudy, such as comparison of dispositions by CIT and non-CIT officersand whether characteristics of officers affect the disposition of calls.

Acknowledgements

This paper is based on work supported by grants from the OhioDepartment of Mental Health (03–05.1176), the Office of the OhioCriminal Justice Services (2003-DG-COV-7068), and the CIT Center atthe University of Memphis. The authors would like to express theirappreciation to the Akron Police Department (Lt. Michael Woody,Retired; Sgt. Michael Yohe; Michael Carillon; Lt. Michael Prebonick;and Chief Michael T. Matulavich, Retired) for their assistance andpatience. We would also like to acknowledge the contributions of thefollowing undergraduate and graduate students who assisted in datapreparation and paper reviewing: Natalie Bonfine, Mary Gallagher,

Marcee Jones, Kris Kodzev, David Skubby, and Dana Sohmer. Wethank the editor and anonymous reviewers for their suggestions andinsights, though any errors are the responsibility of the authors.

Appendix A. Coding scheme

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Category and code

Suspected mental illnessSuspected mental illness

Suspected suicideSuspected suicide

AssaultFight

Meet a citizenMeet personTake report

Calls for assistanceEmergencyEMS or ambulanceMisc. medical problemEMS needs policePolice needs EMSNon-emergency requests for backupCheck property, welfare, missing personBe on the lookout for, noisyEmergency traffic

Suspicious personSuspicious person

Suspicion of crimeRobberyStabbingShootingRapeBurglaryTampering motor vehicleAlarm dropBomb threatFireShop lifterCheck for stolen autoDrunkMisdemeanor warrantFelony warrantShots firedAccident

OtherOff duty extra jobUnknownTraffic complaintTraffic stop



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