Learning Together: The CIT ECHO for Training Law Enforcement International Association of Chiefs of Police October 22, 2017 Presented by: Detective Matthew Tinney Dr. Nils Rosenbaum Dr. Dan Duhigg MATT

“The Network is amazing in providing useful information “The Network is amazing in providing useful information. Although I came in with a significant amount of training in the area of CIT, the Network provides me more information, and also keeps my skills sharp.” MATT Define the CIT Knowledge Network on this slide.

Zoom Cloud Meetings How to download Zoom MATT Instruct participants to download the zoom app during at the beginning of the presentation so they can use the app by the end of the talk. 95% of CIT ECHO participants agreed/strongly agreed that they were satisfied with their overall experience with the technology

Multiple Points of Interaction with Individuals with Mental Illness and Substance Use Disorders One in four people with mental illness have histories of police arrest One in 10 individuals have police involved in their pathway to mental health care.1 One in 100 police dispatches and encounters involve people with mental health problems.1 Among males aged 18-49 (2009 data).2 Probation Parole General Pop Serious Psychological Distress 20% 16.8% 9.7% Illicit drug or alcohol dependence or abuse in past year 40.7% 34.6% 15.8% Any mental illness 33.3% 29% 18.8% MATT A review of over 85 studies found that.. (Livingston in 2016). Serious Psychological Distress (SPD) is defined for this table as having a score of 13 or higher on the K6 scale during the past year The Kessler 6 (K6) nonspecific psychological distress scale was used to assess those who met the threshold for SPD in the 30 days prior to the interview. The K6 is a six-question tool developed to screen for serious mental illness among adults age 18 or older in the general U.S. population, with a score of 13 or higher indicating SPD.1 Inmates were asked how often during the 30 days prior to the interview they felt— ƒ nervous ƒ hopeless ƒ restless or fidgety ƒ so depressed that nothing could cheer them up ƒ everything was an effort ƒ worthless. The response options were (1) all of the time, (2) most of the time, (3) some of the time, (4) a little of the time, and (5) none of the time. The responses were recoded from 4 to 0, with 4 assigned to “all of the time” and 0 assigned to “none of the time. Any Mental Illness (AMI) is defined as having a diagnosable mental, behavioral, or emotional disorder, other than a substance use disorder, that met the criteria found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In 2008, a split-sample design assigned adults aged 18 or older randomly to one of two impairment scales, the World Health Organization Disability Assessment Schedule (WHODAS) or the Sheehan Disability Scale (SDS). For comparability purposes, estimates for Any Mental Illness for 2008 are based only on the WHODAS half-sample. For details, see Section B.4.3 in Appendix B of the Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings. 1Livingston, (2016), Contact Between Police and People with Mental Disorders: A Review of Rates, Psychiatric Services, 67:8, 2016; 2Feucht & Gfroerer, (2011) Mental and Substance Use Disorders among Adult Men on Probation or Parole: Substance Abuse and Mental Health Services Administration Data Review, Summer May 2011

Need for Specialized and Ongoing Training Training historically focused on command/control and officer safety Non-compliance may result in the use of force Historically, no special training focused on interactions with people living with mental illness A lack of guidance and training on how to apply police tactics to people living with mental illness resulted in highly publicized of uses of force CIT (Crisis Intervention Team) programs are local initiatives designed to improve the way law enforcement and the community respond to people experiencing mental health crises. They are built on strong partnerships between law enforcement, mental health provider agencies and individuals and families affected by mental illness. CIT, Crisis Intervention Teams MATT 1987 Memphis Model created Closure of long-term psychiatric treatment facilities resulted in more chronically psychiatrically ill people living in our communities Law enforcement & public safety have become a more common point of contact for people living with mental illness The CIT Knowledge Network is based on Crisis Intervention Training (CIT), a first-responder model for police interactions with people living with mental illness. CIT is a pre-booking approach to increase officers’ abilities to respectfully and safely interact with persons living with mental illness and is associated with improved knowledge and attitudes

APD’S CRISIS INTERVENTION UNIT (CIU) MATT CIT (Crisis Intervention Team) programs are local initiatives designed to improve the way law enforcement and the community respond to people experiencing mental health crises. They are built on strong partnerships between law enforcement, mental health provider agencies and individuals and families affected by mental illness. Matt and Nils attended an ECHO clinic and thought there was a great need for a clinic dealing with behavioral health and law enforcement

PARTNERS MATT

Grant Funding $250,000 Three-Year Grant BJA FY 2015 Justice and Mental Health Collaboration Program: Planning and Implementation DAN

Traditional CIT Training The CIT ECHO Model 40 hour class. No upkeep. ! ? ? ! DAN Pros: Impact and reach more people Keep skills fresh Lifelong learning Pro: Effective training Con: Perishable skills Con: Officer must dedicate time to learn

ECHO Model Case based learning Demonopolizing knowledge Video-conferencing network DAN

THE CIT ECHO HUB TEAM DAN Dr. Daniel Duhigg Addiction Psychiatrist Presbyterian Healthcare Services UNM Department of Psychiatry and Behavioral Sciences Matthew Tinney Detective Crisis Intervention Albuquerque Police Department Dr. Nils Rosenbaum Psychiatrist Medical Director Behavioral Health Division Albuquerque Police Department DAN Dr. Nancy Martin Psychiatrist UNM Department of Psychiatry and Behavioral Sciences Denise Hovey-Thomas Crisis Specialist Crisis Intervention Albuquerque Police Department Jennifer Earheart Project Coordinator UNM Department of Psychiatry and Behavioral Sciences

CIT ECHO Session Connect to Zoom from 1:30-3:00(MST) on Tuesdays Brief didactic + Q&A for 30 minutes Debriefing cases/calls presented to network for feedback and discussion for 20 minutes Adjourn Certificates of participation given for each hour connected DAN

The CIT ECHO Is Using Project ECHO To Provide Critical, Ongoing Training To Agencies Around New Mexico And The Nation. NILS

Participating Agencies MARYLAND Wicomico County Health Department/ Core Service Agency MINNESOTA St. Paul Police Department NEW MEXICO Alamogordo Police Department Albuquerque Ambulance Albuquerque Fire Department Albuquerque Police Department Bernalillo County Sheriff’s Department Bosque Farms Police Department Corrales Police Department Farmington Police Department Las Cruces Police Department Los Lunas Police Department New Mexico Department of Public Safety New Mexico State Police Portales Police Department Rio Arriba Sheriff’s Office Rio Rancho Police Department  San Juan County Sheriff’s Department Sandoval County Sheriff’s Office United States Probation and Parole University of New Mexico Veteran’s Administration NEW YORK New York Ambulance/ Mental Health America Chaplain Center for Urban Community Services OREGON Portland Police Department TEXAS Hale County Sheriff's Office WASHINGTON Comprehensive Healthcare Everett Police Department King County Washington Sheriff's Department Kirkland Police Department Washington State Criminal Justice Training Center Yakima Police Department WISCONSIN Stevens Point Police Department NILS

THE CIT ECHO: First Year Reach NILS The data presented here is from the project’s pilot year – which was in 2016 Mention that the project first launched with the bootcamp (bootcamp is important bc this shows where the program started to where we are now) At the bootcamp 31 public safety personnel attended representing 9 agencies across New Mexico

CIT ECHO CURRICULUM: 6 MODULES CIT Policing Resources Psychiatric Diagnoses De-escalation/communication Self-management Special training NILS

CIT ECHO Curriculum MODULE 1: CIT POLICING MODULE 3: PSYCHIATRIC DIAGNOSES 101 MODULE 5: SELF MANAGEMENT Intro to CIT policing Schizophrenia and First Episode Psychosis Officer Suicide CIT Team Roles Bipolar Disorder Burnout prevention for police CIT Guidelines Depression Workplace mental health awareness How to Interface with the Medical System Anxiety I: GAD, OCD, Panic Mindfulness Based Stress Reduction for police Triage Anxiety II: PTSD 10 Deadly Errors: How to Avoid Becoming a Victim Cop Spree Killings Autism Spectrum Disorders Homelessness Substance Use Disorders MODULE 6: SPECIAL TRAININGS Barricades and High Risk Suicide Medication Awareness for Police Identifying Drug Induced Intoxication in the Field Recognizing signs and side-effects of medications, drugs, mental illness for police: What is a threat vs. a side-effect? Traumatic Brain Injury Rising Rates of Homicide: A look at the data Alzheimer’s and Dementia When to go to the hospital (psychiatric emergencies) MODULE 4: DE-ESCALATION & COMMUNICATION Media Relations Q&A Role of Media in Reporting Mass Shootings Hallucinations and psychosis: how to respond De-escalation Techniques Suicide by Cop MODULE 2: RESOURCES 7 Active Listening Skills Communicating with medical professionals Adult Protective Services PURE Model I Disability Rights PURE Model II Sexuality and Stress Resources for Veterans Transgender 101 NILS

What are the benefits to law enforcement? FREE Training without travel Certificates given after training Decreasing variability in tactical responses Identification of areas needing improvement/training/changes to SOPs Live access to specialty consultation with CIT experts, psychiatrists, law enforcement trainers Development of CIT programs and infrastructure Decreasing liability through peer review Development of best practices Access to medical professionals MATT Matt – this may be a good place to talk about leadership buy-in/what reception to the project has been like.

Case Examples Case 1 – Impact on training policies at police academy: Using a PA system in crisis situations. Case 2 – Impact on decreasing use of force: De-escalation and positioning techniques on crisis calls. Case 3 – Impact on improving de-escalation skills for high risk suicide. MATT Case 1 – PA System Case 2 – Sgt. Dietzel Case 3 – Murder suicide example

CIT INC. www.goCIT.org Searchable for CIT program information CIT ECHO didactics No recorded cases MATT

EVALUATION Semi-structured interviews with stakeholders to obtain feedback about the face validity and practical utility Online surveys to assess satisfaction with the technology and curriculum and impact on self-efficacy Online surveys to assess impact on knowledge related to the content presented in the session DAN

Preliminary Data: Impact on self-efficacy 61 officers completed at least 3 or more sessions and were thus eligible to complete the survey.   Preliminary data from online surveys (N=42) shows a positive impact on officer self-efficacy. Because of my participation in the CIT ECHO sessions I feel I am able to determine if a person living with mental illness who has committed a crime should be taken to jail or to a hospital or emergency room. DAN 82.93% agreed or strongly agreed that after participation in the CIT ECHO they were able to determine if a person living with mental illness who has committed a crime should be taken to jail or to a hospital or emergency room.

Preliminary Data: Impact on self-efficacy It is the job of law enforcement to link/connect people living with mental illness into treatment. DAN Law enforcement are more likely to agree that they have a role in linking/connecting people with mental illness to treatment after participating in the CIT ECHO.

Preliminary Data: Impact on self-efficacy People living with mental illness often require the use of force to maintain officer safety. DAN Law enforcement are more likely to strongly disagree that use of force is necessary to maintain officers’ safety when interacting with people with mental illness after participating in the CIT ECHO.

Preliminary Data: Weekly Feedback Surveys Table 1. Means, impact on knowledge and practical utility Date Didactic Mean 1 1/10/2017 Rising Homicide 4.09 1/17/2017 Bipolar Disorder 4.55 1/24/2017 Mindfulness 4.67 1/31/2017 Deadly Errors 3.71 2/7/2017 Barricades/High Risk Suicide 3.89 3/7/2017 First Episode Psychosis 4.29 3/21/2017 Suicide by Cop 3.91 3/28/2017 Stress Management 3.85 4/4/2017 Media & Mass Shootings 3.92 4/18/2017 Identifying Intoxication 4.42 4/25/2017 Psychiatric Emergenices 4.18 5/2/2017 PURE Model I 4.1 5/9/2017 PURE Model II 4.46 5/16/2017 Paranoia 4.36 5/30/2017 Effective Coping Mechanisms 3.5 6/6/2017 Communicating with TBI 4.44 6/13/2017 Jumpers/High Risk Suicide 4 6/20/2017 Autism Spectrum Disorder 4.25 6/27/2017 First Break Psychosis 7/11/2017 PURE Model III 4.13 7/25/2017 Alcohol Use Disorder 4.17 8/1/2017 PURE Model IV 4.33 8/8/2017 Alzheimer's & Dementia 4.23 8/22/2017 Sequential Intercept Model 3.94 8/29/2017 Psychiatric Illness due to Medical Causes 4.06 Totals: 4.1496 To what extent did the information improve your knowledge of the topic? Not at All Very Little Somewhat Much Very Much DAN

Preliminary Data: Weekly Feedback Surveys Table 2. Means, impact on knowledge and practical utility Date Didactic Mean 2 1/10/2017 Rising Homicide 3.73 1/17/2017 Bipolar Disorder 4.27 1/24/2017 Mindfulness 4.44 1/31/2017 Deadly Errors 4 2/7/2017 Barricades/High Risk Suicide 4.33 3/7/2017 First Episode Psychosis 4.29 3/21/2017 Suicide by Cop 3.82 3/28/2017 Stress Management 4/4/2017 Media & Mass Shootings 3.75 4/18/2017 Identifying Intoxication 4.17 4/25/2017 Psychiatric Emergenices 4.18 5/2/2017 PURE Model I 4.1 5/9/2017 PURE Model II 4.31 5/16/2017 Paranoia 4.43 5/30/2017 Effective Coping Mechanisms 3.88 6/6/2017 Communicating with TBI 4.39 6/13/2017 Jumpers/High Risk Suicide 6/20/2017 Autism Spectrum Disorder 4.45 6/27/2017 First Break Psychosis 7/11/2017 PURE Model III 4.13 7/25/2017 Alcohol Use Disorder 8/1/2017 PURE Model IV 4.47 8/8/2017 Alzheimer's & Dementia 4.54 8/22/2017 Sequential Intercept Model 3.53 8/29/2017 Psychiatric Illness due to Medical Causes 4.06 Totals: 4.158 How likely are you to use the information you learned in this week’s session in your job? Not at All Very Little Somewhat Much Very Much DAN

Qualitative Feedback: Weekly Feedback “I will keep in mind that individuals with this disorder are very smart and can catch on to my reactions and behavior. Even though the likelihood that things are happening as they say are probably not, it is still very real and scary for them.” “I think at times you become somewhat relaxed and complacent when dealing with people who suffer from mental illness, especially those you have dealt with quite often. Be mindful and getting in the right mindset and keeping it will definitely help me on future contacts.” “I really enjoyed being a part of these conversations. Going beyond ‘do this, this way’ to discussing aspects officers never really would of thought about. I love these training sessions.” “I liked the give and take of the session and getting to hear from both law enforcement officers and from physicians. I enjoyed hearing all of the different perspectives. I also enjoyed hearing the feedback [case debriefing] about the delusional individuals that one of the participants was trying to deal with and find resources. I actually learned a few things from that.” DAN

Stakeholder Interviews Semi-structured interviews with key stakeholders have identified positive feedback. The four respondents interviewed thus far, including a captain, two sergeants, and a field officer have emphasized how the sessions have served as refreshers for their initial training. “I’ve been doing this job a long time. Though the information isn’t new, it’s a refresher for me. It tells me that what I’m doing is best practice. The meetings help validate my skills.” DAN

Questions? Matthew Tinney mtinney@cabq.gov 505-553-2229 Nils Rosenbaum, MD nrosenbaum@cabq.gov Daniel Duhigg, DO dduhigg@phs.org Jennifer Earheart jearheart@cabq.gov DAN