Tips From Program's Successful Collaboration With Law Enforcement During Mental Health Crises

Margaret (Margie) E. Balfour, MD, PhD, and Sergeant Jason Winsky, BA, discuss collaborative approaches with law enforcement in responding to behavioral health emergencies. In this video, Dr Balfour who is the chief of quality and clinical innovation at Connections Health Solutions in Tuscon, Arizona, and Sgt Winsky, the supervisor of the Tuscon Police Department’s Mental Health Support Team, discuss the following topics:

• How law enforcement fits into in the continuum of a crisis response model
• Law enforcement’s integration with the Tucson, Arizona Crisis Response Center
• Crisis intervention and Mental Health First Aid training for police officers
• The successful patient-centered processes at the Crisis Response Center

In the upcoming parts 2 and 3 of this series, they will discuss the processes that occur at the Crisis Response Center once a patient is being treated, the community impact of this collaboration, tips for family members and clinicians during a mental health crisis, and the upcoming 988 hotline launching in June 2022.

Dr Balfour and Sgt Winsky recently published a paper titled, “Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies” that reviews best practices for law enforcement responding to mental health crises, strategies for collaboration, policy considerations, and more.

>>WATCH New 3-Digit Crisis Hotline Will Connect Callers With Mental Health Professionals

Read the Transcript

Sergeant Jason Winsky:  Hello, everyone. My name is Jason Winsky, and I'm a sergeant with the Tucson, Arizona, Police Department.

I am the supervisor of our Mental Health Support Team, which is a dedicated team of officers and detectives and soon‑to‑be CMCO responders as well, which we'll talk about a little bit later on in the chat today. I will speak more about how our team got started and how it works in just a minute.

Joining me today also is Dr Margie Balfour. Margie, do you want to introduce yourself?

Dr Margie Balfour: Hi, I'm Margie Balfour. I'm a psychiatrist with Connections Health Solutions. We operate crisis centers across Arizona and soon to be in other states as well. I'm the chief of Quality and Clinical Innovation. I'm also an Associate Professor of Psychiatry at the University of Arizona.

Sgt. Winsky: All right. Today, we're going to talk a little bit about how my team works on the law enforcement end in the continuum of crisis response? How we got started and how we interact with Dr Balfour in the crisis center? A little bit, we'll touch about the training that our first responders receive as well.

Like I said, my name is Jason and I'm the supervisor of the Tucson Police Department Mental Health Support Team. To give you a little bit of scale, if you're watching this across the country, to someplace, it's about 850 commissioned officers serving a population and about 550,000 people, so we're right there.

We're definitely not a very large agency, but we're definitely right there in the middle. About seven years ago, responding to various crisis in the community, and unmet needs here in Tucson and Pima County we started along with our chairs from here about the exact same time what we call MHST or the Mental Health Support Team.

How our team works is responsible for quite a few things. The biggest thing you want to know about our team is that we are dedicated and not designated, which means detectives and the officers that work on my team, they're not responding to car accidents or burglaries or anything else crisis is pretty much all we do all day every day.

We divide our work into a few different areas. One is we are responsible for all of the civil commitment pickup orders. Around the country these might be called different things. They might be called emergency applications or court‑ordered treatment or AOT. We call it COT here in Arizona.

Basically, I'm describing people that are out in the community and need to be transported to an evaluating facility.

My team goes out, they pick those people up, and they take them to an evaluating facility. Usually that's going to be a place like the Crisis Response Center where Dr. Balfour works.

Our team dresses like me, like what you see right now. We take a really low and slow approach. We don't do lights and sirens. We don't do marked police vehicles. We don't wear the traditional uniforms. We like to describe ourselves as the Crisis Intervention Training model in action.

If you're familiar with CIT, that Memphis‑based 40‑hour crisis training, we go out into the community. We take that low and slow de‑escalation approach. We pick people up, and we take them to treatment.

The detectives do a lot of our preventative and proactive work. What our detectives do is do the follow‑up. They do people that might be high utilizers, people that have fallen through the cracks of the system, people that have maybe been to the hospital 2 or 3 or 4 times, and they still need that extra level of attention.

The other thing that we're responsible for that we wanted to touch on today is we are responsible for all of the training that occurs at the Tucson Police Department around crisis response. I already mentioned CIT. That's our gold standard of law enforcement crisis training. It's a full 40‑hour, it's an immersion experience.

The other thing we do that's really important to the first responder element of our police department is we do the Mental Health First Aid. Mental Health First Aid is an eight‑hour class. I hope I get this right because they changed their name. It was sponsored or created by the National Council for Mental Well‑being.

Margie, did I say their new name right? Great. I actually like their new name.

Mental Health First Aid is a unique and dynamic training that I really like. I've been an instructor for a few years now. Like I said, it's an 8 hour course. It comes with a really cool book. It's almost like a textbook or a manual that a lot of the other trainings we have don't come with. The student, in this case, the law enforcement or EMS—we train EMS in it as well here—you get to keep the book. It just works its way through.

"What are the most common diagnoses or crisis situations that a first responder might run into?" and it gives you down‑to‑earth tips and tricks of how to recognize that crisis, how to respond to it, and what to do with that crisis. Mental Health First Aid is a big part of what we do.

One-hundred percent of our Tucson Police Department and Pima County Sheriff's deputies are trained in Mental Health First Aid. They get that right at the end of the academy. It's something that we, for sure, are dedicated and invested in. It's something that we want to make sure that 100% of our people are trained in.

We are doing a lot of proactive things here in Tucson and Pima County, but we do still face a lot of challenges, both here and nationwide, as first responders.

The biggest one that I can think of is once you deescalated that crisis you've responded appropriately, what's next? What's the continuum of options that that person has, everything from a crisis line to maybe a mobile team response to an inpatient stay somewhere?

For us, our bread and butter here in Tucson is the Crisis Response Center. We do thousands of drop‑offs there a year. They operate under a No Wrong Door policy. We are able to take people there 24/7, it is free. You don't have to have insurance to go there. Because we tested it, they can handle just about anything we throw at them.

Now, I'm going to turn it over, and let Dr Balfour talk about how the CRC works and that continuum of options for a crisis that we have here at Tucson.

Dr Balfour: Thanks, Jason. We're very fortunate out here in Arizona that over the last 15 years or so, the state has invested in crisis services. The state divided into 3 regions, the north, the south, the central. We're in the south, down in Pima County in Tucson.

Our crisis center sits in the middle of a larger continuum, where all the services are aligned so that there's different levels of services, depending on the level of care that you need.

That are designed to keep people with mental health emergencies, and substance use emergencies out of the emergency rooms because emergency rooms are not a good place for people with mental health emergencies to be. They're loud.

Most of them don't have mental health or psychiatric services in them, so you end up waiting for hours to be transferred somewhere else to a psych unit somewhere else, when it might not even be inpatient psychiatric care that you need. It's just not a good place to be.

The other thing is, since in most communities if you call 911 if you've got chest pain, you get an ambulance. If you are suicidal or have a psychiatric mental health crisis, then you end up getting the police.

That's one of the reasons why a quarter of police‑involved shootings involve people with mental health issues. People with mental health issues tend to end up in jail, much more often than the general population does. This whole system has been set up to try to provide the care that people need.

In Southern Arizona, we've got a crisis line that receives about 10,000 calls a month, and they are able to resolve about 80% of the calls that they get over the phone. They do that via telephonic counseling. They have the ability to make appointments with the clinics in the area.

If a crisis is more acute than can be handled on phone, then they are the centralized dispatch for around 16 mobile teams that operate across Pima County. They can dispatch a mobile team that usually arrives within the hour. Two clinicians, usually, can do a face‑to‑face interaction. When they do that, they're able to resolve about 70% of the crises that they intervene on.

For even high‑level crisis, there are the crisis centers like ours. We operate the Crisis Response Center, which is the centerpiece of the Tucson, Pima County crisis system. It was built in 2011 with county bond funds. The services are all funded via the healthcare system, via our Medicaid system in Arizona that blends together a lot of different funding sources.

Like Jason said, anybody can get services there. Everyone in Arizona finds themself in a crisis, they are entitled to crisis services. Pima County built the building. It was driven by a goal of reducing the numbers of people with mental health and substance‑use needs who end up in jail or emergency rooms.

The way that the CRC achieves this is through a couple different strategies. One is we get a little under half of all of our volume comes directly from the police. If we are trying to reduce the numbers of people who are in jail, it's the police that have the people that they would take to jail.

Our philosophy is we're going to treat the police as a preferred customer similarly to how we treat our patients as a preferred customer. We've figured out over the years what police want. They want their own dedicated entrance, so they don't have to be parading people through a busy waiting room, which is awkward and not good for the person.

They want to get in and out as quick as possible because they are busy, and they have crimes to fight. We were told it takes 20 minutes to book somebody into the Pima County Jail. It actually takes longer, I think. We get the officers out in five minutes or less.

The other thing they don't like is being hassled about taking their guns off. They've got a secure gated entry that's dedicated for them. When they bring people to us to drop them off, they have everything they need. They have a little office, and a bathroom, and refreshments.

They can do their paperwork and everything right there so that they don't have to be wandering around our building and being hassled by the staff to take their gun off. In short, the whole thing is set up to make it easier, and faster, and preferable for the officer to use the CRC rather than to take people to jail.

They get a lot of training on how to do the right thing. If the system makes it hard for them to do the right thing, then jail becomes the path of least resistance. In a lot of communities, they get trained to recognize signs and symptoms of mental illness and divert them to treatment. The first question is always, divert to what?

If the emergency room is their main option, a lot of emergency rooms make the officer stay with the person for hours sometimes days while they're waiting to transfer them somewhere out to a psych hospital somewhere. We want to make it easy for them to do the right thing. We also receive people who are dropped off by the mobile crisis teams.

We also get people who come in on their own, or their family brings them, or emergency rooms transfer them.

Margie Balfour, MD, PhD, is a psychiatrist and national leader in quality improvement and behavioral health crisis care. She is chief of quality and clinical innovation at Connections Health Solutions, Tuscon, Arizona. She is also an associate professor of psychiatry at the University of Arizona. Dr Balfour was named Doctor of the Year by the National Council for Behavioral Health for her work at the Crisis Response Center in Tucson and received the Tucson Police Department’s medal of honor for helping law enforcement better serve people with mental illness. She contributes to expert panels for SAMHSA and the DOJ. Her pioneering work on crisis metrics has been adopted as a national standard, and she co-authored Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practices. Dr. Balfour is a Distinguished Fellow of the American Psychiatric Association and serves on the Quality-of-Care Council. A native of Monroe, Louisiana, Dr. Balfour earned a BA in Biology at Johns Hopkins University followed by her MD and PhD in Neuroscience from the University of Cincinnati. She completed residency and fellowship in Community Psychiatry at the University of Texas Southwestern Medical Center in Dallas.

Sergeant (Sgt) Jason Winsky is a 17-year veteran of the Tucson Police Department (TPD), where he has led the creation and growth of mental health programs that serve the community's most vulnerable populations.  He supervises TPD’s pioneering Mental Health Support Team, a squad of officers, detectives, and peer co-responders dedicated to positive, compassionate responses to persons experiencing a mental health crisis, and he oversaw the development of the Substance Use Response and Homeless Outreach Teams.  A skilled educator, Sgt. Winsky trains police officers in communication and de-escalation techniques across southern Arizona.  He is a Mental Health First Aid Instructor and has taught over 1,000 officers in Crisis Intervention Team Training.  Under his leadership, TPD was designated a Police-Mental Health Collaboration Learning Site by the US Department of Justice and won the Mental Health First Aid Community Impact Award from the National Council for Behavioral Health.  Sgt. Winsky also serves on the Boards of both the Tucson Police Officers Association and the Combined Law Enforcement Associations of Arizona and leads their governmental and legislative affairs activities.  The Arizona Capitol Times named him the 2016 Healthcare Leader of the Year, and in 2021 he received the St. Thomas More Award for his lifelong dedication to community service and integrity in the field of law enforcement.  Sgt. Winsky is a native of Tucson and received a BA in Political Science from the University of Arizona prior to joining the Tucson Police Department.