Hello and welcome. My name is Dr. Dionne Hart. I am the AMA liaison to the National Commission on Correctional Health Care. I am pleased that you are joining us today for the Striving for Excellence series, Black and Blue, the Intersection of Mental Health, Policing, and Race in a Crisis Response. Funding for the Striving for Excellence series was made possible by a grant number H79FG000591 from the SAMHSA of the U.S. Department of Health and Human Services, HHS. The contents are those of the author and do not necessarily represent the official views of nor endorsement by SAMHSA, HHS, or the U.S. government. It is important that we also state that this presentation is not intended to assume an anti-police stance directly or indirectly, rather as a call for safe policing and an end to the criminalization of severe mental illness and an effort to advocate for increased public safety. Today's webinar has been designated for an AMA Physician Recognition at Category 1, Credit for Physicians. Credit for participating in today's webinar will be available for 60 days. The PDF of the slides will be available in the chat tab. Captioning for today's presentation is available. To enable the captions, click Show Captions at the bottom of the screen. Click the arrow and select View Full Transcript to open the captions in a side window. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Myself, Chief Anthony Campbell, and Mrs. Tan do not have any relevant disclosures. Dr. Matthew Goldman is a paid consultant on crisis service research and policy for vibrant emotional health via Full Tilt Strategies funded by SAMHSA, California Health and Human Services Agency via Desert Vista Consulting, University of California Davis funded by the California Mental Health Services Oversight and Accountability Commission, National Commission for Mental Health Wellbeing funded by SAMHSA, and PEGS Foundation funded by PEGS Foundation and Pew Charitable Trusts. Now it is my pleasure to introduce our presenters. Today I am presenting with three incredible advocates. They are very accomplished, so I will share just a few highlights. I encourage you to review their full bios on the APA website or LinkedIn. First, Mrs. Tan Hall. Tan is wife to Scott and the mother of Miles and Alexis. The day Tan's son Miles was shot and killed, she stepped into her life's work, creating change to protect families from a system that failed her son. Since June 2, 2019, Tan has worked tirelessly with her husband, Scott, and daughter, Alexis, to not only promote awareness of the problems embedded in the care for those living with mental illness, but to identify where the levers of change are. Her advocacy led to the creation of the Miles Hall Foundation. Tan has formed alliances with other families, organizations, and politicians across the country who are working for change. She is a featured speaker and panelist on media and public and private events. Her message? Black lives matter. Black minds matter. Her son Miles matters, and change is possible and inevitable. Next is Chief Anthony Campbell. Chief Campbell was born in Harlem, where he graduated as a valedictorian of his high school. Later moving to New Haven, he would attend Yale University, where he made the decision to change his electrical engineering major to religious studies with an emphasis on counseling and psychology. Chief Campbell received his undergraduate degree from Yale University as well as a Master of Divinity degree. Chief Campbell has been an adjunct professor with the Yale Divinity School since 2015. In March 2019, Chief Campbell retired from the New Haven Police Department, where he has served since 1998, having risen through the ranks to become chief in 2016. In 2019, after retiring, Chief Campbell joined Yale University Police Department as an assistant chief, and 31 years after arriving at Yale as an undergraduate, he was named chief of police for the Yale University Police Department, his current position. Chief Campbell is a minister, committed servant leader. He develops the personal and professional strengths of officers through quality training, emerging law enforcement technology, and opportunities for advancement. Chief Campbell has trained in counterterrorism and law enforcement management, as well as crisis leadership in higher education at the Harvard Kennedy School. Next is Dr. Matthew Kennedy. Dr. Goldman, sorry, Dr. Matthew Goldman. Dr. Goldman recently began a new role as the medical director for the King County Crisis Care Center levy implementation plan, a voter approved initiative to invest $1.25 billion into five crisis centers, new residential treatment facilities, and workforce development programs across Seattle, King County. Prior to joining King County, he was the medical director for comprehensive crisis services in the San Francisco Department of Public Health, where he had direct clinical and administrative oversight of a crisis call center and adult and child mobile crisis teams, lab planning for the 988 implementations, and advised on the development of a new crisis stabilization unit. Dr. Goldman is a volunteer clinical assistant professor in the UCSF Department of Psychiatry and Behavioral Sciences. He serves as a board member of the American Association of Community Psychiatry. He sits on the expanding first response commission for the Council of State Governments Justice System, and he serves on the National Council for Mental Wellbeing's Medical Director Institute, where he co-chairs a committee on crisis services. Finally, I'm Dr. Deon Hart. I'm an adjunct assistant professor of psychiatry at Mayo Clinic College of Medicine and Science in Rochester, Minnesota. In addition to providing clinical care in multiple sites within Minnesota State, I am very active in organized medicine. My positions include being an APA delegate to the AMA House of Delegates, chairperson of the National Medical Association's Region 4, a Minnesota Medical Association trustee, inaugural chairperson of the AMA Minority Affairs Section, and the AMA liaison to the National Commission on Correctional Health Care Board of Representatives. Throughout the presentation, please share your reactions using the hashtags, say their names, smiles for miles, and SMI is not a crime. Here are our objectives. Please tag APA Psychiatric, at little doc, at Matt G underscore psych MD, and justice for miles. In addition, please tag Yale University at Yale. We have a very diverse audience, so let's begin by ensuring we are all on the same page. During this presentation, we will refer to Black Lives Matter, the movement, not the organization. The movement began in July 2013, following the killing of Trayvon Martin with the use of the hashtag Black Lives Matter on social media after the acquittal of the person charged with the shooting death of Trayvon Martin. It became nationally recognized for street demonstrations following the deaths of Michael Brown in Ferguson, Missouri, and Eric Gardner in New York City. BLM is a decentralized political, social, and grassroots movement that seeks to highlight racism, discrimination, and racial inequity experienced by Black people. Its primary concerns are incidents of police brutality and racially motivated violence against Black people. This session is intended to humanize people living with mental health disorders, particularly those who identify as a racial minority, to ensure they receive empathy and compassion. We are focused on improving, and in some cases, saving the lives of people who are living with mental illness and preventing trauma. Now, because we have a diverse audience, we want to make sure that we understand what we're talking about. We are focused on individuals who are experiencing a mental health crisis. Their symptoms have not been identified, and they may not be Their symptoms may include trouble with daily tasks, including activities of daily living, sudden extreme changes in mood, increased agitation, abusive behavior towards self and others, including substance use or self-harm, isolation, abusive behavior to self and others, including symptoms of psychosis, like difficulty recognizing family or friends, auditory visual hallucinations, and paranoia. They often do not have the ability to consistently problem-solve, ability to follow rapid instructions, high probability of using emotional reasoning rather than rational thoughts, and they may or may not include some degree of insight into their illness. So, let's begin with our first presenter, Chief Anthony Campbell. Thank you, Dr. Hart. Good afternoon to everyone who's joined us today. I think it's important for us to understand how policing developed in the United States of America. When we think of policing, we think of one of the 18,000 police departments that exist in our country, and we think about the 911 system, but we need to understand that these departments and this system did not always exist. Policing began as a result of Sir Robert Peel, who was in England, who ultimately is called the father of policing. Originally started in England with him taking what was a loosely founded government organization and making it something that was controlled by the government, having it along an efficient military-style organization, which is why all police departments are paramilitary organizations, and professionalizing it with training, with recruiting, and specifications as to who would be a police officer. And that model worked extremely well for England, and when it was adopted in the United States, unfortunately, it started differently here. The origins of policing in the United States go back to slavery. The earliest parts of policing deal with slave masters who hired people to retrieve those who may have escaped from the plantations, and to bring them back. So, the history of policing from its very origins in this country is tainted as opposed to its origins in other countries. You fast forward to the first full foundation of a police department in the United States, which was in Boston, Massachusetts, in 1838. Over that period of time, policing has gone through a number of transformations, including development, professionalization, but one of the things that has always stayed rooted is its origins. Human beings learn through the oral tradition, and especially for those marginalized people, those who had been slaves in this country in its foundation, the policing has always been something that has been very touchy for people of color, and those who have been marginalized in this society. And that is still true today, and it falls upon police departments, all 18,000 across the country, to know their history, and to make sure that we in the policing field understand when we're dealing with all members of society, how many people view us. This uniform represents safety for many, but for others, it represents fear and oppression, and we have to be mindful of that. Next slide, please. Dr. Martin Luther King, in 1963, summarized it, I think, best. He said, there are those who are seeking the devotees of civil rights. When will you be satisfied, said Martin Luther King, Jr., in his I Have a Dream speech in 1963. He said, we can never be satisfied as long as the Negro is the victim of unspeakable horrors of police brutality. When we think of the civil rights movement, we have a tendency to think about marches, marches for jobs, marches for desegregation of schools. But one of the key factors that Dr. King and many others in the 60s were fighting for was that they wanted African American people, or the Negro, as they referred to us back then, to make sure that we had the same rights, and would be treated fairly by law enforcement officials. They were experiencing Jim Crow, which was a system of oppression, which was being enforced by police officers at that time, which helped to continue the system of oppression in the United States. This system caused many people to fear and distrust the police, so that when they would have issues and problems, they did not want to reach out to the police. And so we now have a system that many people, through the oral tradition, have passed on to their children and their grandchildren, so that although policing has transformed and become professionalized, it has also been exposed to responding to things that it should not necessarily respond to. Next slide. That leads us to a place where we wind up with a different type of civil rights movement. The professionalization of policing led to it incorporating many members of our society. I'm here because of that. But one of the things that ultimately happened is that police officers began being dispatched to all sorts of things that had no criminal nexus. Officers across this country were not trained originally in how to deal with crises, how to deal with someone who was having a mental health crisis, how to deal with de-escalation if the situation was not criminal in nature, and also to remember the community that you are policing and what they bring to the table, their history and their memory of what policing has been to them. All of those things collided in a modern-day civil rights movement. And as Dr. Hart talked about, whether it was Eric Garner and ultimately Freddie Gray, which led to many of the images that you're seeing on your screen, people had reached the point where they were fed up. They'd reached the point where they still had the fresh memories of how the police had treated them during Jim Crow eras. They had those fresh memories of how the police had used dogs and had used force, including deadly force, against them. And so we wound up with yet another situation after Freddie Gray's death. And that situation has continued. Next slide, please. It has continued because of the 18,000 police departments in this country, it is only now, thanks to the work that is being done by many of the speakers that you're hearing today, who will share many of their stories about how there has been tragedy and loss, it is only now that law enforcement, after George Floyd's death and after some of the issues we've seen in the last three to five years, that we're realizing that the police should not and cannot be the ones who are primarily dispatched to deal with people who are experiencing mental illness, especially those members of our society who have been marginalized throughout our history. Because the fact is, statistically, a person with untreated mental illness is 16 times more likely to be killed during a police encounter. Most police departments are not, as I said before, crisis intervention trained. Most police departments have not trained their officers in de-escalation. These terms and these trainings are new to the 18,000 police departments. And so there is a greater chance that someone who is having a mental illness crisis may be killed by a law enforcement officer. Those with untreated mental illness were involved in at least one in four fatal police shootings. It is important that police departments understand that their officers may not be qualified to deal with mental health issues. They are not hired as mental health professionals. And yet they are sent into some of the most dangerous and volatile mental health situations, armed only with the tools that they've been given to deal with criminal situations. And those instances lead to tragedy. The rules of lethal force do not differ because someone is mentally ill and presents an imminent threat of death or great bodily harm. That's how we train our officers. You use deadly force when someone presents a situation where your life or the life of someone else is in danger. We aren't trained that it should be a different set of rules if that person is mentally ill. And so in many countries, the standard is different. And yet in these United States with all 18,000 police departments, that standard is not different. So there's a lot we can learn from other countries and that we need to adopt. Next slide, please. It's important to know that black people without a mental illness are three times more likely to be killed by police than white people. And those with mental illness have an even higher risk. And this says something about the origins of policing in our country. It is not condemning the 700,000 women and men who police this country, but it is showing that our system needs to change. Our system where police officers are sent by themselves to deal with someone who is having a mental health crisis, it doesn't work. We need to have it where police officers are accompanied either by a mental health professional, social worker, and maybe those are the first contacts so that we can reduce these numbers, especially in our marginalized communities. We can reduce the reality that over 300 black Americans are killed annually by police officers, of which 25% were unarmed. When you factor in the mental illness situations that officers are dispatched to, it adds to those numbers and creates even more distrust between the community and the police. And it's also important that negative police interactions have been correlated with medical mistrust. We have to remember that police officers, because of this uniform, we are the lowest level of government that many people will ever deal with. And if they have a negative interaction with us, it creates distrust for other systems of government, for resources that are out and available to the community members. Because of that distrust, many people, including those who are marginalized, members of the LGBTQ community feel that they cannot reach out for the resources because they feel that they will be discriminated against or even harmed. Next slide. Next. Our system also has a flaw in that people return home from prison and face legal discrimination in virtually all areas of social and economic and political life. They are legally discriminated against employment, barred from public housing and denied other public benefits as well. Next slide, please. Over-policing is something that I personally experienced in New York City coming up when I was born and raised in Harlem, New York. Over-policing is a situation where you look at the community that is being policed and ask whether or not it has input into how it is being policed. And in many situations, the answer is no. On the screen, you see a picture of Eric Garner. Many, if not all of you know the story, ultimately what happened, how he was confronted for a low level situation that in many instances, many departments wouldn't even have arrested him for. And ultimately the man wound up losing his life while his last words were, I cannot breathe. That put not only a stain on the police department in New York City, but it created great distrust, ultimately, which led up to after Freddie Gray's death to much of the violence that we saw. It also, that combined with George Clooney's death has created a situation where to this very day, many people, particularly those who come from marginalized communities, particularly those who experienced mental health have an increased level of distrust for police. These situations and many others can be avoided if we simply shift our model and rather than sending police officers into situations where they should not be, we redefine the role and responsibility of a police officer. And if we simply won't get away from that model, then we have to equip our police officers and train them or partner them with mental health professionals who can bring resources that police officers cannot bring to bear to ensure that these situations do not continue. Next slide. When we're able to do that, then we won't wind up with situations like the ones on this slide, where a mentally ill man during COVID calls for help from the police. He's ultimately cuffed and a mask put over his face because they were afraid he would start spitting. That man winds up dying a few days later. The history of policing has to be remembered if it had just been in the forefront of those officers' minds. If they had some training on really how to deal with someone who was mentally ill, to calm them down, to deescalate, this situation could have been avoided. And when you look at a situation where this man is not threatening anyone and is surrounded by four police officers and is treated a certain way versus this other situation where the lower slide, this gentleman is a white male who shot nine people and he was potentially armed. And yet they were able to deescalate that situation to take this young man into custody with no further incident. And he gets to walk away breathing, safe, available to his family, available to have a defense. We have to look at how we've been doing policing in this country. We have to reform it and we have to partner with our mental health professionals to ensure that lives are not lost because that's what we're talking about here. Lives are on the line. Our history tells us what we've done wrong. We need to learn from that history and get it right. I'll turn it back over to you, Dr. Thank you, Chief. So as Chief Campbell outlined a great deal about law enforcement and how we got here, but I also want to give some more information about the state of mental health in black America. As most of you know, black Americans often we present to the emergency room rather than outpatient setting, present in a crisis with more severe symptoms. And often that is related to the fact that there's mistrust and that is related to a history of being misdiagnosed. African-Americans are more likely to be diagnosed with a thought disorder such as schizophrenia rather than a mood disorder, like depression or bipolar disorder compared to their white counterparts, even when showing similar or the same symptoms. They're often less likely to be offered evidence-based medication, therapy, and more likely to receive higher doses of antipsychotics and involuntary treatment, placing them at higher risk of side effects. Distrust of the healthcare system is also strong in the community, considering historical events such as the Tuskegee Men and Syphilis Experiment. Access to mental health is also poor, often due to a lack of insurance or high out-of-pocket costs. Access to mental health treatment is often suboptimal due to cultural stigma. In the black community, mental illness may be perceived as weakness. Black Americans with mental health disorders, including those with the most severe or serious symptoms, often solely rely upon places of worship, prayer groups, and healing circles. Lack of providers is also a factor. There's only 2% of practicing psychiatrists in the U.S. who identify as blacks. Psychologists, 4%. A lack of providers from diverse racial ethnic groups plays a role. Often, like many other groups, black people prefer to talk to someone who not only looks like them, but also someone who will understand their experience. When we look at a lack of culturally competent providers, we not only see that clinicians are not trained to be aware of their biases, but how their biases may impact mental health and wellbeing. Sorry, I'm trying to get rid of this. Go back. Okay. Individuals with untreated severe mental illness generate no less than one in 10 calls for police service. Those with untreated severe mental illness often find themselves in not a hospital bed, but a prison or a jail cell. Unfortunately, when blacks are in a mental health crisis, their symptoms are often unrecognized or misinterpreted as antisocial behavior, drug-induced symptoms, or are the result of excited delirium, also known as agitated delirium or excited delirium syndrome. This syndrome is often diagnosed post-mortem in young adult black males. They are often physically restrained at the time of their death. Often, excited delirium is used to explain or justify death in custody, and is often associated with taser use. Excited delirium is not only not included in the DSM or ICD-9, it is not recognized by the AMA, the APA, the American Academy of Emergency Medicine. It is accepted primarily by the American College of Emergency Physicians. The image here is Elijah McClain. He was a 23-year-old massage therapist. He was an introvert, and multiple sources online reported he had autism. When he was approached by officers who were looking for a masked black man who had been involved in a crime, he was ordered to stop. His last words, I can't breathe. I have my ID right here. My name is Elijah McClain. That's my house. I was just going home. I'm an introvert. I'm just different, that's all. I'm so sorry. I have no gun. I don't do that stuff. I don't do any fighting. Why are you attacking me? I don't even kill flies. I don't eat meat, but I don't judge people. I don't judge people who do eat meat. Forgive me. All I was trying to do was become better. I will do it. I will do anything. Sacrifice my identity. I'll do it. You are all, you all are phenomenal. You are beautiful and I love you. Try to forgive me. I'm a mood Gemini. I'm sorry. I'm so sorry. Ow, that really hurt. You're all very strong. Teamwork makes the dream work. Oh, I'm sorry. I wasn't trying to do that. He said that after he vomited. I just can't breathe correctly. He was then forcibly held to the ground with his hands cuffed behind his back, then twice placed into a choke hold. He stopped, vomited, and told officers that he could not breathe. He was given ketamine by paramedics to treat excited delirium. At the scene, he went into cardiac arrest. Three days later, he was declared brain dead. Six days after the encounter, life-saving support was removed and he died. Why are we talking about this more? What has changed? Miles and Elijah are not the first to lose their lives and sadly will not be the last. But camera, social media, the internet and body cameras give everyone often a chance to witness what we have always known in the black community, that police brutality is real. On June 16th, 2023, the Department of Justice released this report investigating the Minneapolis Police Department following the death of Mr. George Floyd. Mr. Floyd was also reportedly experiencing excited delirium. Sorry. No, I'm not attempting to disparage the city of Minneapolis or its residents. In fact, many of the issues discussed In fact, many of the issues discussed are likely applicable in your hometown. But here are a few facts about Minneapolis. It's a diverse, prosperous city and the largest city in Minnesota. Minneapolis has a population of approximately 425,000 people with 63% who are non-Hispanic, white, 18% black, 10% Hispanic, 6% Asian and 1.3% Native Americans. It's home to multiple Fortune 500 companies and over two dozen colleges and universities. It has a higher than average proportion of residents with a four-year college education. Yet it has some of the starkest racial disparities on economic measures, including income and homeownership. The Department of Justice study the Minneapolis Police Department and the city of Minneapolis. And they found that they engaged in a pattern of practice of conduct that deprived people of their rights under constitution and federal law. That they use excessive force, including unjustified, deadly force and other types of force. They unlawfully discriminate against blacks and Native American people in their enforcement activities. They violated the rights of people engaged in protective speech. And Minneapolis Police Department and the city of Minneapolis discriminated against people with behavioral health disabilities when responding to calls for assistance. The basis for their findings were the American Disability Act. The ADA requires a public entity to take appropriate steps to ensure that communications with applicants, participants, members of the public and companions with disability are as effective as communications with other. It prohibits any discrimination against people with disabilities. Individuals with behavioral disabilities must be able to participate in or benefit from the city's services, programs and activities to an extent afforded others. The Minneapolis Police Department asks, deprive people with behavioral health disabilities an equal opportunity to benefit from the city's emergency response services. As Chief Campbell mentioned, 10% of all calls to emergency lines are related to a crisis call. Of the million emergency calls and non-emergency 911 calls between January, 2016 and August 9th, 2022, 100,000 dealt with behavioral health emergencies. Yet, the police led the primary response to those calls. Even when calls were appropriately routed to a crisis team, they were often rerouted to the police as a primary if the response was not within 10 minutes. The Minneapolis Department has lost many officers because policing and policing in the current climate takes a toll on the psychological and emotional health of officers. And the challenges in the last few years have only exacerbated that toll on the officers and the community at large. Officers, as Chief Campbell mentioned, are not always properly trained and they often use inappropriate tactics for communicating with individuals who are in a mental health crisis. As we mentioned, they are not likely to have rational thought and often have emotional responses. They can't respond to rapid, fast, or complex directives. The Minneapolis Police Department, although equipped with the opportunity to learn some skills to deescalate, failed to do so. They often use inappropriate deescalation techniques that would have included giving the person extra space or time, speaking slowly and calmly, and actively listening. The officers often, in unnecessarily escalated situations, and in many cases, use avoidable force against people with behavioral health disabilities. And just by nature of their presence, they showed up with lethal and also non-lethal weapons. The results are often dire. And Mrs. Taun Hall will share her story of miles. Hi, everybody. Hi, thank you so much for having me here today. I apologize, it might be a little loud. I'm actually at the Capitol right now in D.C. I just was testifying for a bill that's in place right now. It's a bill that's gonna help save lives. But I'm here, I'm here today. Because unfortunately, as Dion mentioned, Dr. Hart, my son, Miles Hall, was killed in a mental health crisis, emergency. And unfortunately, it's a very, very reactive system. And it's a system that eventually ended up killing my son. And even though we had known Miles was going through mental health challenges as a child, a young child, we tried to, basically, you see your loved one declining and there's not much you can do. There are certain criteria you have to be, you have to be a danger to self, danger to others, gravely ill. And Miles didn't have any of those things. And what we learned was that the system is very reactive. It's not a proactive system. And what we could get Miles off was involving police. So we did that early on to make sure that they knew who Miles was when he wasn't. And he was never a criminal. And we were successful one year before he was killed in getting Miles at 5150, which is, as everyone knows what that is. And so I thought, we were able to have safety with Miles that police knew who he was. But then a year later, Miles broke a sliding glass door. And I'm almost called. And then even though they knew Miles that the history that Miles now has schizoaffective disorder. They came and shot Miles within 30 seconds. And mind you, he had a garden tool that he thought it was a staff of God. Because again, hallucinations and delusions are something that is common with someone in a schizoaffective disorder. So now it's my life's work. We pray to the Miles Hall Foundation to make sure that these type of responses don't happen to other families. In the state of California, we have now a bill, it's called AB-988. It's called the Miles Hall Lifeline Act and Suicide Prevention. And that bill would have been exactly would have been a life-saving bill that could have saved Miles. Because the day before Miles was killed, as I explained, I had now a relationship with the police. I called and said, it looks like he's having delusions and hallucinations again. So if a bill like AB-988 was in place that involved non-police response, Miles would most likely be here today. So it's like I said, it's my life's work to advocate for the people, for Miles now that he's an angel of heaven and guiding the work that I do, but also to make sure that this doesn't happen to somebody else. As Dr. Hart explained, Elijah McClain, sweet as pie, Miles is the same kind of person. And we have to take the criminalization out of mental health. And that's really what our mission is to do, is to make sure that police don't show up to mental health calls when they don't need to be there. So I appreciate this time. I appreciate you listening. And also, please go to our website. We have a website. It's called themileshallfoundation.org. We're on Facebook, Twitter, and Instagram. And our main focus, like I said, is to make sure this doesn't happen to another family. So thank you for the work that you all are doing. Say his name, Miles Hall. Thank you for sharing your story. Thank you for sharing Miles's legacy with us. And to continue that conversation about how we can make it safer, Dr. Goldman is going to talk to us about his work. Thanks, all. Thanks, Dr. Hart and Chief Campbell and Ton so much for sharing. We've got about 15 minutes left today. And I'm going to try to do a bit of a whirlwind through what we know about some of the interventions and the evidence base for interventions that can address some of what we've heard about today. So if the goal is we don't think that law enforcement is the right response to every single mental health crisis happening out in the world, then what is the right response? What are the alternatives? And I start with this slide here to really frame that our behavioral health systems, as they're supposed to be responding to situations like this, are in many ways failing, and they're failing inequitably. So we know that there's an increase in suicides and overdose deaths across the country, and that's happening inequitably. During COVID-19 in Maryland, suicides halved among white people but doubled in the Black population. The criminal legal carceral involvement we know is a deepening issue, and obviously there are tremendous disparities there. One example among many is that Black people account for 41% of those receiving mental health services in LA County jails, even though they represent only 30% of the overall jailed population. Emergency department boarding is a huge issue, which is reflective of our not having adequate crisis services for those who do need supports, and that's impacting populations inequitably. There's one study that showed longer ED wait time for non-Hispanic Black population versus non-Hispanic white population, and just generally inadequate access and capacity to mental health services, which again cuts along race, ethnicity lines. So there's disparities at the core of all of these challenges, and these are the very systems that we really need to improve upon in order to better serve folks who otherwise might be involved in criminal legal carceral type systems inappropriately. Next slide. So society is catching on to this. There's been quite a bit of news coverage on topics like policing of people with mental illness, with headlines like in the New York Times saying a mental health crisis is not a crime. This has been covered in a lot of different news areas, and so I think people are finally getting this at a societal level, but there's still a lot of catch-up for the actual mental health systems themselves to do to be responsive to, I think, what society is really demanding. Next slide. A brief synopsis of the history of crisis services in the United States. So 9-1-1 was founded in 1968. There's a whole interesting history of 9-1-1 as really being created as a mechanism for communities to control people who they felt were threatening to them in communities, and there's actually quite a bit of sort of structural racism built into the history of 9-1-1 itself, but that first 9-1-1 call was placed from the floor of Congress in 1968 when it was first initiated. In 1987, crisis intervention team model was founded, which I'll talk a little bit about more later. In 2005 was when the National Suicide Prevention Lifeline was funded by the Substance Abuse Mental Health Services Administration, and subsequent suicide prevention-focused activities, including Zero Suicide, the National Action Alliance for Suicide Prevention, then followed, and all of that work sort of pointed to, well, when people are in a suicidal crisis, then who's responding? What's the actual capacity? And so that's really what actually led to the surge of crisis service investments and development across the U.S. that we're seeing now. In 2019, the Federal Communications Commission designated 988 as the national number that would become the 988 Suicide and Crisis Lifeline. In 2020 is when SAMHSA released its national guidelines, the Best Practices Toolkit on Crisis Services. 2021, the National Council for Mental Well-Being released its own report called The Roadmap to an Ideal Crisis System, and in 2022, of course, just almost exactly a year ago, is when 988 went live, transitioning that 1-800-273-TALK, National Suicide Prevention Lifeline phone number to 988. So, you know, there's a lot of history in this space. A lot of it has been around really suicide prevention driving crisis services, but in 2020, with the pandemic, with George Floyd's murder, with, again, sort of Black Lives Matter really taking off, there was this kind of amazing confluence of recognition of suicide prevention needing to be more robust, needing to have actual crisis services to respond to folks in their time of need, and needing appropriate alternatives to law enforcement-based responses to people who are in crisis. Next slide. I also just wanted to call out the Sequential Intercept Model. This is another sort of framing from SAMHSA, basically identifying different pathways along the criminal, legal, carceral system pathways, where people with mental illness could be diverted or deflected from involvement in these systems, and you can see here Intercept 1 is 911 and local law enforcement, so wanting to really have diversion from 911 and alternatives to local law enforcement, those would be what would be considered Intercept 0, where crisis lines and other components of the crisis care continuum would be located, which is what I'll talk a bit more about today. Next slide. The Arizona crisis system is in many ways regarded as kind of the gold standard for how crisis continuums should operate, the idea here being that when there's a person in crisis, in order to, you know, all the way at the right side there, you see decreased use of ED, jails, and inpatient. The way to get there is by having multiple potential interventions that are working in concert, all with the goal of reducing the law enforcement involvement. So if a person in crisis can call a crisis line instead of 911, or even if a 911 line can transfer to a dedicated behavioral health crisis call for appropriate calls, 80 percent of calls are able to be resolved on the phone in Arizona. For those that need an in-person response, a mobile crisis team can be dispatched, and that can be an alternative to law enforcement, or law enforcement itself can request mobile crisis to co-respond, and those programs are resolving 71 percent of calls in the field in Arizona. For those that need additional stabilization, they can go to a dedicated crisis facility as an alternative to jail or emergency departments, and police also, if they do encounter somebody who they pick up, can directly drop off at a crisis facility, and 68 percent of those folks can be discharged safely to the community, and Arizona's post-crisis wraparound services are able to maintain 85 percent of people who engage with crisis services safely in community-based care. So all of this goes towards decreasing use of these acute, intensive services, really promoting pre-arrest diversion, and also serving people in less restrictive and less costly environments. Next slide. So what I'm going to do is a really quick tour through the evidence base for these different kinds of interventions, starting with crisis call centers. Next slide. So first, the National Suicide Prevention Lifeline, which is now 988, is this network of 200-plus call centers that's administered by Vibrant Emotional Health, receiving grant funding from SAMHSA. There's a Spanish and American Sign Language line. There's now a pilot for LGBTQ-plus populations. There's a new tribal line in Washington, and actually, just a couple days ago, the chat and text feature of 988, which is available nationwide, just added on a Spanish-language component in chat and text, which is very exciting. This all works in close concert with the Veterans Crisis Line, which is a key to the Veteran Health Administration Suicide Prevention Strategy. In January of 2023, the total routed contacts to 988 were 450,000 calls, and there's 66,000 calls that were offered to veterans, and there's also various other crisis lines and warm lines, many of which are peer-operated. Next slide. So the transition to 988 is a big deal. It has demonstrated an increased volume of calls, chats, and texts, expanding crisis call center responder roles, raising issues related to 911, 988 interoperability, and needed interfaces with local programs, including mobile crisis. There's still ongoing work related to geo-routing of 988 calls, meaning that people who are calling 988 in present day, their phone calls get routed by area code, and that's currently an operational challenge, so needing to transition those calls to be routed instead by cell tower, and lots of questions around equity and access in these calls. On the right side there, you see that 911 calls comprise a large majority of behavioral health related crisis calls, and also in the yellow there, there's still many more local, county, and state-operated crisis lines that are receiving a larger volume of calls even than 988 currently. Next slide. Also just flagging here that there's a whole area of work around 911 diversion, meaning that people who are calling 911 can have their call diverted to 988 or other behavioral health specialists, and there's a playbook that Nashbin put out that answers some of this. Next slide. So mobile crisis programs can go to the next slide here. There are many flavors of what mobile crisis looks like. First were established back in the 1930s, and as of March of last year, at least 45 states have mobile crisis teams, although a few operate statewide. Typically, these programs have one or two clinicians. Usually, you'll almost always have a behavioral health clinician plus or minus somebody like a technician, or also in many cases, they include peers. There are also co-responder ride-along models where a behavioral health clinician and a police officer would co-respond, although these are least preferred by people in crisis and their families. There's also a cahoots model that's very widely known with behavioral health clinician and paramedic. Next slide. Reaching mobile crisis teams is currently most often through self-dispatch. This is some work that we did with a survey nationally of mobile crisis teams. 911 law enforcement also are regularly requesting mobile team services, but you can see there, the third to last row, there are national suicide prevention lifeline, and only 32% of mobile teams currently report being able to be dispatched by 988. So there's still quite a bit of work related to integrating the crisis continuum that's needed. Next slide. The crisis intervention team model I mentioned, which was established in Memphis in the 80s, was actually in response to a police shooting involving a person with mental illness who was Black who was killed by police. About 3,000 jurisdictions across the US have CIT programs, and these typically tend to be officer-only programs, but training them in skills and how to best serve folks in their moment of crisis. Next slide. There's some evidence for mobile crisis. They tend to be single-site quasi-experimental studies, but in general, their findings are focused on service use, and there's been very little done on how people actually experience mobile crisis services and whether they benefit from those types of interventions. So still more work needed to be done in this area as well. Next slide. For youth, there's also some work that's been done more specifically on youth, and again, so for example, a couple studies, one found reduction in ED use, another found increase in ED use. But there were important disparities that were found in youth mobile crisis services, so that's an area of further work as well. Sorry, I'm going so quickly here, but we only have a few minutes left, so that's why I'm racing through these. Next slide, please. Finally, for crisis facilities, you can go to the next slide here. So there are also many versions of crisis facilities where they can range from 23-hour observation to subacute. There's a living room model, other substance use-focused settings, and crisis residential. Really, the point here is all of these might be called a crisis stabilization unit, but there's a lot of confusion around nomenclature and licensing state to state. So really, the goal here, though, is that there's a behavioral health specialty setting for bringing somebody in crisis. Next slide. There is some evidence, although most of these different types of settings are minimally studied, is sort of the takeaway here. Next slide. And residential programs are actually some of the best studied, and in general, they show greater client satisfaction than traditional inpatient settings, as well as lower costs. Next slide. Finally, in terms of impact on equity, this is a powerful quote that basically summarizes. It says that we need to be able to measure disparities and to be able to observe impacts of disparities, but that's not currently possible in the current systems functioning, and so there's much more work needed to be done to be able to really demonstrate disparities and how programs reduce disparities. Next slide. There have been some studies focusing specifically on disparities, and they do measure different race, ethnicity groups, outcomes, and some of those have actually been very robust in demonstrating impacts on the populations that are most trying to reach. Next slide. And so basically, in summary, there's many strategies to advance crisis services research to further this evidence base. We can discuss those more in the Q&A that we'll have just a couple minutes left, so I think we can move forward to the end. With just this last takeaway for crisis clinicians, that engaging with communities served to understand their needs and inform quality goals is crucial. Building programs where evidence is available is important, but drawing on clinician best practices from other settings is really how we need to approach this as psychiatrists and as clinicians. It's critical to track data on quality of care, including stratifying race and ethnicity and partnering with colleagues to evaluate implementation of new programs to really expand the evidence base. So with that, I'll hand it back to Dr. Hart. Thank you. Thank you, Dr. Goldman. I think we want to start and end with a call to remember the victims and their loved ones, to advocate for safer policing, to, of course, say their names and to remember the people who lost their fight with mental illness when they actually were seeking help. So we have just a couple minutes for Q&A. I'm going to ask staff to make sure that we are able to see the questions. Okay. So see, Dr. Cundiff asked about the criteria for excited delirium, if it's clear or not clear. And actually, it's kind of like very unclear, which is one of the problems. It's kind of like a catch-all. And that's why it has not been recognized. And Dr. Cundiff said the ACEP, which is American College of Emergency Physicians, recognizes hyperactive delirium syndrome with severe agitation based on vital signs, mental status, and metabolic derangements. And again, that has not been supported by the AMA or the APA. And furthermore, Dr. Cundiff says the ACEP does not recognize the use of the term excited delirium and its use in clinical settings. I don't see any other questions. So again, we want to thank you for taking the time to be with us for this hour. It went by very quickly. And we always think about this being the start of conversation that we started in APA and we continue today. And we hope that you will join us for future sessions to really talk about this very important problem, but also to focus on the solutions. So thank you again for your time. We will see you next time and we'll see you on social media. Have a great afternoon. We will have another webinar tomorrow, 3 to 4 p.m. Eastern time, titled Technology, Acceptance, and the Digital Divide. We hope you can join us for the webinar. Thanks again and take care.

mental health

policing

race

crisis response

safe policing

criminalization of severe mental illness

Black community

access to care

alternative responses

racial disparities