 Good afternoon. On behalf of the McLean Center and the University of Chicago Trauma Center, I'm delighted to welcome you to this lecture in our 2017-18 series on ethical issues in violence, trauma, and trauma surgery. It's a pleasure to introduce our speaker today, Professor Harold Pollock. Harold is the Helen Ross Professor at the University of Chicago's School of Social Service Administration and an affiliate professor here in the Biological Sciences Division and the Department of Public Health Sciences. Harold is a co-director of both the University of Chicago's crime lab, as well as the health lab and is the acting faculty director of the university's graduate program in health administration and policy. Professor Pollock also is a member of the McLean Center as a faculty member. Professor Pollock graduated in Agda Krumlada from Princeton University with degrees in electrical engineering and computer science. He then went on to receive a master's and a PhD in public policy from the Kennedy School of Government at Harvard. And before coming to Chicago in 2003, Professor Pollock was a Robert Wood Johnson fellow in health policy at Yale and a faculty member in health management and policy at the University of Michigan. Professor Pollock has published widely at the intersection of public health, health administration, and poverty policy with special expertise relating to Medicaid. His research appears in journals like The Journal of the AMA, the American Journal of Public Health, Health Services Research, Pediatrics, and Social Science Service Review, and his writings appear regularly in national publications like The Washington Post, The New York Times, The Nation, Atlantic, The New Republic. A 2012-2015 Robert Wood Johnson senior investigator in health policy research, Professor Pollock has served on three committees of the National Academy of Sciences. He's past president of the Health Politics Policy Section of the American Political Science Association and an elected fellow of the American Academy of Social Insurance. Today, Professor Pollock will speak to us on the title behind me, Responses to Individuals Who Experience Behavioral Crises. Please join me in giving a warm welcome to Harold Pollock. Thanks for that lovely introduction, Mark. It's intimidating speaking in this August room with all the people looking down on me from the portraits. I should say that I am from the co-director of the university's crime lab and health lab. I'm the Joe Biden of those efforts. Jens Ludwig is the Barack Obama of the crime lab and David Meltzer is the Barack Obama of the health lab. I have a jocular slide of Joe Biden washing a sports car if I had a somewhat less serious topic. I would have had more joke slides. But I should say that I am not at all the smartest person in the room on these efforts. And I will be discussing work that is with a large number of collaborators on our team. There's Tony Sadler, who's a doctoral student at SSA, who has done some qualitative work I'll talk about. And Amy Spellman, who manages, among other things, our relationships with the fire department and other first responders and who works closely with our street-level folk. And Andrew Intentner, who's a gifted data scientist. And Cameron Day, who's also contributed to the data science. And Ruth Kaufman, who's the executive director of the health lab. And one thing that I've learned in this work is you never want to be the smartest person in the room. And fortunately, I'm not on this effort. So here's my roadmap for today. I want to talk about street-level realities. I want systemic barriers and opportunities to use big data to do a better job in serving the needs of people who encounter often our first responders because they're in a behavioral crisis. And that behavioral crisis could arise from severe mental illness. We all have stereotypical images in our head about what those crises might be. It could be a vet who has schizophrenia, who's experiencing an episode. It could be a young person who is cursing out the people around him. It could be someone experiencing who has diabetes who is not responding in a way that people expect. There's a wide range of behaviors and situations that people might be experiencing that bring them into contact with first responders. I'm actually going to start by telling you a story about a young man who has an intellectual disability, partly because I see Dr. Masal coming in, so I had to mention that. But I think actually intellectual disability is often overlooked when we talk about issues around first responders and people who come into contact with police. But you'll see that the elements in that story apply to a lot of other situations as well. And then I'll give you some results from a qualitative study of Chicago's emergency response. And then I'll give you a little bit about how we're trying to use administrative data to do better. So we'll get out of here probably about 8.30 tonight, and we'll sort of see how that goes. So it's a really difficult challenge for first responders to successfully interact with people who are experiencing various kinds of mental health or behavioral crises. Someone calls 911. The 911 operator, there might be a 25-second phone call to the 911 operator, where the 911 operator is trying to figure out what is going on. Talking to a person who is frightened, could be the person in crisis, could be that person's mom, could be a neighbor, it could be a prank call, it could be whatever it is. And then through a complicated process, police or fire, first responders will be sent to the scene, and then they have to interact with that person and hopefully help them and interact with them safely for everyone concerned, and also hopefully bring them some kind of long-term help that doesn't just resolve that situation peacefully, but addresses whatever their underlying issue is. Wow, that's hard. And it's something that we don't, that everyone, I think, recognizes that we don't do in Chicago very well, although I think that people really are trying hard. Sorry, I have about 9,000 pieces of paper here that are my psychological crutch there. So, but people, first responders come on the scene. Someone has some sort of an issue which they don't fully understand. They're not responding the way one expects or hopes. And it's interesting, by the way, that police in particular have images, have a typology in their head. There's the mentally ill vet box. So if you show up, someone my age with sort of some stubble of beard, some gray hair who's talking to Jesus and Jesus is responding in real time, police actually are pretty good at those situations. They're like, I get that. 22-year-old African-American man behaving very similarly, different box. Not because police, by the way, are racist and evil, but because it just triggers a different stereotype in their head in both cases. And also, the people around watching that police officer are expecting something different when they're someone who's obviously mentally ill in a stereotypical way compared to someone who is behaviorally dysregulated in a different way. That's not as obvious to onlookers. The, oops, sorry. So in Chicago, of course, the most famous case was the Laquan McDonald case. Remember that? This was a video where Officer Jerry Van Dyke actually shot Laquan McDonald. Laquan McDonald was a 17-year-old young man who had a knife and who was walking down the street and yelling and in various ways being dysregulated. There was no one within 25, 30 feet of him. The object that he attacked was a car tire. As far as we know, that's the only object he attacked. And there's a number of police officers who are following him. And has anybody watched that video? So what's interesting about that video is the first, everything up till the first several minutes of that video could actually be a training video of effective police response for someone who is obviously in some kind of behaviorally dysregulated state. All these officers standing around they're creating time and distance. Those are the two fundamental principles that I'll mention in a minute. They're not putting themselves in a position where he could hurt them. They're not putting themselves in a position where they will hurt him. And they are trying to get help. They're calling, asking for someone to come who has different equipment because they may have to restrain him and they didn't have the right equipment with them. And they're trying to find somebody who might come who has a relationship with him or who could deal with him in a way to talk him down. And they're all following him. And then one officer drives up and he empties his gun into the kid. He empties his gun into the kid. And the kid's lying on the ground. And you can see, if you watch, he's shot, I think 16 times, is that right? And you can see the little dust things coming up. And it's just a baffling story. The part of that story that is the most devastating in terms of the legitimacy of the Chicago Police Department is actually not that this boy was killed, though. It was that all those officers who were doing exactly the right thing and who watched their colleague drive up and shoot this kid, they all lined up around a story that wasn't true about how that happened. And that was actually much more devastating in terms of this city than the fact that one officer committed an atrocity. And we'll see that's going to play out in the courts to see exactly who said what. But that case was a classic example of what police are up against and how most police actually dealt with it very well in that moment, except unfortunately for that one officer. But that's the Laquan-McDonald case. I guess I've got a laser pointer here. That's the Laquan-McDonald case. Another case was Quintonio-Laguer. Anybody remember that case? So what happened with Laquanio-Laguer? Getting Boston grandma's climb in debt, she can't control what these violent shoots both him and the grandma was burnt out. Yeah, by the way, unfortunately, this was in Chicago. But yeah. So another case, he actually had a bad. He called 911 himself a couple of times before he was trying to get help. Not unusual, by the way, for someone to call 911 saying, I need help, and also be aggressive and violent when the help comes. I mean, people with mental illness, like I'm having a lot of trouble, that combination is not totally unfamiliar. So we have a number of cases here in Chicago that have led to calls for reform. We had the Police Accountability Task Force. The Justice Department was quite active to deal with this and to try to institute improvements in the way the Chicago Police Department responds to things. And in particular, to strengthen the training of officers to deal more effectively and to have more officers who are trained in CIT methods. And which is a critical incident, teams. So you'll see this all over the headlines, how there's an effort to give more training and also police dispatchers are getting additional training in mental health awareness. And it's a very serious and very sincerely pursued initiative which is improving the city's response. So let me focus on intellectual disability for a minute. A lot of the famous cases, Freddie Gray was in Baltimore. Remember, Freddie Gray was killed because he was in a patrol car that they sort of put him cuffed in the back of the car and they went on a wild ride and he was somehow badly injured. He was in Laquan, MacDonald was also, it turns out he was a foster youth who had some developmental challenges. And there was another case involving intellectual disability where actually a mental health worker named Charles Kinsey was shot because he went out in the street to try to help a young man who was in distress and an officer opened fire and shot the mental health worker who was not killed, but he was shot. He was shot while he was, I believe, in the position with his hands up like that. But let me tell you a story about how things can go badly wrong when officers are poorly trained. That's about someone named Robert Saylor. And this is, Robert Saylor was a young man. In January 2013, do I need to turn off this mic? Is that causing reverberation or anything? Okay. Anything I can do to improve your listening pleasure, please. So in January 2013, Saylor went to see a movie in Frederick County, Maryland. And he was accompanied by a young attendant named Mary Crosby. And she was 18, 19 years old, but she was his attendant. And when the movie ended, she asked him if he was ready to go home. And he started to get really agitated. So Ms. Crosby didn't exactly know what to do. She was trying to calm him down and wasn't working too well. She calls his mom and his mom suggested that Crosby go get the car, swing it around. Maybe they'll give him some time to kind of calm down. And Mrs. Saylor started, his mom got in the car started driving to the theater. There was maybe six miles away, something like that. Now, while Crosby left for the car, Saylor went back inside the theater and he sat down in his original seat. The reason why he was agitated was that he wanted to see the movie again. And he was asked to leave because he didn't pay for a second ticket. You're supposed to pay before you come back in to see the movie again. And so he refused to leave. And he got more and more angry and the manager came out and he was arguing with the manager. So by this time that his attendant, Ms. Crosby, comes back and she goes back in and she sees the manager's arguing. And she says, please don't touch him, whatever, manager looks at her, manager's my age, looks at, he's like he's gonna take direction from this 18, 19 year old chicky that's telling him what to do in this situation when he's hot under the collar with this patron who's not leaving. He calls three off duty, he calls this the mall security, which is three off duty local sheriffs. And so the sheriff deputies come. Crosby says, his mom is on the way, please don't do anything. They of course look at her and say, we're gonna listen to this young chicky telling us what to do when we're here doing our security job. So they decide that they're gonna remove him physically from the theater. And he's sitting in a chair. One of the most dangerous maneuvers is to remove someone from a chair who doesn't wanna be removed. Remember that United Airlines thing where the guy was dragged off the flight? And all, and everybody at U of C because we're basically middle class people who fly a lot, we're all like, wow, this is really about United Airlines horrible service. I don't care about their service. I don't even care if he was right or wrong. They took a nonviolent person, they dragged him out of a chair where he wasn't bothering anybody and they could have very easily hurt him. Well, Salem was 300 pounds and they're trying to drag him out and he ends up underneath them in cuffs. And his mother arrives on the scene to find that he's just died. He just died. That he had a fractured larynx from being pushed prone on the ground. And the medical examiner actually rolled it a homicide from positional asphyxia and a judge, it was a scathing legal case, judge said it was over a $12 movie ticket. Now this case is particularly poignant, particularly because Robert Saylor had a Down syndrome, could have easily been a person with severe mental illness playing exactly the same way. The fact that he was developmentally disabled is really not the key part of the story. By the way, the officers, their successful legal defense was that they had followed their training in the steady escalation of force. They told them if you don't get up, we're gonna take you out. At every step they threatened them, they said, at every step they said, if you don't comply, here's what we're gonna do. And they kept escalating it to assure his compliance. And that's pretty typical of situations that go really badly for everybody. By the way, I should say I do not believe for a moment that those deputies intended for this to happen. I think that they, I'm sure that they feel horribly, horrible remorse that this occurred. But they responded to a person who was not responding to their instructions in the way that they wanted or expected or understood. And when you think about it, all the elements were there for them to have reached a successful outcome. He had someone who knew him was right there. His mom was on the way. He wasn't actually hurting anyone but he was behaving in a belligerent way. He was not dangerous but he was belligerent. And if they had followed the two most important principles, time and distance, 10 minutes after he died, either he would have left the theater or someone would have bought a movie ticket and he just would have watched it in the seat that he was in and the planet would have kept rotating. Now some aspects of their training, I do think people need to be trained about the distinctive clinical issues around people with intellectual disabilities. One thing that is important is there are some physical vulnerabilities that officers and clinicians, people who work with people with intellectual disabilities, aren't always aware of that basically you never wanna, you never wanna restrain anyone prone, particularly someone who's intellectually disabled because there's some morphological issues that make people vulnerable. But the way that people need to be restrained is on their side so you can see their face and make sure basically that they're breathing. That's harder to do though because if somebody's really strong and struggling, it's actually kinda easier to mash them down on the ground than it is to have the person on their side. But GI reflux and respiratory disorders, things like that can cause people to asphyxiate when they're prone. So one of the most important things is make sure that that's not done. Most officers have very little training in this. I should say that the CIT training that Chicago officers have, they have a 40 hour training when they sign up for, when they take the special training for dealing with people with mental illness and other behavioral crises. There's a half an hour spent on, 40 minutes spent on intellectual disability. Most common questions that officers ask, how do I know that someone's faking? And how do I diagnose what the issue is? That's also by the way a very common issue when officers are dealing with people who have severe mental illness. How do I diagnose what the person's condition is so that I would know how to respond? And there's two aspects of that that are important. One is you can't diagnose. In fact, people are terrible. They will get it wrong most of the time. Trained mental health professionals will not very often will misdiagnose someone who is just behaving, who's acting out in the moment and you're sort of encountering that person for the first time. But secondly, it doesn't matter what the diagnosis is. The behavior that the officers and other first responders need to display is the same independent of the diagnosis, which is time, distance, cover. Cover if that person is really being very aggressive. And knowing the person's diagnosis does not give you any, generally does not give you useful information to know how to respond to deal with that person. Michael. There's a famous study where 100 mothers who were intellectually disabled came to an emergency department with a health concern about their child and no ED DAC picked up that the mothers, all of whom had IQs less than 50. Less than 50. Or intellectually limited. So. You know what I mean? It's all based on, you could tell by looking and it's not, the second thing I'll say on sale, it takes a tremendous amount of force to fracture one's wearings. A shove against the wall, even if I hit the windshield, usually doesn't fracture it, they apply the equivalent of 500 pounds brute force. It's almost like they all jumped on his neck. That's what they would have had to do to fracture his wearings. Well, the reason why that happens though is once you get your hands on somebody, then you can't, you really can't predict what's gonna happen. That's why that's maintaining that distance is so important. And. Look at this guy's neck. Look at this guy's neck. I mean, he's a sumo wrestler. Well that, I think that's right. And I think they had a lot of trouble. I think he's a strong guy. And they, people have positive stereotypes about people with intellectual disabilities that can go very wrong when people start behaving differently. It's kind of a double edged sword that people have such a positive view of people with intellectual disabilities because when they don't behave, according to the life goes on script, then people don't know quite what to, how to respond. All of the behavioral science are not to do this tough escalating show more power, whether I'm demented, whether I'm mentally ill, or whether I'm intellectually disabled, or wrong disease. And we have to get rid of that junk, show force when I'm dealing with uncertainty. The problem, but I think the problem is that officers, that's a very difficult thing for police officers because the way that officers, a lot around the daily life of a police officer, is the way that I keep myself safe and everybody else safe, is I maintain authoritative control over a scary situation. People don't want to come, people don't want to call the police and then see the police come and retreat. That is very difficult for police. So the finding ways to show quiet authority that don't involve being aggressive, that police actually find that there's a dignified way for police to go about their day is actually really important in trying to help change the behavior of police in those types of situations. I'm sorry, Peter, why on God's screen avert these situations when you send the police a non-crisis behavior halting? Because the number of crisis behavior health teams is so small that they're not available and I'll come back to that. I should say, I'll say one or two other things and then I'll get off of IDD. Rebecca Feinstein and I did this study of caregivers for people with Fragile X syndrome and one of the things that was really striking was family violence was a real issue. Most of the caregivers we interviewed were taking care of their young adult sons and a third of them in the national study are regularly injured by their sons. So the idea that you would call the police is something that people really have to deal with as families a lot. And it is striking that when I talk to, so we talk to people and the kinds of comments we heard were he's not aggressive or violent just for the sake of it, I know what triggers it, I spend the best majority of my day working around it and another mom told me how she accidentally, she got pushed down the stairs by her son and he broke a rib and punctured her lung and she basically was really, she admitted that he's a safety risk but she said, look, any place that I really like, they won't take him because of the way he behaves and the places that will take him, they've got other young guys who behave the same way and if he's getting into it with me, what's gonna happen if he's got a 22 year old down the hall? And another thing that was really striking was all the families were very, very hesitant about whether they should call the police. You know, one of the problems that we have with these notorious cases like the Laquan McDonald cases, family members of people with mental health problems and other issues are thinking, do I call the police if there is an issue? Because who's gonna come and how are they gonna behave? What are they gonna know about how to respond? Yeah. Well, that's a real problem because often police are the people that have the help that people need and so when you don't call and I can tell you that my wife and I take care of her brother who's 260 pounds and she said, she just told me over the breakfast table one day, she just said, never call the police, I don't care what's happening, just never call the police. It was right after one of these cases and you know, you can't, that's leaving people without help when they need it. So a couple of policy implications and suggestions from this, one is it would be good if police had more training, but really it's not about intellectual disability at all, it's about how do you approach the general challenge. So de-escalation training, time distance and cover, explain to officers that you shouldn't try to diagnose people and some particular issues. But then as I'll get into in the next segment of my talk, it's not just how the police behave in the moment, it's also a set of larger institutional and cultural issues around how first response works and what happens after you intervene to make sure that if we trained everybody perfectly to respond in the moment, we would still have a lot of failures that are not the fault of the first responders, that the fault of everything else that happens. One of the challenges I think that we really leave police holding the bag in a lot of these cases because what's really failed is the mental health system, the disability system, all these other systems and then people call the police because the police are the people we call when every other system fails. So you have people with chronic mental health issues who've been poorly served by the mental health system and at some point they interact with police in a really negative way and we all say, wow, why did the police screw that up? Because you have the iPhone camera when the police come and you don't have the iPhone camera when you're in the emergency department and they've screwed up what to do with that person. So some things about our Chicago case study. So largely, Toni Sather was the first author on this and she really spent a lot of time talking to police officers, ambulance drivers, 911 dispatchers, ED folk and really try to understand what are the systemic successes and failures that we're dealing with. And she attended the CIT training which has a pretty nice curriculum and they've actually done a nice job of bringing NAMI in and bringing other groups in to educate police officers about the experience of mental illness, co-occurring substance use. It's a very serious effort that the police department is undergoing. The officers, by the way, who seek out this training are a very interesting select group. Disproportionately, women, women, by the way, are very effective in working with people in behavioral crisis because the de-escalation skills, a lot of the women officers are very good at the de-escalation skills and many of the people that they encounter will react in a less violent way to a woman officer and that is sometimes valuable. And of course the flip side of that is there is a safety issue when they don't behave that way. But also a lot of the CIT folk are veterans and they're very interested in helping other veterans or they have a family member with a mental illness. It is really striking how what a pretty remarkable group of people they are. So we did focus groups and in-depth personal interviews to try to understand the strengths and weaknesses of what Chicago is doing. I should say there's a lot of limitations in our approach, like all qualitative studies. So we have a lot of very powerfully felt anecdotal experiences of first responders. So one thing is that is a big challenge is that the situations that first responders are trying to deal with are inherently messy. It's out in the parking lot. It's in somebody's house and you don't know what else is going on in the house. You've got police there in fire and they have slightly different protocols about where to take the person if you have to take them to the hospital. You have family members in the background. And so one person described it, he said, it's like a mash unit. It's like trying to stop the bleeding but not fixing any of the broken bones and it's very dirty and primitive when we're out on the street trying to get people to calm down. And conversely in the emergency department it's not as dirty. The person may be more calm. The environment is more sterile. I think that there's a lot of Monday morning quarterbacking when these things go poorly and we do have to understand it's a big challenge for people. The biggest challenge that people have is the mismatch between what their official training in mental health related subjects tells them and the daily realities of being on the street. So I mentioned this time and distance paradigm. In that Maryland movie theater those three security people definitely screwed up because they could have just waited for 10 minutes and that situation would have resolved itself. But that's not always the way it is. That's a quiet shopping mall. There's nothing else going on. So we were talking to a police woman in some work that I was doing with the police accountability task force where she was describing how there was a gentleman in Englewood who was having some serious mental health problems. He was basically sitting on his bed and so she comes and she's talking to him trying to get him to come with her in the police car so that they could take him to a mental health facility. And she's talking to him and he's gradually calming down and it's actually going really well. There's only one problem. It's a Saturday night in Englewood. And so she's talking to him and being really calm and taking the time and everything that her supervisor who's standing behind her is getting all sorts of calls and texts saying, hey, come on, we got a lot of other calls. It's Saturday night in Englewood. We need you. And at some point time kind of runs out and the guy rushes past her, her supervisor. He tackles the guy and he cuffs him and he manhandles him out to the car. Guy gets to the mental hospital but he's now had a really traumatic experience basically because they ran out of time. You know, officers in, if it's a Tuesday at three o'clock you can really do this. If it's in a high crime area at a high crime time they just don't have the manpower to behave, to give people the kind of interaction that they know that they need to do. And the sort of daily, same as in the emergency department, you're gonna behave differently when it's really hopping than you will when it's quiet. And you're gonna give people more time, more attention, a little bit more humanity when there's more time. And so a lot of my newsflash, I'm a liberal Democrat, a lot of my friends really think like having more police is really like we don't, that's adding to the carceral state and it's all part of the neoliberal plot or whatever. The more police you have, the more you can really do the kind of labor-intensive things to treat people decently that you just cannot do when you're overstretched. And that's one of the biggest things that we heard was that it was just really hard. And it's harder now, by the way, because there's so many issues between police and community. One of the things that we're finding that we were told by a number of people from the fire department was that the fire department, police come, fire comes, and the police say, you know what, and they say to the ambulance drivers, you know what, you guys can handle it. I don't wanna create a tragedy here, I don't wanna create a video of something bad happening. You guys, you handle it, and sometimes that doesn't work because you need police to deal with people sometimes. And it is, so there's all those kinds of practical, practical issues. By the way, it was interesting that the smartest people that I had never really talked to before were the people in the fire department who run the ambulance response. They know Chicago like nobody else does, and I'll get to some results of that in a minute. So I should say, another problem that people have is just basic coordination. The process, so someone calls up 911. You have a 20 second conversation where they're scared, where the person calling is scared, and the dispatcher's trying to figure out what's going on, and they actually look for some smart keywords. For example, when they hear the word check day, when they hear the word payee, and it's the first of the month, they're actually trained to know, this actually means they're probably fighting over somebody's SSI check, something like that. The dispatchers are very highly trained, but they're still in 20 seconds, you're trying to figure out what's going on, and then you dispatch the call, and then there's a whole other set of communication to police, a whole other set with fire. Different people have different information about what just happened, and they all kind of come, all of which is fragmentary, and they kind of come and try to say, okay, how do I respond? And we have some ideas for how to do better with that, but OEMC are the people who run the 911 system, it's a big challenge to try to just make sure that people understand what's happening. The other problem is just the city's lack of mental health resources and related resources. So in the area of intellectual disability, there's very often no psychiatric hospital that will take someone with an intellectual disability that's available when someone's in a crisis. So police do everything great, and they've got the guy to come with them in their car, and then the question comes up, okay, where do we go? What happens now? And most of the evaluation evidence on improved police response to mental health calls says that if we do a great job training police, it is less likely that the person that someone will be injured in the police encounter with that person, either the police officer or the person, it's not clear it improves long-term outcomes, because that depends on what happens after you take that person someplace. So in Chicago, that is one of the biggest problems. And what's especially disturbing to the officers is when they take someone to an emergency department. So I've dealt with you, you know, marks and dysregulation, I deal with them great, I get them to come with me, I take them to the psychiatric emergency department. I feel good, you know, he hasn't been hurt, people in the community haven't had to listen to him ranting at them or whatever he was doing. Only one problem, I come back three hours later, he's at the same corner ranting at people again. Because he wasn't deemed a threat to self or others when he was in the emergency department, once he calmed down, he just decided to leave. And the officer's like, I went to a whole lot of trouble and nothing happened, that was good. At least if I take him to the jail, something will happen. He will be incapacitated for some period of time, he will get some mental health services as part of the jail if I arrest him. And when that is the day-to-day experience of officers, that is a big, that is very, very hard to take that experience and encourage them to not arrest people. Because what they see is arresting people actually leads to a better outcome in a lot of those cases. And so that is, that was something we heard quite a lot. And the other thing is within the police department, you know, the people that are, you know, if you're the people who chase down gang bangers and arrest them and do undercover drug buys and stuff like that, you are like one of the cool people. You know, you're doing kinetic stuff, you're arresting people, you're catching bad guys. If you're sort of talking to mentally ill people for a long time and kind of, you know, taking 45 minutes and then bringing the guy over to the hospital, that's like not, like there's no, there's really no adventure TV series about that. And so there's a big issue of status and prestige and that sort of thing. So let me, I'll just mention briefly that a lot of the calls are to the same addresses and I'll come back to that in a minute. Let me go up to our data stuff because I think I've ranted a lot. So we're trying to help this process in a different way at the Urban Law. We're doing, we have a new project that we call M-Heart. I think by the way, the entire project is gonna change its fundamental orientation because we wanted to make an acronym that sounded cool. So that's a mental health emergencies alternative response and treatment. So can we use data better? You remember how I said the whole, you know, they have this phone call that comes in and in 20 seconds they have to figure out all this stuff. Well, that person, there's been seven other 911 calls maybe about that person. Wouldn't it be great if you could actually see who that person was, what was going on, what their issue is instead of having to start from scratch and figure out everything from, you know, anew. So what we did is we tried to look and see can we use linked city administrative data to identify people that were their frequent callers and if we could do that, the city first asked us, could we do that so that we could know when to send out that crisis team when there was a 911 call, which is a worthy objective, but then we quickly realized, you know, if we could do that, why are we waiting for the next 911 call? Why don't we send someone out to help that person when they're not in crisis? That seems kind of a much smarter idea. And so we've been working on linking data to try to identify a subset of people that have a lot of encounters with law enforcement and with the mental health system. So, and we were looking actually at two different things. We were looking at a person-based approach. Are there people where there's lots of calls? And we also wanted to look at a place-based approach. Are there places where this just happens a lot? And are the high-use people, is this happening in the high-use places? What's the Venn diagram look like? There's lots of people at Union Station where there's calls. Are these the same people all the time? Well, what's going on? I should say, by the way, it was a very humbling experience to go talk to the fire folk as we started to do our big data. We had these really great algorithms to look at the big data and we discovered we had neighborhood and zip code and all these things that were popping up in our analysis. So we go down to the fire department and we show this zip code really lit up in the data. And the guy who's sort of the coordinator of a lot of the ambulance things said, dude, there's nothing interesting about neighborhood or zip code. That's the end of the red line. Nobody in that, there's nothing to do with anybody in that neighborhood. This is, there's nothing, there's no zip code, there's no neighborhood. That's just, that's just, those are guys who were asleep at the end of the red line and there's lots of calls. And they were, and they actually knew they had an amazing tactile sense of every major location that we had. Homeless shelters where they had closed their clinic and they kept calling. One of the biggest problems, by the way, are people with severe mental health problems who actually have a medical problem, but when someone calls, people think that it is that they're having a mental health emergency. So in a homeless shelter, there's a man with schizophrenia who has a toe infection. But the call comes in, schizophrenic man needs medical assistance at this location. And then they're like sending out the SWAT team and the guy's like putting his toe up, you know. But someone can get hurt, you know. And it's also a colossal waste of resources. So we looked, so we did a lot of big data work where we tried to understand how these data systems work together. I would say 80% of the project was data use agreements and all the contractual stuff, HIPAA, all that kind of stuff. And we looked to identify within the fire department who are the people where there's lots of ambulances being sent where they were also being arrested and within the police department who are the people where there's arrest but there's also a mental health component. And so we created lots of cool PowerPoint graphs that look like this, which I won't go into a lot of detail about, but we were able to merge the fire department and the police data to try to identify unique people. Yeah, that was, like, by the way, every time you write a paper like this, 99% of the work has nothing to do with any word that's gonna appear in the paper. It's like we had 55 meetings about getting the data use agreement and all this kind of stuff. And so we came out and we identified, so we had a definition of people who were at risk who had one more fire department behavioral health event in a year and also had one more arrest. And so we looked and we found there were about 1,842 people in that Venn diagram. And then within that 1842, we had a tougher group that were considered to be high risk that actually had at least four events in the year and that were sort of our high use group. We found 330 high users. And we looked at that group of 330 quite closely. I should say that they're mostly men. About 27% of them were homeless. One of the interesting things about these data, by the way, is the word homeless is a really interesting word. There's no one definition of homeless that actually works. You know, you have this person who's mentally ill who's sleeping on the couch of their cousin. Is he homeless? You know, there's various definitions of what that term means that, but we found a lot of them were precariously housed. Probably they were precariously housed because their behavior made it really hard for people to live with them. And also, their homelessness made it hard for them to stabilize their behavior. And you can see how that becomes a vicious circle. They were arrested on average 3.6 times in the year. And there was actually two different age groups. There was a group of people around 50 and there's a group of people in their 20s that sort of, it was kind of an interestingly bimodal age distribution. Here's, by the way, I'll just show you a couple of people. Because my goal here is to drown you in weird anecdotes that I don't actually provide a coherent explanation of. So here's just a person who was one of our high users. And the way that this graph works is that the needles pointing up are their police arrests and the needles pointing down are their fire department mental health events. So you can kind of see what's happening to this person over the year. So this person shows up, they have a misdemeanor arrest on the CTA. But one of the most striking things about these people is when you start reading their sort of longitudinal, you just take 10 people and start reading the trajectory of their police and fire. Every stereotype and prior expectation that you have, you're gonna discover is off. So there's, and when you look at the police side of it and the fire side of it, you get a totally different view of that person. So there's an example of someone on the fire side where he's got a substance use issue and you see this person's going to the fire station saying, can you get me into a drug treatment? And having all these medical problems and you think this is like the poster child for if I'm doing an ad for Medicaid expansion, you know, he would be on it. Then you look at the police report and you say, oh, there was the time that he was trying to shove women on the CTA platform. And you're like, wow, this guy's actually kind of dangerous. And you know, people don't wear black hats and white hats. I should say by the way that in order to be in this dataset, if you think about this definition for a minute, you can't be Jeffrey Dahmer and be in this dataset because they'd lock you up. So it's somebody, there are people that have lots of encounters with police and fire and a lot of misdemeanor arrests, a lot of things that could kind of go either way. For instance, the most common arrest is shoplifting alcohol. An incredible number of people with arrests for shoplifting alcohol. And most of the time that's kind of treated as a misdemeanor, but every now and then. So for instance, there was a woman who was shoplifting. And she was shoplifting a lot with no real, not really causing any major problems. But then there was that one time where the 85 year old shopkeeper came out and confronted her and she heard it. And you know, there's always that potential when people are behaviorally dysregulated that something like that can happen. So this guy just followed, so here's a typical trajectory of kind of a high use guy. So he starts, he has a misdemeanor arrest, he's bugging people, he's bothering people on the CTA and then he's shoplifting alcohol. Here, day 63, he actually has two ambulance calls within hours. He's intoxicated, he's a dual diagnosis person, he's intoxicated, he's taken to an emergency department two times on that day. These people are very, very expensive for the healthcare system. They're ringing up pretty impressive bills. And then we see that in this other stretch, he's got five arrests, including one felony. So there's something happening about, you know, about three, four months into him. And here he's requesting to be sent to a rehab and he's taken to an ER. And they have all these crises going on. And then they, by the way, they disappear from the data for some stretch. We think some of those disappearances are, they were in jail. But we haven't done the OJ trial to get all the jail data included yet, but that's coming. And so we identified 330 people who have trajectories kind of like this. And we looked and we also tried to see were they being arrested or taken to the hospital from common locations. And so we mapped all the locations in the city. We did all kinds of GPS stuff. And we found the top 1,000, the top 100, and the top 10 locations. By the way, we showed this list of top 10 locations, some of which we have to mask. When we went with the fire people, boy did they have opinions about all 10. By the way, a surprising number of calls come from within police stations. You might say, why is there a, there will be a 911 call to police from a police station. And it's because when someone has a mental health issue in the station house, they got to come and, somebody's got to come and deal with that. Mark, you look like you had a question. They're, so, for instance, that homeless shelter, they basically, they don't have a medical clinic. It's a large homeless shelter. And so they have huge numbers of mental health calls, most of which do not require any kind of police involvement at all. There was a mental health facility that had a rule that anyone who showed up to the door with a physical health problem had to go to an emergency room to be checked out medically for their physical health problems. So this emergency department, the psychiatric facilities regularly calling 911. They send a fire truck. They send whatever they have to send. They go up there. There's a hospital within a quarter mile that they take the person to. And then they bring the person back. You can imagine the fire department enjoys that. And then the red line stations were, CTA stations in the airport and the bus station. We actually didn't find that these places where there's lots of calls, that they involved kind of the high use people. The typical person at Union Station who has a mental health issue and someone has to call to get help. That person's actually not, that's kind of a one off for that person usually. It's not like this, the same people all the time, which is kind of interesting. One of the policy implications we think that what police and fire should do is go to each of these high use locations and make a plan in advance. And the same is true by the way in group homes where there's lots of calls. When group homes cannot handle a resident, they will call the police. There's nothing that makes police more angry than that. Because police show up, there's a guy, maybe it's a psychiatric, maybe it's a group home for people with psychiatric issues. Maybe it's developmental disabilities. And the police officer walks in and he says, now wait a minute, let me get this straight. You are trained to deal with this person and you don't know how to do it. So you're asking, so you're calling me Mr. 25 year old patrol officer to come over here. Like what do you expect I'm supposed to do? And the implicit expectation by the way is that when the person sees the police officer that they're just gonna back off. It's to intimidate the person. Police do not like that. There was one case that an officer was telling me about where the group home had gotten rid of somebody's dog without telling him. He came home one day and his dog was gone and he flipped out and they called the police. And the police came and they said, why didn't you get rid of his dog? You know, this actually is from a, this is a Tennessee example. It actually turns out Tennessee has fantastic resources in this area. Memphis is actually also where some of the original models for policing were developed. That's because their state system was under consent degree and this came because of it. And similar individuals are doing the same in Illinois with the bureaucracy. Yeah, we can be really, Illinois is very good for dispelling stereotypes about blue states. So we have a number of recommendations I won't go into now where we think we can do better with locations by having being proactive. So with family caregivers and programming staff and also a lot of the high use locations are serious organizations like Union Station. You could actually have a protocol so that when police are called that there's a good plan. And what we're doing now with these 330 people, the 330 people that we're right now we are designing a randomized trial where we're using that 330 people as the sample frame and we're actually gonna do assertive community treatment with a mental health partner where we're going to go out and offer ACT services to a random subset of these 330 and we think that we can show that we can reduce arrests and subsequent medical utilization and bad outcomes by being proactive and we're not gonna wait for them to call 911 again. Some of these people, there's 25 911 calls, 47 911 calls in a year, something like that. So we're using city administrative data to define a set of people for service and we're gonna see how successful we're gonna be. I think I'm gonna stop here because I wanna leave room for dialogue, yeah. How do you feel? Feel free to applaud, I enjoy that. Well, we don't. Any questions in your mind? Well, I think our ability to engage those people, I think I'm not an equipoise, are they better off having a mental health worker or zero worker? I am an equipoise about how perceptive are these folks gonna be, how many of these people can we really find and engage? We've raised money, we're raising money now for at least one but possibly two ACT teams and we're gonna see how receptive people are and I think that I don't wanna overpromise what we can do, I think there's many ways that this will turn out to be a huge challenge. The people, these 330 people, when we just look at how many places, a typical person in that 330, very often they're all over the city and they're hard to find and they're hard to track when you do find them so there's a lot of ways that we're coming in that's assuming that we're making three really bad errors but we don't have any way to know what those are yet till we try, any question? Do I make any sense at all? I sort of felt like I was up there babbling and covered too many things, yes. Yeah, this is your back. Homes. And before the 80s for Ronald Reagan, we used to actually have facilities for these people. We had facilities for these people to be in that they now have their civil rights to live like this. Well, you know, the de-institutionalization issue requires a whole other rambling talk. It is certainly true that for cases of severe mental illness that we have done a poor job of providing the continuum of residential services that people need and support and I think one of the, you know, we now have Medicaid expansion. Everybody that we're dealing with here is basically a Medicaid recipient. So we, which was not true five years ago, a lot of these people would have been uninsured and that's great. We don't know how to use Medicaid yet and one of the big issues is can we use Medicaid to provide those kinds of services? Now the issue of getting homes for them, in the case of intellectual disability, de-institutionalization has worked out very, very well on the whole. Even in Illinois, which is horrible, we ranked number 47 or something like that in intellectual disability services, you will, it's very unusual to see someone with IDD who's homeless. And the reason is that there's a very powerful constituency that basically says to politicians in Springfield, we will come and kill you if you do not meet the needs of our loved ones. And that is, you know, that's kind of what you need. People with severe mental illness have, also people with IDD typically have more stable housing needs. Once you house someone, you'd have a much longer period where you kind of know that they're stably housed. But we've somehow gotten huge amounts of money and political consensus that to do that, that we haven't gotten in the mental health area. Right now, there's a big debate that's been occasioned by the opioid epidemic about modifying something called the IMD exclusion. If I said IMD exclusion, how many people know what those words, have heard those words before? How many have not heard those words before? So most of us have. So Medicaid since 1965 has never paid for inpatient care for substance use or psychiatric services at an inpatient facility that has more than 16 beds and more than half of those are for addiction or mental health. Medicaid, and this was done that way because the federal government did not want to buy state mental hospitals because civil libertarians believed that there needed to be an alternative to warehousing people. There is now a split. The Obama administration relaxed the IMD, allowed states to relax the IMD exclusion if they wanted for an emergency stay of less than 15 days, but not for permanent. And the Trump administration is more accommodating of the idea of getting rid of the IMD exclusion and there's a big split within the mental health disability community about this because, for instance, if you talk to NAMI, a lot of the NAMI people will say pretty much what you just said, that now my loved one has the right to be out there on the street and die. If you talk to self-advocates, what they will say is I don't want to live in the types of facilities that were available and what I want to see is care for me in the least restrictive environment possible that is not the state home for the whatever. And there's a lot of, so we're fighting this out. I think that there will be some greater use of greater ability to use Medicaid for inpatient services, but it's gonna be constrained for all the reasons that I just said. Other questions? Harold, excellent presentation. And I think there's three things. There is no right to housing. So I think that's the basic need problem of whether one has autism or intellectual disability or persistent mental illness. Number two, when I look at your graphs and stuff, it's the height of nonsense that there isn't a mobile health clinic next to that homeless shelter. Like, because each of these cases, I did what I call the, you said you have approximately 300 frequent fliers who have at least four incidents a year. Each of these is the equivalent of a $1,000 Uber ride and a $5,000 primital justice court hassle factor expenses. That means those 300 individuals eat $6 million of services a year. Oh, that is, I love much more. This is like astronomically wasteful, but the system only has a way of responding to the crisis. And so I think there's three things. First, there is no mental health system in Illinois that has the full array of services that individuals need. And until there's equity in doing that, we can guarantee that we'll have these crisis. The second thing is your story about the dog is classical. I've experienced when I've consulted for group homes with intellectual, for individuals with intellectual disability or autism spectrum, a colleague dies, a favorite teacher dies, the dog or cat dies, grandpa dies, and nobody does anything about it. And then they wonder why Johnny in mourning is becoming refractory. So the basic stuff isn't there. This is a great thing and it's only the beginning. And my assumption would be that there needs to be a better triage so that police can say this really belongs in fire, that fire says this really belongs in police. We have a crisis behavior management team that has some capacity. So you put some of the individuals in a padded room instead of having to do shorter shows of force. So, well, let me take a couple. Why don't I take, there's a bunch of hands up. Why don't I take a bunch of them and then I will give an artisanal response to the collective group so that everyone gets a chance to, yes. All right, it's, okay. Hi, I was wondering in terms of budgeting, whether or not you have any numbers regarding. The issue that we have, so one of the complexities of this, by the way, this was something that the people who were the architects of deinstitutionalization didn't completely understand, which is that there's no unified budget. You know, in Dr. Masalti, there's no mental health system. There's many different financial flows and the fact that you reduce a burden in one pipe has nothing to do with whether there's more resources in that other pipe. One of the challenges that we had with deinstitutionalization was people said, you know, the state mental hospitals, all these people who don't need, who are sitting there playing cards in the back, they don't need to be there. And the hospital, there's a $10 million hospital, it's got 100 people in it and that's $100,000 per person. So, this guy who's playing cards in the back and why don't we just give him some community resources getting him out of that hospital? Two, as a human argument, that was completely right. As an economic argument, it was completely wrong for two reasons. The first was, if we saved a bunch of money in the state mental hospital, there was some sort of an immaculate conception that was gonna pick up those dollars and bring them over to the community mental health system where they were, which has done a different level of government by a totally different everything and somehow sprinkle those dollars where they were needed. And that just, that's not, now that happened with intellectual disability because there was a political group that said we're gonna make this happen. But that's not gonna happen. The other issue is the people that were de-institutionalized, the guy who was playing cards in the back, guess what, there weren't a lot of staff spending a lot of time with that guy. So, you took him out of the state mental hospital, you didn't save a lot of money because he was a low-cost patient and the staff were all spending their time with the guy who was not in the back who really had all sorts of profound needs. So, I think that the budgetary argument can be made but it's a complicated argument and I do think that as Medicaid becomes the dominant payer for everything, it's gonna be easier to make that argument because Medicaid is picking up more and more of the costs of more and more things and it will become the unified, if we have a unified mental health system it will come out of Medicaid because the states will say, hey, we're gonna pay for this. Other questions, comments? Yes? Very good lecture, thank you. I think you kind of summarized my whole professional career as an EMF physician. I would make an observation that as an EMF physician I work law enforcement a lot and I'll use the analogy of narcotic overdoses. In our EMS system we've tried multiple times to get police to carry Narcan into administer it because often they're arriving first and they don't wanna do it because if they did wanna do it they would have pursued a paramedic license and so oftentimes this is not things that they wanna do. I think that we have to, I mean, using a social work analogy because I see that I've got social work folk here, we have to be culturally competent about all the cultures we deal with, including the police and we have to find a way that the police find dignity and honor in pursuing a public health mission when they are the people that are called upon to do it and I do think that the opioid epidemic gives us an opportunity. The sad thing is it gives us an opportunity because the framing in the public mind is so much it's suburban and rural white people and not our inner city heroin users who are dying so now that just puts us in a whole different headspace but I think that police have, there's a lot about the daily experience of police that makes their apparently callous behavior in some situations more comprehensible and so it's partly that they didn't go into it to do that but the same by the way we've talked about ER docs, look at all the things that we should be doing in the emergency department for people with complex psychosocial needs and a lot of ER docs are like, I didn't become an ER doc to take care of somebody's homelessness. I'm like the guy who takes care of somebody's traumatic brain injury and there's always those issues where you're trying to get somebody, they are the person in the position to do the thing that's not necessarily the thing that they thought they were training to do and so I must say I think a lot of police now have a more humane attitude about some of these issues than they did five, 10 years ago and that's something we need to build on. Other comments, questions? Maybe running out of time, yeah. Maybe, folks. I think, do you wanna ask a question? No. Who hasn't, do we have time for one more question? I thought right there. I'll stay afterwards for a little bit for those that wanna ask questions but I wanna liberate the rest of you. We don't wanna have a behavioral crisis here. Listen, Harold, I mean, I think maybe some policemen are more humane but it seems like the whole selection process is a little bit out of step. I mean, you talked about escalating and exerting power and it seems like a lot of people are attracted to the police force by the power involved and the policemen I've dealt with have been very difficult, even for me who does not have a mental disability. So, I think the more fundamental change is needed in terms of who we select to become police officers at this point. Well, I think, by the way, that is partly why the CIT officers are sort of a different breed within the department because, but you know, the world is changing and I think that, I do think we have tremendous personnel issues among police and that a lot of, certainly the Chicago Police Department's aware of this where they need to be more diverse, not just in terms of race, ethnicity, but also in other ways so that the culture is more open to the outside world. It's actually, I think, by the way, that is one of the challenges we have here in Chicago is that culture change is easier to affect when the crime rate is low than when the crime rate is high. Right now, they're really facing a huge challenge from violence. One of the good things about the current environment is that police are less interested in just arresting people for the sake of arresting people. On the drug area, I'm struck by how many of my police colleagues, they said, look, I can't arrest people selling drugs all day long. What I really need to do is arrest the people who are gonna shoot somebody. And you know, I just got a real, you know, the world's on fire when it comes to guns, so I can't be worried about the guy selling a dime bag who is the lowest level guy. So, you know, police are aware and they're making adjustments to the environment. We have to give them the resources and the manpower and the leadership so that they can get on that page in a dignified, graceful way. I think that-