Reprinted with permission of National Association of Drug Court Professionals, copyright 2020. Reprinted from the Journal for Advancing Justice, Volume III, Emerging Best Practices in Law Enforcement Deflection and Community Supervision Programs. https://www.nadcp.org/wp-content/uploads/2020/10/Journal-for-Advancing-Justice-Volume-III_final.pdf

Deflection: Police-led Responses to Behavioral Health Challenges[1]

In jurisdictions across the nation, behavioral health is a major societal issue with public health and criminal justice implications. In 2017, an estimated 19.7 million Americans aged 12 and older had SUDs, 46.6 million had a mental health disorder, and 8.5 million had co-occurring SUDs and mental health disorders.[2] Research has consistently shown the effectiveness of treatment or therapeutic interventions for behavioral health conditions,[3] medications for opioid and alcohol use disorders,[4] case management,[5] and wraparound services such as housing and education.[6] However, barriers may impede access to treatment, including treatment waitlists,[7] stigma,[8] financial barriers such as costs and lack of insurance,[9] and transportation.[10]

Police are employing deflection to overcome such barriers, promoting public safety through improved service connections for individuals in their communities.[11] Officers often encounter individuals displaying behavioral health symptoms and who also appear to be in crisis and have basic needs, which makes deflection a natural extension of police work.[12] Police serve as the referral source and point of contact for deflection initiatives, but they are not the providers of treatment, services, or case management. Table 1 presents five deflection pathways for law enforcement (three of which can also be performed by fire services and emergency medical services) to connect people to behavioral health treatment, recovery, housing, and other services.[13]

Table 1. Five Deflection Pathways

Pathway Definition Initiator of contact Initiation location Program examples
Self-referral (also can be done by fire and emergency medical services [EMS] without law enforcement) An individual voluntarily initiates contact with a first responder (a law enforcement, fire services, or EMS professional) seeking access to treatment—without fear of arrest—and receives a referral to a treatment provider Individual community member Police department, fire station, EMS Angel, A Way Out, Safe Stations, Safe Passage
Active outreach (also can be done by fire and EMS without law enforcement) A law enforcement officer or other first responder identifies or seeks out an individual in need of substance use or mental health treatment (can include housing and other services), and a referral is made to a provider who engages them in treatment (and ideally case management services are also provided). Police officer, often with outreach personnel In the community Arlington (Massachusetts), Outreach Initiative, Homeless Outreach Team (HOT)
Naloxone-plus (also can be done by fire and EMS without law enforcement) A law enforcement officer or other first responder engages an individual in treatment as part of an overdose response, preferably at the point of overdose or as close to the point of overdose as possible, such as at the emergency department. Team with a combination of police, social worker, peer recovery specialist, faith-based leader In the community, hospital (emergency department), residence Quick Response Team (QRT), Drug Action Response Team (DART), Substance use disorder (SUD) co-responder models
Officer prevention (also can be done in a co-responder approach) A law enforcement officer, alone or as a member of a co-responder team, initiates treatment engagement (which can also be directly to a case manager first), but no criminal charges exist or are present, and hence no criminal charges can be filed. Officer prevention occurs as part of police patrol duties including “on view,” citizen “flag down,” or in response to a call for service. Police officer and, if present in a co-responder approach, mental health, treatment, social worker, case manager, or peer In the community, “on view,” in response to a call, on patrol Stop, Triage, Engage, Educate and Rehabilitate (STEER), Law Enforcement Assisted Diversion (LEAD)
Officer intervention (law enforcement required, also can be done in a co-responder approach) A law enforcement officer, alone or as a member of a co-responder team, initiates treatment engagement (which can also be directly to a case manager first), and either charges are filed and held in abeyance or a citation with treatment requirement is issued. Note: This is not the same as citation in lieu of arrest, as it involves some type of mandated treatment assessment or participation. Officer intervention occurs as part of police patrol duties including “on-view,” citizen “flag down,” or in response to a call for service Police officer and, if present in a co-responder approach, mental health, treatment, social worker, case manager, or peer In the community, “on view,” in response to a call, on patrol Civil Citation Network (CCN), LEAD, Crisis Intervention Team (CIT), Co-responder
Source: Adapted from the U.S. Department of Justice, Bureau of Justice Assistance

Within this five-pathway typology, several named approaches to one or more pathways have emerged and have been replicated in other jurisdictions. These preestablished approaches are referred to as deflection “brands” and present themselves as a specific, off-the-shelf way of managing one or more deflection pathways for a specific purpose and/or with a specific target population. Some deflection sites use a combination of these deflection brands to implement multiple deflection pathways. Further, more deflection brands are on the horizon as the field continues its rapid growth and development. For example, the Civil Citation Network (CCN) reflects the officer intervention pathway. The program is operational in 86 jurisdictions, comprising 67 juvenile civil citation sites and 19 adult civil citation sites (T. Olk, personal communication, April 24, 2020). Law Enforcement Assisted Diversion (LEAD), a program that reflects the officer prevention and officer intervention pathways, has been implemented in 38 jurisdictions.[14] The Police Assisted Addiction and Recovery Initiative (PAARI) represents programs in over 550 jurisdictions using the self-referral pathway and the active outreach pathway (PAARI, n.d.). Finally, the Quick Response Team (QRT) program adopts the naloxone-plus pathway and has been implemented in 161 jurisdictions (D. Meloy, personal communication, April 7, 2020).

When developing deflection initiatives in local communities, law enforcement should select deflection pathways based on specific community problems and challenges that need to be addressed and resources available to address them. Problems may include substance use, mental health issues, sex trafficking, and homelessness. Resources to consider include behavioral health treatment capacity, law enforcement and community leadership, the presence of a case management structure, and the strength of local recovery networks. Communities can maximize deflection program reach by developing multiple pathways as resources allow.

Challenges for Deflection Programs

Numerous issues may challenge current and potential deflection programs, including sparse resources and funding, lack of transportation to treatment and other services, racial inequities in program access and outcomes, and societal stigma attached to drug use. Two main challenges documented in the literature include insufficient treatment capacity and a police culture that relies on arrests for drug-related offenses.

Treatment Capacity

As the number of police deflection programs grows, and as more individuals seek or agree to SUD treatment as a result of police assistance, communities may encounter a new or exacerbated shortage of available SUD treatment. Police deflection programs have identified treatment capacity as a barrier to their success.[15] Limited treatment may lead to waiting lists, which reduces the number following through with treatment, especially in a timely manner. [16]

If waiting periods occur, deflection program team staff can use that time to engage individuals and maintain their motivation for treatment and behavior change. Team staff can discuss harm reduction strategies, which shows promise as a practice;[17] provide linkages to peer recovery coaches and supports, which generally show promise;[18] and offer brief motivational interventions, which have been shown to be effective.[19] However, harm reduction, peer recovery supports, and brief motivational interventions have yet to be tested in relation to police and deflection programs. Individuals with opioid use disorder (OUD) can be provided take-home naloxone, which has been proven effective at preventing fatal overdoses,[20] and referred to a health care provider for medications.[21] One study found that patients prescribed medication for OUD while on treatment waiting lists had a statistically significant reduction in opioid use compared to those not taking medication.[22]

Police Culture

Police culture has been perceived as an obstacle to the implementation of police deflection.[23] In many departments, the police culture approach to drug-related offenses emphasizes the maintenance of order (i.e., the suppression of crime and disorder through invasive law enforcement methods), with a reliance on arrest,[24] in contrast to police deflection’s public health approach.[25] Research has shown that a public health and therapeutic approach to addressing SUDs can improve behavioral health outcomes and reduce criminal activity.[26]

In order to change police culture, officer training is necessary.[27] In addition to providing information on how deflection programs operate, regular trainings can offer information on the physiology and psychology of SUD and recovery, how to recognize substance misuse, stigma related to SUDs, treatment services and levels of care, Motivational Interviewing and brief interventions, and screening and treatment referrals.[28] While training officers on how to address another behavioral health issue—mental health disorders—has been observed to produce notable benefits,[29] a 2018 systematic review of Crisis Intervention Team training found mixed results, and there is need for further research.[30]

Research on Deflection

While police deflection programs have rapidly proliferated across the country over the past decade to an estimated 850 known sites, research has not kept pace with the growing field. To date, limited research has focused on describing program participants[31] or offering qualitative data (interviews and/or focus groups) to understand police, participant, and community perspectives.[32]

One evaluation of a police self-referral deflection program in Lee County, Illinois, found positive feedback on the program from community stakeholders (i.e., probation, courts, local health department, faith-based community, hospitals, city council, community groups, and volunteers), police officers, treatment providers, and clients.[33] An evaluation of an adult civil citation program using the officer intervention pathway in Leon County, Florida, found that participants with greater behavioral health problems and propensity for crime and violence were more likely to fail the program, and that greater behavioral health problems were also associated with a higher probability of post-program arrest.[34] Also in Leon County, Florida, an evaluation compared the arrest outcomes for participants in a prearrest adult civil citation program to those of participants in a postbooking diversion program and found the programs had similar post-program arrest rates.[35]

One deflection program model that has been researched is the LEAD program in King County (Seattle), Washington, which aligns with the officer prevention and officer intervention pathways. The program features services—including case management, SUD treatment, and wraparound support—to individuals postarrest but in lieu of further booking and prosecution.[36] LEAD clients were found to have statistically significant reductions in recidivism and criminal justice contact compared to a comparison group using a nonrandomized control design.[37] They also were found to have improved housing and employment outcomes among participants.[38] However, when LEAD was replicated in Albany, New York, diversions in its first year were few in number, and officer attitudes toward the program were mixed,[39] raising concerns about replicability in communities beyond Seattle.

The efficacy of most police programs, including deflection programs, has yet to be tested using a randomized controlled trial (RCT), the scientific gold standard.[40] However, program aspects, regardless of deflection pathway, could be randomized (e.g., how contact is initiated and by whom, how the program is offered and by whom, how referrals are made and by whom, training content). Some pathways (all except self-referral) could randomly test whether active, officer-initiated offers of treatment or services result in better outcomes compared to arrest-as-usual, with the establishment of treatment and control groups (by officer, shifts, beats, precincts/districts, or departments). The self-referral pathway is less conducive to being studied through an RCT approach because it is a referral program, similar to a helpline, in which participants voluntarily request referrals to services. In this model, withholding referrals to create a control group would pose a challenge for police relations and procedural justice. However, this does not mean self-referral pathway programs cannot be evaluated; quasi-experimental designs may be employed, or alternatively, referrals to local social services could be randomized (e.g., some participants referred to treatment provider A and some to treatment provider B). These research approaches could examine outcomes involving police contact, morbidity and mortality, and treatment quality, engagement, and retention.

Evolution of the Deflection Field

The field of deflection has evolved over the past decade. Figure 1 offers a timeline of milestones in the development of the field, beginning in 2011. As shown, the early years of 2013 to 2015 represent a period of innovation by the end of which all five deflection pathways came into existence, followed by rapid growth in sites and mounting recognition as a new and distinct field of practice from 2016 to the present. Of note are partnerships not involving the police.

In 2016, the Police, Treatment, and Community Collaborative (PTACC) was developed to provide national leadership and vision for the field of deflection and prearrest diversion. Today PTACC, which serves as the field’s national voice and knowledge leader, much as the National Association of Drug Court professionals does for the treatment court community and the International Association of Chiefs of Police (IACP) does for police chiefs, is dedicated to the growth and development of the entire field, across all five pathways and inclusive of nonpolice responses to behavioral health encounters. Currently comprising 42 national and international organizations, PTACC offers deflection guides for understanding the five pathways and suggested core metrics; resources for behavioral health, housing, and recovery; model state deflection laws; policy examples; and webinars. The group addresses the critical topics of race and equity, children, victims of crime, and core values for the field, and it convenes the only national, fieldwide annual conference to facilitate collaborative learning, sharing, networking, and growth (see ptaccollaborative.org).

Figure 1

Major Development Milestones in the Field of Deflection

Year Milestone
2011 First officer prevention program, Law Enforcement Assisted Diversion (LEAD), starts in King County (Seattle), Washington
2013 National convention is held in Chicago exploring how police and treatment can work together to address addiction (includes the Treatment Alternatives for Safe Communities Center for Health and Justice [TASC CHJ]; Office of National Drug Control Policy [ONDCP]; National Institute on Drug Abuse; Substance Abuse and Mental Health Services Administration [SAMHSA] Center for Substance Abuse Treatment; U.S. Department of Justice, Bureau of Justice Assistance [DOJ BJA]; International Association of Chiefs of Police; National Sheriffs’ Association; and National Judicial College); First officer intervention program, the Civil Citation Network, is formed in Florida
2014 First naloxone-plus program, Drug Action Response Team (DART), starts in Lucas County, Ohio; Term deflection is coined to describe these new partnerships between police and treatment; First deflection site typology is formulated by TASC CHJ
2015 First self-referral program, Angel, starts in Gloucester, Massachusetts Expanded naloxone-plus program, Quick Response Team (QRT), starts in Coleraine Township, Ohio; First active outreach program, Arlington Outreach Initiative, starts in Arlington, Massachusetts; First published article uses the term deflection to distinguish the work of the emerging field from the longstanding term diversion. Diversion is a criminal justice term for policies and practices related to those individuals who have already entered the justice system. In deflection, inclusive of the term prearrest diversion, a person does not move into the justice system beyond the initial contact with police. Prearrest diversion as a term is any officer intervention pathway to deflection where charges are held in abeyance or a citation with a mandate for treatment or treatment assessment is required. As such, prearrest diversion is a form of deflection.
2016 Police, Treatment, and Community Collaborative (PTACC) is formed Police Assisted Addiction Recovery Initiative is formed as a network of self-referral (Angel) and active outreach (Arlington Outreach Initiative) sites
2017 DOJ BJA incorporates the five deflection pathways in the Comprehensive Addiction and Recovery Act’s Comprehensive Opioid Abuse Program (COAP) national solicitation; First BJA funding source is established through COAP using the term first responder diversion (inclusive of fire services and EMS)
2018 QRT National is formed as the national association for QRT sites PTACC convenes inaugural, fieldwide U.S. conference on deflection and prearrest diversion; Illinois passes first comprehensive five-pathway deflection legislation; National Association of Counties passes resolution supporting deflection as part of its Justice and Public Safety 2018–2019 platform
2019 ONDCP adds deflection and prearrest diversion to the National Drug Control Strategy; National Alliance of Model State Drug Laws releases first “deflection to treatment” model law; National Institute of Justice issues first request for proposals for police deflection evaluation; First deflection (first responder diversion) mentor sites established by BJA via Opioid, Stimulant, and Substance Abuse Program funding; Centers for Disease Control and Prevention and SAMHSA release first site-based funding for deflection with health department as leads in conjunction with law enforcement; PTACC adds 40th national partner
2020 National Association of Drug Court Professionals’ Journal for Advancing Justice calls for first papers on deflection research

The federal government began supporting the field’s development in 2017 with national technical assistance and site-based grants provided by the U.S. Department of Justice’s Bureau of Justice Assistance (BJA), followed in 2018 by an expansion of site-based grants, the first mentor sites, and expanded technical assistance available to communities that were not federal grantees. Research support was provided through the National Institute for Justice and its police deflection site evaluation research. The Office of National Drug Control Policy included deflection in its 2019 and 2020 National Drug Control Strategy reports, and SAMHSA and the Centers for Disease Control and Prevention have distributed site-based grants. Additionally, BJA is currently undertaking the first national survey of deflection sites.

As increasing numbers of deflection sites came online, deflection-related legislation and public policies have been advanced to facilitate their development and implementation. In 2018, Illinois became the first state to pass comprehensive deflection legislation, the Community–Law Enforcement Partnership for Deflection and Substance Use Disorder Treatment Act (Public Act 100-1025). The Act supports all five deflection pathways, provides a funding mechanism for implementation and expansion, and includes performance measurement provisions. The National Alliance for Model State Drug Laws (NAMSDL) created guidance for states seeking to introduce similar comprehensive legislation.[41] Finally, California, Colorado, Florida, Kentucky, New Jersey, North Carolina, Ohio, Pennsylvania, West Virginia, and Wisconsin have all passed legislation or developed state policies to support deflection pathways.[42]

Contributions of the Articles in this Special Issue

The articles in this special issue explored effective practices for police deflection, as well as lessons learned from established programs. In doing so, they offer new knowledge and a more nuanced understanding of such programs.

In “Engagement in Mental Health Services After CIT: The Effects of Mobile Crisis Team Involvement,” Rhonda Smith, Robert Mindrup, Linda Foley, Rita Porter, Frieda Herron, David Patterson, and Raymond Wooten examined Crisis Intervention Teams (CITs), a prearrest diversion program (an officer prevention pathway) designed to train officers to reduce harm when responding to mental health crisis calls and divert individuals from jail to treatment. The authors presented findings from a study on how collaboration between CITs and Mobile Crisis Teams (MCTs) affects engagement in mental health services for individuals experiencing mental health crises. MCTs assess and provide services for those in crisis in the least restrictive environment and can assist CIT officers to deescalate situations, make treatment referrals, and provide follow-up services. The authors concluded that when CIT officers used MCT, participants had a significantly higher rate of compliance with follow-up appointments, as well as less time to mental health treatment engagement. The authors further concluded that MCTs are important to the CIT process to divert individuals with mental health disorders from jail detention and improve their outcomes.

In “Law Enforcement Deflection and Prearrest Diversion Programs: A Tale of Two Initiatives,” Albert Kopak and Lily Gleicher offered an overview of two law enforcement deflection programs—one in Illinois called the Safe Passage initiative (a self-referral pathway) and one in Florida known as the Civil Citation Network (an officer intervention pathway). Both offer services for individuals with SUDs, aim to reduce justice system involvement, have operated for several years, and are located in states with legislation to support deflection. However, the programs have notable differences, including referral mechanism (or pathway), goals, and target populations. The authors discussed lessons learned from the programs to promote successful implementation and operations. These included building relationships with program stakeholders, ensuring availability of treatment, and sharing information for evaluation purposes. The authors concluded that additional monitoring and evaluation of deflection programs are needed to assess and enhance deflection programs.

Conclusion

While deflection has evolved to serve a variety of purposes, and studies have documented the emerging field, many research questions remain unanswered.[43] Questions center around race and equity (racial bias in the application of deflection, transparency, policy, and legislation development); the extent and impact of program operations (e.g., training, staffing, marketing, stakeholders, coordination, collaboration, sustainability, fidelity, net-widening, measurement of risk and needs); officer discretion (who gets offered deflection and why); program staff (e.g., roles, background, training, knowledge, support); treatment issues (e.g., barriers, limits, availability, accessibility, types, medications); participants (e.g., characteristics, needs, levels of support and engagement, substances used); the community (e.g., characteristics, level of support and engagement, relations with police, stigma); impact on children (e.g., foster care, drug endangerment); and outcomes (e.g., criminal justice contact, treatment engagement and retention, substance use, risky behaviors, motivation for change, education, employment, housing). This special issue expanded the current literature, and we hope it will engender further study and research-to-practice efforts as deflection sites continue emerging and expanding across the country.

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