International Journal of Law and Psychiatry 34 (2011) 287–294

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

CIT in context: The impact of mental health resource availability and district
saturation on call dispositions
Amy C. Watson a,⁎, Victor C. Ottati b, Jeff Draine c, Melissa Morabito d
a

Jane Addams College of Social Work, University of Illinois at Chicago, 1040 W Harrison Street, MC 309, Chicago, IL 60607, United States
Loyola University-Chicago, IL USA
Temple University, Philadelphia, PA, USA
d
University of Massachusetts, Boston, MA, USA
b
c

a r t i c l e

i n f o

Available online 5 August 2011
Keywords:
Crisis Intervention Teams
Policing
Mental Health Treatment Access

a b s t r a c t
The goals of Crisis Intervention Team (CIT) programs include improving safety during encounters between
police and persons with mental illnesses, diverting persons with mental illnesses away from the criminal
justice system, and increasing referral and access to mental health services. CIT is a systemic intervention, and
as such, its implementation and effectiveness are inﬂuenced by existing practices and infrastructures.
However, little research has considered the context in which CIT programs are implemented. In this paper, we
present research on CIT in four Chicago police districts that vary in terms of two contextual factors
hypothesized to inﬂuence the impact of CIT training on how calls involving persons with mental illnesses are
resolved. Using data from 112 patrol ofﬁcers in four Chicago police districts, we consider the impact of mental
health services availability and CIT saturation (the percentage of district personnel that are CIT certiﬁed).
Findings indicate that CIT training increased direction to mental health services primarily in districts with
greater availability of mental health services. In districts with low service availability, higher CIT saturation
increased direction to mental services. The opposite pattern emerged for contact only or informal call
resolution. No effects were found for arrest as a call outcome.
© 2011 Elsevier Ltd. All rights reserved.

1. Introduction
Crisis Intervention Team programs are being implemented by
police agencies across the United States to improve police response to
persons with mental illnesses. The goals of CIT programs include
improving safety in encounters between police and persons with
mental illnesses, diverting persons with mental illnesses away from
the criminal justice system, and increasing access to mental health
services. The limited, but growing body of literature suggests that CIT
may be positively inﬂuencing these outcomes (see Compton, Bahora,
Watson, & Oliva, 2008 for review). CIT is a systemic intervention, and
as such, it builds on existing practices and infrastructures. However,
little research on CIT has considered such contextual factors and the
extent to which they inﬂuence CIT effectiveness. In this paper, we
consider two contextual factors (one community, one organizational)
conceptualized on the police district level that are hypothesized to
inﬂuence the impact of CIT training on how calls involving persons
with mental illnesses are resolved by Chicago police ofﬁcers. We
examine the role of mental health services availability and CIT

⁎ Corresponding author. Tel.: + 1 312 996 0039.
E-mail address: acwatson@gmail.com (A.C. Watson).
0160-2527/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijlp.2011.07.008

saturation, deﬁned as the percentage of district personnel that are CIT
certiﬁed.
1.1. The CIT model
CIT is a specialized police-based response model to improve police
response to individuals experiencing mental health crises. The CIT
model was ﬁrst developed in Memphis, TN in 1988 following the fatal
shooting of a man with a history of mental illness and substance abuse
by a Memphis police ofﬁcer (Dupont & Cochran, 2000). Following this
tragedy, a community task force comprised of law enforcement,
mental health and addiction professionals, and mental health
advocates collaborated to develop what is now internationally
known as the Memphis CIT model. The goals of CIT are to increase
safety during mental health crisis calls and to divert individuals with
mental illness away from the criminal justice system and to
appropriate mental health services.
While the centerpiece of the model is 40 h of specialized training
for a select group of ofﬁcers that volunteer to become CIT ofﬁcers,
proponents stress that CIT is more than just training. CIT is an
organizational and community intervention that involves changes in
police department procedures as well as collaboration with mental
health providers and other community stakeholders. Ofﬁcers volunteer to receive 40 h of training provided by mental health clinicians,

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consumer and family advocates, and police trainers. Call dispatchers
are trained to identify mental disturbance calls and assign these calls
to CIT trained ofﬁcers. If necessary, the CIT ofﬁcer uses de-escalation
techniques and assesses if referral to services or transport for mental
health evaluation is appropriate. An important component of the
model is a central designated psychiatric emergency drop off site with
a no refusal policy (Steadman et al., 2001). This allows the ofﬁcer to
transport an individual for emergency evaluation and treatment and
get back out on the street to his or her other duties in a timely manner.
Enthusiasm about the CIT model has spread quickly as police
agencies struggle to demonstrate greater responsiveness to the
growing numbers of persons with mental illness they encounter.
Current estimates suggest that worldwide, there are over 1000 CIT
programs being implemented (Compton et al., 2011). The evidence
regarding CIT's effectiveness is limited, but guardedly positive. Initial
reports from Memphis suggest that the CIT program has reduced
arrests and increased safety and diversion to mental health services
(Dupont & Cochran, 2000). Subsequent research supports an
association between CIT and lower arrests rates of persons with
mental illnesses (Steadman, Deane, Borum, & Morrissey, 2000);
increases in the number of mental health related calls identiﬁed;
increases among CIT ofﬁcers in transports to the hospital for
psychiatric evaluation and increases in the proportion of transports
that are voluntary (Teller, Munetz, Gil, & Ritter, 2006). Only one study
has examined outcomes for persons with mental illnesses beyond the
immediate CIT encounter. Broner, Lattimore, Cowell, and Schlenger
(2004) found that diversion from arrest by pre-booking programs
such as CIT increased mental health service utilization in the
subsequent 12 months for persons with serious mental illnesses.
Several studies have examined safety outcomes with mixed ﬁndings.
While Dupont and Cochran (2000) have reported an association
between CIT implementation in Memphis and decreased use of highintensity police units such as Special Weapons and Tactics (SWAT)
teams, Compton, Demir, Oliva, and Boyce (2009) did not ﬁnd an
association between CIT implementation and SWAT call outs (Compton
et al., 2009). A few studies have examined CIT's impact on use of force
and injuries. Skeem and Bibeau (2008) found that CIT ofﬁcers used force
in only 15% of encounters rated as high violence risk and that when they
did use force, they generally relied on low-lethality methods. In analysis
of data from our Chicago study reported elsewhere (Morabito, Kerr,
Watson et al., 2010), we found that CIT ofﬁcers used less force as subject
resistance increased than ofﬁcers that were not CIT trained. We did not
ﬁnd a CIT effect on injuries (Kerr, Morabito, & Watson, 2010). However,
in a qualitative study (Hanaﬁ, Bahora, Demir, & Compton, 2008) ofﬁcers
reported that application of their CIT skills reduces the risk of injury to
ofﬁcers and persons with mental illness.
Additional research on CIT has shown CIT training is associated
with improvements in attitudes and knowledge about mental illness
(Compton et al., 2006) and ofﬁcers' conﬁdence in identifying and
responding to persons with mental illness (Wells & Schafer, 2006).
While the existing research suffers from a variety of methodological
limitations, overall, it suggests that CIT may be positively impacting at
least some of its intended outcomes. However, no research to date has
examined how variations in model implementation or the context CIT
is implemented in inﬂuence the outcomes of calls involving persons
with mental illnesses.
1.2. CIT in context
More than 40 years ago Reiss and Bordua (1967) noted that police
must regularly transact with external entities (such as hospitals,
mental health agencies), many of which are antagonistic to the police.
They asserted, and Klinger (2004) echoes, that these external entities,
as well as the broader social context and the nature of the tasks
ofﬁcers are called on to perform, largely inﬂuence police behavior. In
this vein, the availability and characteristics of mental health services,

as well as other characteristics of the community police ofﬁcers are
working in may inﬂuence the nature of and frequency of mental
disturbance calls, the resources available to ofﬁcers for responding,
and ultimately, the effectiveness of CIT programs. Despite the
importance of context, there has been little discussion in the CIT
literature of variations within or even between cities. This paper seeks
to better understand how variations within a police department and
across communities served by the department might affect the
implementation of CIT and the subsequent outcomes of calls for
service involving people with mental illness.
1.2.1. The mental health system matters
Given that a key outcome espoused by CIT proponents is the
diversion of persons with mental illness from the criminal justice
system to appropriate mental health treatment, the availability of
mental health treatment resources may be extremely important to
CIT's success. There is extensive evidence dating back several decades
that police ofﬁcers ﬁnd accessing crisis and emergency psychiatric
treatment for persons with mental illness extremely frustrating and
time consuming (Bittner, 1967; Green, 1997; Teplin & Pruett, 1992)
and that they are dissatisﬁed with the available options (Wells &
Schafer, 2006). In order to divert individuals with mental illnesses to
mental health services, ofﬁcers must interact with providers from the
mental health system. This can only occur if responsive mental health
services exist; and if ofﬁcers are able to efﬁciently link individuals to
treatment to resolve a mental health call. Additionally, police need
access to community mental health resources to respond to individuals who are in need of services but do not meet criteria for
emergency evaluation at the hospital.
1.2.2. Organizational factors matter: CIT saturation
Organizational factors may also inﬂuence police ofﬁcer behavior
and the effectiveness of policing innovations such as CIT. One factor
that has been discussed in the CIT literature pertains to optimal
stafﬁng, or the percentage of personnel (patrol and supervisory) that
are CIT certiﬁed, necessary to maximize the effectiveness of a CIT
program. We call this saturation. Initial recommendations for CIT
saturation range from 15 to 25% of all patrol ofﬁcers in order to ensure
24/7 CIT coverage (Reuland, 2004; Thompson & Borum, 2006). More
recently, some departments have moved to have all ofﬁcers complete
CIT training (100% saturation). However, the optimal saturation level
has not been empirically tested.
Saturation may be more complex than simply having enough
ofﬁcers trained to ensure 24/7 availability. Optimal saturation may be
the point at which enough ofﬁcers are trained to produce a self
sustaining change in how the department responds to persons
experiencing mental health crisis. Rogers (2003) provides an example
of diffusion of innovation that is useful for understanding how the CIT
saturation level at its critical mass may inﬂuence larger changes in
department practice. A single log in a ﬁreplace will not continue to
burn by itself. A second log must be present so that each log reﬂects its
heat onto the other (p. 349). Once enough logs are burning, the ﬁre
can provide heat for the entire organization. Thus, CIT trained ofﬁcers
may need a certain number of trained colleagues and supervisors in
order to put CIT into practice and take a new approach to mental
health crisis calls. However, it may not be necessary to have a large
number of CIT trained personnel or 24/7 coverage in order to trigger
an overall change in how ofﬁcers in the organization approach and
manage these calls. Using the log example, saturation could involve
enough CIT trained ofﬁcers to provide opportunities and support for
other personnel to learn and practice new ways of responding to
mental health crisis situations from their CIT trained colleagues.
1.2.3. Understanding CIT in context
In a previous paper (Watson et al., 2010), we examined the effect
of “individual ofﬁcer CIT training” on various outcomes while simply

 A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

289

controlling for the effect of the police district in which the individual
ofﬁcer works. Results indicated that CIT training increased direction to
mental health services as a call disposition. In contrast, the present
approach distinguishes police districts along two dimensions. These
are “district mental health resource availability” (low versus high)
and “district saturation” (low versus high). This enables us to examine
the degree to which these two contextual variables moderate the
effect of “individual ofﬁcer CIT training” on key outcome variables
(e.g., direction to mental health services). We hypothesize that the
“individual ofﬁcer CIT training” effect of increasing direction to mental
health service (and decreasing informal dispositions) will be
enhanced in contexts with high levels of mental health resource
availability, as ofﬁcers will have a greater number of mental health
options to direct call subjects toward. Additionally, we expect greater
CIT saturation to enhance the CIT effect. CIT trained ofﬁcers in highly
saturated contexts may feel more supported by peers and supervisors
in putting their CIT training into practice. Finally, we examine the
interaction between mental health resource context and CIT saturation. Presumably, if the prior hypotheses are supported, call
dispositions will be the impacted the most in high resource and
high saturation contexts.

well as district by district basis. Given the size of the city, a single point
of access/no refusal crisis drop-off point was impractical. Thus,
Chicago's CIT program relies on memorandums of understanding
(MOUs) with designated hospitals throughout the city that establish
no-refusal policies and give police transports priority to reduce the
time that ofﬁcers spend waiting in emergency rooms. These MOU
arrangements and corresponding departmental Special Orders directing ofﬁcers to transport persons in need of psychiatric evaluation and
care to the designated facilities predate the CIT program by several
decades (personal communication, Lt. Jeff Murphy, 6/19/2010). There
is some variation across the city in how well the MOUs are
implemented, and occasionally the police department and hospital
administrators need to revisit or renegotiate the process. The local
NAMI afﬁliate has provided ofﬁcers with resource cards that list
information about mental health and other social service resources
that they can give to persons with mental illness and their families or
use to make referrals (NAMI of Greater Chicago, 2008). As with the
distribution of mental health services across the city, mental health
resources listed on the card are not evenly distributed across the city.

2. Method

Four districts were selected for this study. Two were the CIT pilot
Districts, District A and District B. A comparison district with very few
CIT trained ofﬁcers but similar in other characteristics was selected for
each of the pilot districts using information on availability of mental
health resources, community demographics and crime rates, compiled
from U.S. Census 2000 (U.S. Census Bureau, 2001) and Chicago
Department of Public Health (2006) listings of mental health providers
and service capacity, the Chicago Police Department Annual Report for
2007 (Chicago Police Department, 2008) and personnel lists provided
by the CIT training program and the study District commanders.
Characteristics of study districts are described in detail elsewhere
(Morabito, Kerr, Watson, Draine, & Angell, in press; Watson et al., 2010).
Here, we brieﬂy describe the districts in terms of mental health
resources and saturation.

CIT was ﬁrst implemented in 2005 as a pilot program in two of the
Chicago Police Department's 25 districts. The Department began
planning city-wide expansion of the program in 2006. Given this
unique opportunity, we sought to examine CIT in districts where it
was already established (high saturation) and districts where it was
just recently being implemented (low saturation). We also had the
opportunity to examine districts with greater access to mental health
treatment and those with less access to mental health treatment.
The Chicago Police Department serves a population of approximately 2.9 million residents in an area of 228.5 mi 2. Chicago is divided
into 25 police districts—each containing 9 to 15 beats. At the end of
2007, the Department had 13,616 sworn/exempt ofﬁcers (Chicago
Police Department, 2008). All ofﬁcers receive training on mental
health issues during their pre-service academy training. In 2005, the
department held two 40 hour CIT trainings and began pilot implementation of CIT in two districts that vary signiﬁcantly in terms of
demographics and availability of mental health services, District A and
District B. Ofﬁcers in these districts were encouraged to apply to the
program. In each district 30–40 ofﬁcers and supervisors were trained
and certiﬁed. Beginning in July 2006, the Department began program
expansion, training approximately 30 ofﬁcers from across the city
each month (rather than rolling out one district at a time). By
February of 2008, when data collection for this study began, 532
ofﬁcers from across the city had completed CIT training.
The 40 hour curriculum, described in greater detail elsewhere
(Watson et al., 2010), is presented by mental health clinicians from
the community, police academy trainers, representatives from the
prosecutor's ofﬁce, advocates, consumers and family members. The
curriculum incorporates lectures, role-play training, and panels of
consumers, family members, and providers. Topics covered include
recognizing signs and symptoms of mental illnesses, co-occurring
disorders, medications, ands legal issues and procedures. A signiﬁcant
portion of the training time is devoted to realistic role-play exercises
in which ofﬁcers practice their de-escalation skills while being
videotaped. Role play actors are consumers from a local community
mental health center theater group. Actors review video tapes of the
role play scenarios with ofﬁcers and provide feedback. Call takers and
dispatch staff in the pilot districts received informal training related to
their role in CIT implementation. Formal citywide training is being
discussed but has not been conducted to date.
Signiﬁcant efforts supported successful collaboration between the
police and the mental health system and are ongoing on a citywide as

2.1. Study districts

Fig. 1. Density of mental health services in Chicago. This is a kernel map of the city of
Chicago. Police districts borders and mental health service providers are plotted. The
darker the color, the higher the density of mental health services. The lighter the color,
the fewer mental health services offered.

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A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

District A serves a predominately African American and disadvantaged population. The density of mental health services is low relative
to the North part of the city (See Fig. 1). At the time of baseline data
collection for this study, a total of 41 ofﬁcers working in District A,
including six supervisors, had completed CIT training. Thus, 17.4% of
the supervisory (Sgt and above) staff and 10.14% of nonprobationary
patrol ofﬁcers were CIT certiﬁed.
District B, serves a more racially and ethnically heterogeneous and
less disadvantaged population. Bordering on the lakefront, District B's
area includes both a number of afﬂuent neighborhoods and areas
dense with mental health services (See Fig. 1) and housing facilities
serving persons with mental illnesses that are sometimes referred to
as the “mental health ghetto.” At the time of baseline data collection
for this study, a total 40 ofﬁcers working in District B, including eight
supervisors, had completed CIT training. Thus, 19.5% of the supervisory (Sgt and above) staff and 13.9% of nonprobationary patrol ofﬁcers
were CIT certiﬁed.
District C was selected because it was very early in the CIT
implementation process, but similar to District A in terms of population
demographics, crime and a low level of resource availability. At the time
of baseline data collection, District C had only 13 CIT trained ofﬁcers,
including one supervisor. Thus, 2.0% of the district's supervisory staff
and 4.7% of patrol ofﬁcers were CIT certiﬁed.
District D was selected because it was early in the CIT implementation process, but similar to District B in terms of other characteristics. District D is similarly dense with mental health resources and
shares a designated hospital for police transports for psychiatric
evaluation. At the time of baseline data collection, District D had only
16 CIT trained ofﬁcers, including four supervisors. Thus, 10.81% of the
district's supervisory staff and 3.95% of nonprobationary patrol
ofﬁcers were CIT certiﬁed.
2.2. Sampling
Using district personnel lists provided by the District commanders
and CIT ofﬁcer lists provided by the CIT training unit, we selected a
total of 80–86 ofﬁcers from each study district to invite to participate
in the study. The resulting list included ofﬁcers of all ranks and district
assignments. All CIT trained ofﬁcers (41, 40, 13 and 16 respectively
from Districts A, B, C and D) were invited to participate. We used
proportionate random sampling based on the number of ofﬁcers
assigned to each watch to select enough non-CIT ofﬁcers to make 80–
86 in each district for a total of 333 ofﬁcers invited.
2.3. Recruitment
Members of the research team visited roll calls for each watch (shift)
to announce the study. The next day, we delivered letters to selected
ofﬁcers at their district. The recruitment letter further described the
study and invited the ofﬁcers to participate. It also gave a phone number
for the ofﬁcers to call by a given date if they did not want to be contacted
further about the study. All other ofﬁcers were contacted in person
while on duty via their watch commander, who asked them to meet
with one of the researchers to learn more about the study and if they
consented, complete the interview. Including six that declined by phone
prior to meeting with the researchers, a total of 58 ofﬁcers declined
participation. We were unable to meet with 59 of the selected ofﬁcers
due to medical leaves, military leaves, and retirements that were not
reﬂected on our initial personnel lists. Our response rate was 65% if the
ofﬁcers we were unable to contact are included in the denominator or
79% if they are not.
2.4. Interview
The interview consisted of four sections. The ﬁrst section asked the
ofﬁcers to brieﬂy describe their most recent call involving an adult

with mental illness. We speciﬁcally instructed ofﬁcers: “This call does
not have to necessarily include a hospitalization of the subject but
could have other outcomes, such as arrest, referral to services or
informal action. Additionally, this does not have to be a call that you
documented or did paper work on.” The deﬁnition of mental illness
relied solely on the perceptions of ofﬁcers, as it is the ofﬁcer's
perception of illness that matters in identifying a potential subject for
CIT intervention. After the ofﬁcers described the call, we asked them a
series of questions about how the subject came to their attention;
characteristics of the subject; the subject's level of resistance; ofﬁcer's
use of force; injuries to the ofﬁcer and subject; other situational
characteristics; the outcome of the call; perception of mental health
system resources if used; and ofﬁcer use of skills in the call. Many of
the items and scales were adapted from existing measures. The items
used in the analysis reported here are described further below in the
measures section. The complete interview instrument is available
from the ﬁrst author on request.
The second section of the interview asked ofﬁcers to think about all
of the calls involving adults with mental illnesses they responded to in
the past month. The same series of questions was repeated, however,
instead of describing a single call, they were asked to indicate how
many subjects/calls in the past month had the subject or situational
characteristics; outcomes; etc. Interviewers carefully crosschecked
the numbers with the total number of calls reported and clariﬁed
inconsistencies with the ofﬁcers.
The third section of the interview included items tapping ofﬁcers'
perceptions of the mental health services available in their area; their
district's ability to effectively respond to persons with mental
illnesses; their own skills for responding to persons with mental
illnesses; their perception of the CIT program; and District level and
organizational support of the CIT program. The ﬁnal section of the
interview asked ofﬁcers to provide personal demographics, job
assignment, and personal familiarity with mental illness. The data
used in the analysis to follow was collected within a ﬁve-week period
during March and April of 2008. Study procedures where approved by
the Behavioral and Social Sciences Institutional Review Board at the
University of Illinois at Chicago. The data on past month calls is the
focus of this paper.
2.5. Measures
2.5.1. Dependent variables
Ofﬁcers indicated the number of past month calls involving an
adult with mental illness that had each of the following outcomes:
arrest only; arrest and transport to hospital for medical treatment;
arrest and transport for psychiatric evaluation; voluntary transport for
psychiatric evaluation; involuntary transport to psychiatric evaluation; transport for medical treatment; transport to mental health
facility other than hospital; referred to mental health/social services;
and contact only. For purposes of the analysis, we collapsed the ten
categories into three mutually exclusive call outcome categories.
These were number of Calls Directed to Mental Health or Social
Services without arrest, number of calls resulting in Contact Only, and
number of calls resulting in Arrest. The number of past month calls
involving an adult with mental illness varied among ofﬁcers, thus, we
converted the number reported in each of these three outcome
categories into a proportion by dividing by the total number of calls
reported. Theoretically, these proportions can range from .00 to 1.00.
2.5.2. Control variables
To select the control variables for the analyses, we ﬁrst examined
bivariate relationships between the outcome variables and numerous
ofﬁcer, subject, and situational variables. Theoretically relevant and
signiﬁcantly correlated variables were retained and constituted the
control variables in the design.

 A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

Prior research suggests that ofﬁcer characteristics inﬂuence
decisions in mental health related calls (Green, 1997). Here, two
ofﬁcer characteristics were included as control variables in the design.
These were ofﬁcer age and race. Ofﬁcer Age was centered at zero and
re-scaled so that one scale unit reﬂects the full range of age from the
youngest to oldest ofﬁcer in the sample. Ofﬁcer Race was coded as
0 for “non-white” and 1 for “white.” This variable was then centered at
zero by subtracting the sample mean from the raw score.
Three Subject Characteristics were also included as control
variables. The ﬁrst two were the number of calls in which the subject
appeared to have a co-occurring substance abuse disorder (Subject
SA) and the number of calls in which the subject was female (Subject
Female). Dividing by the total number of calls, each of these scores
was converted to a proportion. “Substance Abuse Disorder” (Subject
SA) and “Subject Female” proportions were centered at zero by
subtracting the mean. The third characteristic was Subject Resistance.
Ofﬁcers rated Subject Resistance using the categories in the Chicago
Police Department Continuum of Force (Chicago Police Department,
2003). These categories are “cooperative,” “passive resister,” “active
resister,” and “assailant.” Ofﬁcers reported the number of past month
calls in which the subjects' highest level of resistance fell into each of
these categories. These numbers were converted to proportions by
dividing by the total number of past month calls reported. These
proportions were used to calculate a past month resistance index in
which higher scores indicate greater resistance. Using a linear
transformation, these scores were re-scaled such that −.5 equals
one standard deviation below the mean, 0 equals the mean, and +.5
equals one standard deviation above the mean.
Finally, one situational characteristic was included as a control
variable. Prior policing research suggests that complainant requests
inﬂuence police decisions for resolving mental health related calls
(Bittner, 1967). Thus, Complainant Requested Action reﬂected the
number of all past month calls reported by the ofﬁcer in which there
was a complainant (family member, business owner, etc.) that
requested a speciﬁc outcome. Dividing by the total number of calls,
this was converted to a proportion. Using a linear transformation,
these scores were re-scaled such that −.5 equals one standard
deviation below the mean, 0 equals the mean, and +.5 equals one
standard deviation above the mean.
2.5.3. Independent variables
Ofﬁcer CIT Training was coded as a dichotomous variable that
distinguished “Non-CIT Ofﬁcer” from “CIT Ofﬁcer.” District Resources
represents the relative availability of mental health resources in the
district. Ofﬁcers within District B and D were coded as residing in the
“high resource district” condition, whereas ofﬁcers within Districts A
and C were coded as residing the “low resource district” condition.
District Saturation pertains to the percentage of district personnel that
are CIT trained. Ofﬁcers within Districts A and B were coded as
residing in the “high saturation district” condition, whereas ofﬁcers
within Districts C and D were coded as residing the “low saturation
district” condition.

291

Table 1
Sample characteristics.
Frequency/percent
Training status
CIT
non CIT
District
A
B
C
D
Race/Ethnicity
white
African American
Other
Hispanic/Latino
Male
Someone close has mental illness
Age
Years experience
MH calls past month
Call outcome–proportion
Direct to Services
Contact Only
Arrest

56 (50%)
56 (50%)
31
36
31
14

(27.1%)
(32.1%)
(27.7%)
(12.5%)

48 (42.9%)
45 (40.2%)
18 (16.1%)
14 (12.7%)
89 (79.5%)
58 (51.8%)
Mean (SD)
40.5 (9.2)
10.5 (7.4)
5.14 (5.2)
.56 (0.42)
.31 (0.37)
.09 (0.23)

The distribution of ofﬁcers across the study districts and sample
demographics are listed in Table 1. Demographics of the sample are
roughly representative of department personnel overall. The sample
is predominantly male and diverse in terms of race and ethnicity. Over
half reported that someone close to them (self, family, friend) has a
mental illness. On average, CIT ofﬁcers were older (M = 43.20,
SD = 9.45 v. M = 37.76, SD 8.24, t(107) = 3.202, p = .002) and had
more years of police experience (M = 12.40, SD = 7.69 v. 8.54,
SD = 6.57, t(110) = 2.854, p. = .005) than non CIT ofﬁcers. There
was not a signiﬁcant difference between the groups in terms of
gender, race/ethnicity, or familiarity with mental illness. The mean
number of past month calls involving an adult with mental illness
reported was 5.14 (SD = 5.20). CIT ofﬁcers reported more calls per
month (M = 6.43, SD = 6.53) than non CIT ofﬁcers (M = 3.86,
SD = 2.93, t(110) = 2.689, p. = .008). The mean proportion of calls
resolved by direction to mental health services was 0.56 (SD = 0.42)
contact only 0.31 (SD = 0.37), and arrest 0.09 (SD = 0.23).
In the analyses reported below, Arrest, Direction to Mental Health
or Social Services, and Contact Only, were each predicted separately
using ANCOVA. In each of these analyses, the design was constructed
as a 2 × 2 × 2 between subjects design containing the following
independent variables: district resources (low versus high), district
saturation (low versus high), and ofﬁcer CIT training (Non-CIT versus
CIT). The control variables were entered as covariates. All effects were
nonsigniﬁcant when predicting Arrest (p N .15 in all cases). There were
signiﬁcant results for the other two categories of direction to mental
health services and contact only.
3.1. Predicting Direction to Mental Health or Social Services

3. Results
We limited our analysis of call outcomes to patrol and ﬁeld
training ofﬁcers (FTOs), excluding supervisory personnel (Sergeants
and Lieutenants) who have limited involvement in individual calls.
The sample included 183 patrol and 7 FTOs. One FTO and 74 patrol
ofﬁcers reported no calls involving adults with mental illness in the
past month, thus they were excluded from the analysis. We also
excluded two ofﬁcers who indicated that more than 20% of the
subjects they were reporting on had, in their opinion, substance use
disorders only (no mental illness). Our remaining sample of 112
ofﬁcers was evenly split between CIT ofﬁcers and Non-CIT ofﬁcers.

Adjusted mean Direction to Mental Health or Social Services as a
function of District Saturation, District Resources, and Ofﬁcer CIT
Training is presented in Table 2. The ANCOVA yielded a main effect of
Ofﬁcer CIT Training, F(1, 95) = 5.35, p b .05. As anticipated, Direction
to Mental Health was greater among CIT Ofﬁcers (M = .68, SD = .41)
than Non-CIT Ofﬁcers (M = .48, SD = .41).
The two-way interaction between District Resources and Ofﬁcer
CIT Training was signiﬁcant, F(1, 95) = 4.30, p b .05. In the “low
resource” districts, Direction to Mental Health did not signiﬁcantly
differ when comparing CIT Ofﬁcers (M = .59, SD = .42) to Non-CIT
ofﬁcers (M = .57, SD = .42), F(1, 95) = .05, p = .83. In the “high

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A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

Table 2
Adjusted mean “Direction to Mental Health” as a function of district saturation, district
resources, and ofﬁcer cit training (CIT versus Non-CIT).
Ofﬁcer

High saturation
High resources (District B)
Low resources (District A)
Pooled (Districts B and A)
Low saturation
High resources (District D)
Low resources (District C)
Pooled (Districts D and C)
Pooled
High resources (Districts B and D)
Low resources (Districts A and C)
Pooled (All Districts)

CIT

Non-CIT

Pooled

.56 (.40)
.72 (.40)
.64 (.41)

.38 (.38)
.68 (.39)
.53 (.41)

.47 (.39)+
.70 (.39)c
.59 (.41)

.96 (.19)
.47 (.49)
.71 (.39)

.42 (.43)
.45 (.41)
.44 (.41)

.69 (.39)+
.46 (.44)c
.57 (.43)

.76 (.40)b
.59 (.42)
.68 (.41)a

.40 (.39)b
.57 (.42)
.48 (.41)a

.58 (.40)
.58 (.43)

Note. Means are adjusted for the control variables. Raw score standard deviations are
shown in parentheses.
a,b,c
notations identify sets of paired cells where the mean difference in “Direct to Mental
Health” was signiﬁcant a,cp b .05, bp b .01
+ Paired cell mean difference p b .10.

resource” districts, Direction to Mental Health was greater among CIT
Ofﬁcers (M = .76, SD = .40) than Non-CIT Ofﬁcers (M = .40, SD = .39),
F(1, 95) = 8.60, p b .01. Thus, Ofﬁcer CIT Training increased Direction
to Mental Health primarily within the high resource districts. The two
way interaction between Ofﬁcer CIT Training and Saturation was not
signiﬁcant.
The two-way interaction between District Saturation and District
Resources was signiﬁcant, F(1, 95) = 7.93, p b .01. Here, we consider
District Resources as a moderator of the District Saturation effect. In
the “low district resource” condition, Direction to Mental Health was
greater in the high saturation district (District A, M = .70, SD = .39)
than in the low saturation district (District C, M = .46, SD = .44), F(1,
95) = 5.37, p b .05.
3.2. Predicting Contact Only
Adjusted mean Contact Only scores as a function of District
Saturation, District Resources, and Ofﬁcer CIT Training are presented
in Table 3. The ANCOVA yielded a two-way interaction between
District Resources and Ofﬁcer CIT Training, F(1, 95) = 5.38, p b .05. In
the “low resource” districts, Contact Only did not signiﬁcantly differ
when comparing CIT Ofﬁcers (M = .33, SD = .31) to Non-CIT ofﬁcers

Table 3
Adjusted mean “Contact Only” as a Function of District Saturation, District Resources,
and Ofﬁcer CIT Training (CIT versus Non-CIT).
Ofﬁcer

High saturation
High resources (District B)
Low resources (District A)
Pooled (Districts B and A)
Low saturation
High resources (District D)
Low resources (District C)
Pooled (Districts D and C)
Pooled
High resources (Districts B and D)
Low resources (Districts A and C)
Pooled (All Districts)

CIT

Non-CIT

Pooled

.31 (.35)
.21 (.29)
.26 (.33)

49 (.41)
.13 (.29)
.31 (.39)

.40 (.38)+
.17 (.29)b
.28 (.35)

.03 (.19)
.46 (.38)
.24 (.31)

.37 (.35)
.39 (.42)
.38 (.40)

.20 (.31)+
.42 (.41)b
.31 (.38)

.17 (.34)a
.33 (.31)
.25 (.33)

.43 (.39)a
.26 (.39)
.34 (.39)

.30 (.37)
.30 (.36)

Note. Means are adjusted for the control variables. Raw score standard deviations are
shown in parentheses.
a,b
notations identify sets of paired cells where the mean difference in “Contact Only”
was signiﬁcant a,p b .05, bp b .01
+ Paired cell mean difference p b .10.

(M = .26, SD = .39), F(1, 95) = .58, p = .45. In the “high resource”
districts, Contact Only was lower among CIT Ofﬁcers (M = .17,
SD = .34) than Non-CIT Ofﬁcers (M = .43, SD = .39), F(1, 95) = 5.73,
p b .05. Thus, Ofﬁcer CIT Training reduced Contact Only primarily
within the high resource districts. Again, the two way interaction
between Ofﬁcer CIT Training and Saturation was not signiﬁcant.
The two-way interaction between District Saturation and District
Resources was signiﬁcant, F(1, 95) = 10.18, p b .01. This effect can be
considered by viewing District Resources as a moderator of the
District Saturation effect. In the “low district resource” condition,
Contact Only was lower in the high saturation district (District A,
M = .17, SD = .29) than in the low saturation district (District C,
M = .42, SD = .41), F(1, 95) = 7.70, p b .01.
4. Discussion and conclusion
The effectiveness of CIT cannot be fully understood unless
considered in context, and speciﬁcally, the availability of mental
health services is key. Findings indicate that compared to non CIT
ofﬁcers, CIT trained ofﬁcers directed a greater proportion of persons
with mental illnesses to services and resolved a smaller proportion of
encounters without taking any action, predominantly in the high
resource districts. In the lower resource districts, we did not ﬁnd a
signiﬁcant difference between CIT and non CIT ofﬁcers in how they
resolved calls involving persons with mental illnesses. However, in
the lower resource districts, District level CIT saturation inﬂuenced
how ofﬁcers resolved calls. Speciﬁcally, higher saturation was
associated with resolving a greater proportion of calls with direction
to mental health services and a smaller proportion of calls with
contact only. Thus, a “culture” of CIT training produces positive call
outcomes for CIT and Non-CIT trained ofﬁcers working in low
resource districts. In sum, the individual level ofﬁcer CIT training
effect was maximized in high resource districts whereas the district
level CIT training effect (i.e., saturation) was maximized in low
resource districts.
These results support an understanding of the effectiveness of CIT at
a systemic level, based on the interaction of police and behavioral health
service systems in a community setting. The driving force for the
effectiveness of CIT is at a higher level of analysis than the satisfaction of
ofﬁcers with their training or of avoiding arrest in favor of treatment
“when appropriate” in individual police encounters (Draine, Wilson, &
Pogorzelski, 2008). Rather, it is the presence of reliable behavioral health
resources that activate the training and support offered to police ofﬁcers.
Thus, the end result is increased access to responsive behavioral health
services for those who demonstrate a need for those services.
The inﬂuence of mental health resource availability on policing and
how ofﬁcers ultimately resolve calls may occur via multiple paths.
Several studies have documented disparities in spatial accessibility and
quality of mental health services in urban areas, with both access and
quality being lower in poorer, minority communities (Gresenz, Stockdale, & Wells, 2000; Koizumi, Rothbard, & Kuno, 2009). Additionally,
African Americans and Hispanic clients living in poor communities are
less likely to travel further for services (Koizumi et al., 2009), further
limiting their access to quality services. In low income minority
communities where access and quality are limited, there may be greater
reliance on repeated emergency room treatment over ongoing routine
outpatient care (Snowden, 2001). This has a two-fold effect for people
with mental illnesses and their encounters with the police. First, it
means that people with mental illnesses in some urban areas may have
less access to treatment and structured day programs thereby
potentially increasing their likelihood of encounters with the police.
Second, it means that the police have fewer options when such
encounters occur. They may not know of—or there just may not be any
available—agencies to refer a person on the verge of crisis. For lack of
other options, ofﬁcers may simply resolve the encounter informallymissing the opportunity to link the person to services and increasing the

 A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

likelihood of repeat encounters, or arrest the person and initiate a
journey into a criminal justice system that is ill prepared to effectively
meet the person's needs.
Based on our prior analysis (Watson et al., 2010) we were not
surprised by our lack of ﬁndings related to arrests. It appears that in
Chicago, CIT is primarily inﬂuencing ofﬁcers' decisions between
directing persons with mental illnesses to services or resolving
encounters without taking any action. As discussed elsewhere (Watson
et al., 2010), prior to this study, there was a procedural shift within the
Chicago Police Department that directed ofﬁcers to avoid arresting
persons showing signs of mental illness whenever other options are
available. This procedural shift may produce “diversion from” the
criminal justice system, where as CIT appears to result in “direction to”
the mental health system (Broner, Borum, & Gawley, 2002).
The ﬁnding of a saturation effect primarily in the districts with
fewer resources could have several explanations. Perhaps in these
districts, all ofﬁcers are acutely aware of the lack of options and non
CIT trained ofﬁcers are therefore particularly motivated to absorb the
CIT “culture” from their CIT trained peers. Given the small number of
districts in the study, there could also be something unmeasured and
unique to the districts selected that explain this ﬁnding.
4.1. Future research on the systemic impact of CIT
The main results of this paper, and some unpredicted trends in the
data, point to the need to further develop ideas regarding the systemic
impact of CIT in police departments and the interaction of mental
health service access and quality and CIT on outcomes of police
encounters with persons with mental illnesses. While not reaching
statistical signiﬁcance at the p b .05 level, there was an unexpected
trend in the “high district resource” condition. Direction to Mental
Health was borderline lower in the high saturation district than in the
low saturation district (p b .10, see Table 2). A similar trend was
observed for “Contact Only” which was borderline higher in the high
saturation district than in the low saturation district (p b .10, see
Table 3). Thus, while CIT ofﬁcers in the high resource districts resolved
more calls with direction to mental health services and fewer with
contact only than their non CIT trained peers, ofﬁcers (CIT and non
CIT) in the high resource/high saturation district resolved fewer calls
with direction to mental health services (and more calls with contact
only) than their colleagues in the neighboring high resource/low
saturation district.
Based on our experience working in the study districts and
discussing ﬁndings with the CIT team, we offer a potential explanation
that underlines the need for further research. Persons with mental
illnesses residing in communities with greater spatial accessibility may
be more likely to have access to and use ongoing outpatient care. Thus,
there may be less need for police crisis intervention. When mental
health crises requiring police response do occur, the individuals may be
more likely to already be linked with services that ofﬁcers can transport
or refer them back to. In fact, it may be a service provider that calls the
police for assistance. Thus, in higher resource areas, ofﬁcers may have
the beneﬁt of both more information and more options when
responding to crises calls. CIT trained ofﬁcers may be better prepared
to request and use this information. Our counter-intuitive trend for
ofﬁcers in the high resource AND high saturation condition resolving a
smaller proportion of calls by directing subjects to services (and
resolving larger proportion of calls with contact only) could reﬂect a
situation in which more call subjects are already connected to services,
and given the higher level of training in the district, ofﬁcers are more
comfortable making the determination that further referral is unnecessary. This could reﬂect very reasonable decision making that avoids
inappropriate hospital transports and referrals. Or, it could reﬂect the
inﬂuence of factors yet to be considered and measured. Given that this
trend did not meet statistical signiﬁcance criteria, we cannot make more
of the “ﬁnding” than use it to point out the complexity of deﬁning,

293

measuring and understanding CIT effectiveness and the need to further
investigate the interaction between CIT and the context in which it is
implemented.
This study was developmental and an initial foray into considering
the context that CIT is implemented in. As such, it has several
important limitations. Given our inability to dictate the roll out of the
CIT program and police personnel assignments, we were unable to
employ a randomized, pre post design to examine the effectiveness of
CIT. We could not randomize districts to implement CIT or control or
calls to be handled by CIT ofﬁcers or not. We were also not able to
randomize ofﬁcers to CIT training, as one of the key elements of the
CIT model as implemented in Chicago is voluntary participation by
ofﬁcers. Thus, we cannot be sure that any CIT effect on call outcomes
was a result of the training or simply due to characteristics of ofﬁcers
that volunteer for CIT training.
Resource constraints made it impossible to include all 25 Chicago
Police districts, thus, we very purposively selected the study districts to
allow us to make high/low resource and saturation comparisons. With
only four study districts, we cannot be sure that differences we attribute
to level of mental health resources and saturation are not due to
idiosyncratic differences between a small number of districts. Additionally, there are many factors that tend to spatially co-occur with mental
health service scarcity (structural disadvantage, crime, scarcity of other
types resources and social capital) that may also inﬂuence mental health
call outcomes and overall CIT effectiveness for improving access to
mental health services. Larger studies that examine CIT across a greater
number of districts and or jurisdictions would enhance our conﬁdence
in the generalizability of our ﬁndings and our understanding of the
conditions in which CIT programs are most effective and how they may
need to be tailored to various contexts.
An additional limitation is that our data on calls involving persons
with mental illnesses relied on police ofﬁcer recall and self report. This
could introduce bias in terms of recall and in identiﬁcation of persons
with mental illnesses. However, prior research suggests that police
ofﬁcers can accurately identify mental illness (Strauss et al., 2005). To
minimize recall bias, we made every effort to remind ofﬁcers of the
timeframe, anchor their memory and clarify any inconsistencies
reported. While our data is only as good as the ofﬁcers' memories, we
are conﬁdent that it is at least as accurate and more consistently
reported as data derived from ofﬁcial documentation such as call
reports and dispatch records (which we examined).
5. Conclusions
Our data support the argument that CIT is more than training, it
also requires treatment resources. Additional research is needed to
further understand how the mental health resource environment, as
well as other organizational and community level factors, inﬂuence
CIT outcomes. Furthermore, research needs to move beyond the
immediate call outcome and consider longer term mental health and
recidivism outcomes for persons who are the subjects of CIT
interventions. It is likely that the availability mental health treatment
resources will be important to determining as Geller (2008) suggests—
whether CIT “…stand [s] for Consecutive Interventions without
Treatment (p. 58)” or if it results in meaningful intervention and
improved outcomes for police, persons with mental illnesses and the
community.
Acknowledgments
This data was provided by and belongs to the Chicago Police
Department. Any further use of this data must be approved by the
Chicago Police Department. Points of view or opinions contained within
this document are those of the author and do not necessarily represent
the ofﬁcial position or policies of the Chicago Police Department.

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A.C. Watson et al. / International Journal of Law and Psychiatry 34 (2011) 287–294

Work supported by NIMHR34 MH 081588. The contents are solely
the responsibility of the authors and do not necessarily represent the
ofﬁcial views of the NIH.
The authors wish to thank the Chicago Police Department and all of
the personnel that facilitated the study and all of the ofﬁcers that
participated. We would also like to acknowledge the hard work of
Amy Kerr, Project Coordinator.
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