Bridging Crisis and Care: Exploring the Role of Behavioral Health Professionals in a Police Co-Response Model

Bridging Crisis and Care: Exploring the Role of Behavioral Health Professionals in a Police Co-Response Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging Crisis and Care: Exploring the Role of Behavioral Health Professionals in a Police Co-Response Model Rachel Oblath, Corinne A Beaugard, Carolina-Nicole Herrera, Cindy Xu, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7136266/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Health & Justice → Version 1 posted 8 You are reading this latest preprint version Abstract Police co-responder programs are collaborations between law enforcement and healthcare institutions where behavioral health professionals are embedded within police departments to support officers responding to incidents involving mental health and/or substance use. Research suggests that co-responder programs, which have existed for over 20 years in the United States and have become particularly popular in recent years, have the potential to decrease police use of force and divert individuals experiencing behavioral health crises from the criminal justice system. However, scant knowledge exists about the role of behavioral health professionals in these programs. This qualitative study examines nearly three years of clinical notes from the Boston Police Department’s co-response program. Using an inductive approach incorporating aspects of grounded theory and thematic analysis, we analyzed notes from 4,111 co-response encounters between July 2019 and March 2022. Our study yielded a conceptual framework with three domains. First, behavioral health professionals interacted with a wide range of community members, including: police personnel; individuals experiencing behavioral health crises; family members of individuals in crisis; and healthcare and social services providers. Second, and through these interactions, behavioral health professionals assessed behavioral health symptoms, behavioral health history, and indicators of risk. Finally, and in response to their assessments, behavioral health professionals provided clinical supports, police assistance, and general assistance to multiple community members. Our findings suggest potential mechanisms by which co-response programs impact both police and behavioral health outcomes. Implications for practice, policy, and future research are discussed. Co-responder model mental health policing diversion Figures Figure 1 Figure 2 Introduction Approximately 23% of all U.S. adults, or 59.3 million people, meet criteria for a psychiatric disorder, with 15.4 million of them having a serious mental illness (National Institute of Mental Health, 2024). Police officers are often the first to respond when people with SMI are in distress (Balfour et al., 2022 ; Gonzalez Miranda et al., 2024 ). Research indicates that upwards of 7% of calls for service to the police involve people experiencing behavioral health crises (Koziarski et al., 2022 ) and 20–25% of people who have been arrested also experience some behavioral health condition (Bronson & Berzofsky, 2017 ). Over one-third of incarcerated individuals (37% of those in state/federal prisons and 44% of those in local jails) have a history of mental illness, over twice the prevalence in the general population (Bronson & Berzofsky, 2017 ). As a result, programs involving collaboration between law enforcement and mental health professionals are increasingly being implemented across the nation to support the behavioral health needs of individuals in crisis within the context of police encounters (Dempsey et al., 2020 ). Co-response programs are one such collaboration. In this model, behavioral health professionals are embedded within police departments to foster a cohesive and collaborative response to incidents involving behavioral health (Lamin & and Teboh, 2016; Shapiro et al., 2015 ). Co-response pairs (i.e., one officer and one behavioral health professional) perform street triage with the primary goal of safely stabilizing individuals in crisis while reducing unnecessary emergency department (ED) utilization or hospitalization and diverting individuals from criminal justice system involvement when appropriate (Bailey et al., 2022 ; Morabito et al., 2018 ). Research evaluating co-response programs has demonstrated mixed effectiveness of the approach (Marcus & Stergiopoulos, 2022 ). Some studies suggest that co-response pairs have positive criminal justice outcomes in that they resolve the immediate crisis for most individuals (Meehan et al., 2019 ) while also reducing the risk of incarceration (Bailey et al., 2022 )) and police use of force (Blais & Brisebois, 2021 ; Every-Palmer et al., 2023 ; Marcus & Stergiopoulos, 2022 ). Less research has defined or examined the clinical outcomes associated with co-response. For example, there are mixed findings on how co-responder pairs impact transfer to emergency room; in some studies, co-response is associated with increased transfer while in others, it is associated with decreased transfer (Blais & Brisebois, 2021 ; Every-Palmer et al., 2023 ; Meehan et al., 2019 ; Yang et al., 2024 ). Existing co-response research largely focuses on the outcomes of these interactions for people experiencing behavioral health crises in the community (Puntis et al., 2018 ) or officer perceptions of the approach (Bailey et al., 2023 ), largely ignoring the role and perceptions of co-responding behavioral health professionals. Lack of understanding about the role of behavioral health professionals within the co-responder model limits understanding of the mechanisms by which programs may impact both police (e.g., use of force, service user injury, arrest rate, resolution on scene) and clinical outcomes (e.g., transportation to emergency department, referral to mental health services, engagement with mental health services). Given the growing popularity of these partnerships and mixed findings as to their efficacy (Marcus & Stergiopoulos, 2022 ), increased understanding of the role of co-response behavioral health professionals (BHPs) is critical to inform ongoing practice, policy, and research. To address this gap in the literature, we analyzed almost three years of clinical notes from co-responding behavioral health professionals within the Boston Police Department’s co-response program. Our objective was to describe the role of the behavioral health professionals within the co-response program. The analysis yielded a conceptual framework with three domains, which highlights mechanisms by which co-response may impact both police and behavioral health outcomes. Methods Setting In 2011, the Boston Police Department (BPD) launched an embedded co-response program to support the stabilization of individuals experiencing behavioral health crises (“clients”) and to address their needs outside of the criminal justice system when possible (Morabito et al., 2018 ; Morabito & Savage, 2021 ). Co-response pairs are comprised of one police officer and one BHP; these pairs are intended to respond to calls that are generally classified by the emergency response system as involving an “EDP” (i.e., emotionally disturbed person). Behavioral health professionals in the program are Master’s-level behavioral health professionals (BHPs; e.g., licensed mental health counselors, licensed clinical social workers) hired and supervised through the Boston Emergency Services Team (BEST), the public psychiatric emergency services program for the Boston metropolitan area (Oblath et al., 2022 ). During the study period (July 2019 through March 2022), BEST BHPs were available to assist BPD officers Monday-Friday from 7:30 AM to 11 PM and on weekends from 10 AM to 6 PM. In BPD’s co-response program, police officers participate in the co-response program on a volunteer basis and may engage co-response BHPs at their discretion. Officers and BHPs have different shift schedules and do not work in regular pairs. During a co-response shift, a BHP is typically assigned to accompany (i.e., ride along with) one officer. A co-response pair can then be dispatched to specific scenes or can proactively respond to radio calls that they identify as having a probable behavioral health component. For example, co-response pairs may respond to calls involving known individuals or addresses that have benefited from co-response in the past. When BHPs ride along with officers, they remain in the car until the scene is deemed safe and secured by officers. Once a call is deemed safe, co-responding BHPs can assist with de-escalation, assessment, and determination of whether the individual requires diversion, transportation, or other mental health services. Co-response BHPs may also be assigned to spend their shift at a designated district station, where they provide consultations as requested by dispatch or on-scene officers. BHPs provided consults over the phone or in-person (after being transported by an officer to the scene). Data All study procedures were approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board. This study involved the secondary analysis of electronic health records. We analyzed clinical notes from 4,111 co-response encounters occurring between July 2019 and March 2022. After each encounter, BHPs completed a brief form with two open-text fields where they described the complaint (i.e., details about the client and the problem) and the disposition (i.e., any actions they took in response to the situation and the clinical outcome, if available). The length of notes in the complaint field ranged from one to 135 words (M = 10.8, SD = 10.7). The length of notes for the disposition field ranged from one to 374 words (M = 24.5, SD = 33.0). Demographic data were not systematically collected on the post-encounter form until late 2022, when discrete fields pertaining to age, race, sex and housing stability were added. Prior to that—including for our entire study period—BHPs inconsistently reported demographic details in the two open-text fields. As a result, we cannot provide demographic information about clients served during the study period. For context, we did examine the demographics of all clients served in calendar year 2023 (the first full year for which we had demographic data), which we expect was comparable to prior years. In 2023, 12.0% of clients served by the co-response program were under age 18 (M = 13.2, SD = 3.1) and 88.0% were adults (M = 41.5, SD = 15.3). In terms of gender, clients were 50.8% male, 47.5% female, and 1.3% transgender or non-binary (0.4% missing). Clients were 38.5% Black, 25.8% White, 18.1% Hispanic, and 4.9% another race/ethnicity (12.7% missing). This differs substantially from racial and ethnic characteristics of Boston’s general population as reported in the 2020 census (United States Census Bureau, 2020 )44.6% non-Hispanic White, 19.1% non-Hispanic Black, 18.7% Hispanic). Analysis We used an inductive approach to data analysis incorporating aspects of grounded theory and thematic analysis (Braun & Clarke, 2012 ; Charmaz, 2006 ). To reduce bias, our initial coding team was multi-disciplinary, including: a developmental psychologist [redacted], a postdoctoral fellow with a background in public health [redacted], an emergency psychiatrist [redacted], two psychiatry residents [redacted], and two undergraduate research assistants [redacted]. Details about the complaint were often included in the disposition field, so we did not distinguish between these two fields during the coding process. Instead, we focused on all available information related to each encounter. During open coding, team members reviewed each complaint and disposition narrative and assigned codes to meaningful chunks of data. Codes were recorded and the team met weekly to collapse and define them, as well as to identify and discuss emerging themes. After each complaint or disposition field was coded, a second team member reviewed the assigned codes and noted any questions or disagreements. The team discussed and resolved these issues at the weekly meetings and revised the codebook accordingly. After all of the encounters had been coded by at least two team members, the team continued to meet weekly to define, organize, and name the themes that had emerged. Additionally, the coding team met bi-weekly with a team of advisors with expertise related to the program consisting of criminologist [redacted], the BPD deputy director of research and development [redacted], and the clinical supervisor for the co-responders [redacted] to ask questions and discuss emerging themes. This process ultimately yielded a conceptual framework with three themes. We then verified the credibility of this framework using three methods. First, we shared the framework with our advisory team, who evaluated whether it was in alignment with the program as understood by BPD and BEST clinical leadership. Second, we had two members of the research team who did not participate in the open coding process evaluate whether the conceptual framework accurately reflected a random sample of 50 encounters. Our auditors were a postdoctoral fellow with a background in social work [redacted] and a graduate student in nursing [redacted]. Finally, using an adapted version of member checking (Creswell, 2025 ), one team member [redacted] attended a clinical supervision meeting with current co-responders to evaluate how well the framework reflected their experiences in the field and their understanding of their role. Our final framework was refined and revised based on feedback received during these three processes. The quality of BHP reporting varied widely, and some notes did not include complete information about the encounter. As we are not confident that the frequencies of codes accurately reflect how often events occurred, we do not report frequencies of codes. Results Our analyses of clinical notes from over 4,000 co-response encounters yielded a conceptual framework describing the role of the co-response BHP in assessing and responding to mental health needs within the context of police encounters (Fig. 1 ). Our framework includes three domains. First, our analysis highlighted how BHPs interacted with a wide range of community members during co-response encounters. Second, we identified common behavioral symptoms and characteristics of clients. Finally, we were able to describe specific types of supports provided by BHPs during co-response encounters. Community Interactions BHPs reported interacting with a wide range of community members during co-response calls (Table 1 ). Prior to an encounter, police personnel were the primary source of information for co-response BHPs. During encounters, BHPs interacted with a wide range of community members to assess the behavioral health needs of clients and provide support in relation to those needs. Table 1 highlights BHP interactions with specific types of community members, both for the purposes of assessment and provision of support. Table 1 Interactions between co-response BHPs and community members Entity Types of Interactions Assessment Support Police personnel Conduct assessments, provide recommendations, collaborate to develop supports for client “Responding officer stated client’s home is uninhabitable from hoarding but she is refusing to leave.” “Officer highlighted client who has had many recent encounters with Boston Police Department and appears to be homeless and mentally ill” “Consulted with FBI and offered potential support during an outreach encounter.” “Clinician suggested officers document all contacts with client to facilitate possible future Section 35.” Client Conduct assessments and provide supports “This writer evaluated client; client endorsed audial hallucinations and showed evidence of visual hallucinations. Client was upset regarding the food that was given to him in the holding cell, so he made statements about suicidal intent” “This writer face timed client and was able to get client to open the door after an hour of speaking with client.” “After speaking with the client for awhile, this writer was able to get the client to agree to go the hospital in order to get an evaluation.” “This writer spoke with the client and informed her that she will be going to the hospital for an evaluation. Client was then transported without issues.” Family of client Conduct assessments and provide supports “This writer spoke to client’s cousin who has many concerns, including that client is unable to take care of herself” “This writer met with the client’s wife who reported that the client is off his medication, stays up all night, and appears to be going into a manic state.” “This writer spoke with client’s family and informed them that the client is not appropriate for a section 12 but he may need to have a medical evaluation with his doctors to address his pain.” “De-escalated mother of client and provided information about Section 35 process.” Healthcare Provider Conduct assessments, provide recommendations, and collaborate to develop supports for client “This writer spoke with the client’s clinician who reported that the client has a history of making statements that people are stealing from her. The clinician reported that the client has just recently started back on her medications” “This writer called the primary clinician; clinician stated that client is currently not taking his meds and clinician is concerned about client’s aggressive behavior escalating and potentially becoming violent.” “This writer and nurse case manager were able to collaborate regarding the needs and service options of the client and her husband.” “This writer spoke with provider at [hospital], who then made contact with the client about getting them a recovery coach and any other needed services.” Social Services Provider Conduct assessments, provide recommendations, and collaborate to develop supports for client “This writer spoke with the client’s group home who reported the client’s behaviors were her normal baseline. The group home staff reported that the client is okay and usually comes back to the program without any issues.” “Per [shelter] staff, earlier that morning the client had refused to leave the bathroom when other guests needed to use it. Client was suspended for 30 days for being disruptive but refused to leave.” “This writer made several phone calls to shelters to see if any of them had beds available today.” “This writer contacted elder services due to concern for the client’s well-being.” Criminal Justice System Provide recommendations and collaborate to develop supports for client “Court clinician called co-responder requesting a well-being check on client” “Client’s parole officer contacted this writer to ask for a follow-up with the client. Per parole officer, client contacted parole officer through text message stating he wanted to kill himself.” “Consulted with assistant district attorney who will request mental health and substance abuse evaluation through open case.” “Provided attorney with release of information to seek records.” “Referred to mental health court.” School Staff Conduct assessments and collaborate to develop supports for client “Client’s school contacted this writer to report that the client was dysregulated in school today.” “This writer contacted school personnel for info. School staff reported that at the end of the school day the client talked about killing himself when he got home.” “Connected with school staff to develop a safe re-entry plan for client.” “This writer informed the school of the safety plan.” Other Conduct assessments and provide recommendations “This writer was able to speak to a neighbor who helps client out and states that client has food and is able to take care of herself.” “This writer met with the client’s friend who stated that the client texted him stating that she was going to go to the beach and overdose on pills due to him forgetting to pick her up. Client’s friend reported that he has been trying to get the client to calm down but was unsuccessful.” “This writer coordinated with client’s friend and came to the agreement that client would stay with her friend for a few days.” “Provided resources to landlord and suggested she call 911 next time problems arise with tenant.” Police Personnel Police personnel and BHPs interacted frequently both prior to and during encounters. In alignment with the structure of the co-response program, police initiated almost all co-response encounters: e.g., “responding officers requesting consultation and on-scene assistance with emotionally disturbed person off of her meds on a recent drug binge.” Police officers were an important source of information as BHPs assessed client behavioral health, offering their own direct observations of client behavior and symptoms: e.g., “Officer reports client is very upset and made statements about suicidal ideation.” Information sharing between BHPs and officers was bi-directional, and BHPs sometimes communicated important information about a client’s mental health history to officers: e.g., “Provided mental health history and information to officers.” This sharing is in compliance with Health Insurance Portability and Accountability Act (HIPAA) guidelines, which permit a HIPAA-covered entity to disclose personal health information to law enforcement without an individual’s signed authorization to protect the individual or another person from serious harm (Department of Health and Human Services, 2025). The clinical notes also highlighted how BHPs and police officers worked together to determine the best response to client behavioral health needs: This writer and BPD officers discussed next steps. This writer stated that based on the client’s apparent manic and paranoid behavior, numerous false reports against his roommates made to 911, and previous mental health history, it would be best for client to be seen at hospital for a psychiatric evaluation. This writer also advised officers that client does not want to go to the hospital and will likely be non-compliant. Clients BHPs typically interacted with clients themselves, although there were encounters where clients were not present. Typical initial interactions with clients reflected BHPs’ direct observations of behavioral health symptoms: e.g., “This writer spoke with the client who had pressured speech and was very manic.” Clients also shared important information about their mental state: e.g., “The client was tearful and emotional and disclosed to this writer that he suffers from depression and feels like there’s no point in living.” In some cases, BHPs needed to de-escalate a situation prior to assessment and the provision of supports: e,g., “This writer spoke with the client and was able to calm him down. This writer also spoke to the client about seeking assistance for his mood swings.” After assessing the situation, BHPs provided a range of supports for clients, which we discuss in more detail in a later section. In cases where BHPs did not interact directly with clients, other individuals provided information (e.g., family members) Other Community Members In addition to police officers and clients, co-response BHPs gathered information from and provided support to concerned family members. BHPs interacted with healthcare providers to obtain information to help the client and coordinate care. Interactions with healthcare providers typically occurred over the phone, and included the client’s existing providers (e.g., primary care physicians, mental health care providers) and/or potential new providers for referral purposes. BHPs also collaborated with emergency medical personnel (EMTs and paramedics) at the scene of an encounter. Similar to collaborating with healthcare providers, BHPs interacted both in-person and over the phone with existing or potential social service providers, including shelter staff and social workers. In some situations, BHPs interacted with agents of the criminal justice system, most commonly lawyers and parole officers. During encounters involving youth, co-response BHPs sometimes interacted with school staff. Finally, BHPs sometimes interacted with friends, roommates, neighbors, or other members of the public who had contacted police or emergency services about clients. Examples of BHP interactions with a wide range of community members are shown in Table 1 . Behavioral Health Symptoms Co-responding BHPs identified a range of client behavioral health symptoms, the most common of which are highlighted in Table 2 , with examples from clinical notes. Some of the most common symptoms noted by co-response BHPs were suicidal ideations, intentions, or behaviors. For example, Table 2 Behavioral health symptoms of co-response clients Code Definition Example Behavioral health symptoms Intent to harm self/suicidal intent Client has either passive or active thoughts of harming themselves. Includes suicidal ideation or behaviors. “Client is homeless and reports he is choosing to live outside in the elements to die. He stated that he would like to find a gun and kill himself.” “This writer met with the client who reported that he was having feelings of suicidal intent. Due to language barrier the client could not report whether he had a plan or not. Client does have a history of self harm.” “This writer met with the client who reported that she self-harmed by cutting her wrist yesterday after getting into a verbal disagreement with her mother. Client is endorsing recurring thoughts of sucidial intent and has a history of cutting (last time 2 years ago).” Substance use Client appears to be under the influence or reports substance use. “This writer met with client who admitted that she used substances the night before which caused her to yell and scream and act erratically.” “This writer spoke to client, who denied drug use but showed signs of impairment from stimulants.” “Client was intoxicated (alcohol) and stated twice that she would kill her grandson’s father, who lives in the apartment above. ” Psychosis Client exhibits a loss of touch with reality, including hallucinations, delusions, paranoia, and/or disorganized thinking. “Client exhibiting delusion and paranoia. Client’s apartment was barricaded all vents were sealed with cardboard.” “Client reported that he is hearing voices and that they are telling him to hurt people.” “Grossly disorganized decompensated psychosis. Client is tearful and unable to effectively communicate.” Mania Client exhibits euphoria, grandiosity, rapid speech, impulsivity, and/or reckless behavior. “This writer met with the client who was manic, had disorganized thought process. Client admitted to this writer that she had stopped taking her medications due to them making her feel strange.” “Upon arrival client was agitated but was able to calm down. Client denies any suicidal or homicidal intent at this time. Client’s family reported that [he] is manic, has been off his meds for at least a year, and has been decompensating ever since.” Disorganized behavior Client exhibits thoughts, actions, or speech that is incoherent or illogical. Includes inappropriate or bizarre behaviors and emotional dysregulation. “Client was walking around naked in public this morning. Upon arriving at her home, opened her door fully naked. Client stated that she did not want to wear clothes and has suicidal intent.” “Client is making bizarre and threatening comments to strangers in the community.” “This writer met with client who reported that he became dysregulated after he and his mother got into a verbal argument over a mess in the kitchen. Client stated that he was unable to control his behaviors and started to destroy his mother’s home.” This writer met with the client who stated that he wanted to kill himself and he had a plan to obtain a gun and shoot himself. Client stated that he has been dealing with these thoughts for a while and he believes that he is going to act on them at some point soon. Substance-related calls were also common, and BHPs recorded whether clients appeared intoxicated at the time of the encounter: e.g., “Client was drunk and refused EMS services. Client denied any suicidal or homicidal intentions. Client had a bottle of gin in his hand and did allow this writer to put the bottle in the freezer.” Other common symptom categories included psychosis, mania, and/or disorganized behaviors. For example, one BHP noted, “Client is having active paranoia and delusions regarding her family being out to get her. Per mom, client has not slept in days. No mental health history, but client is 2 months postpartum.” We defined disorganized behaviors as behaviors generally considered socially unacceptable or irreconcilable with normal/expected behavior, including dysregulated or out-of-control behavior (American Psychiatric Association, 2013 ): e.g., “Client was walking throughout city in leather coat with several layers of clothing in 100 degree heat; delusional thinking, profusely sweating, exhausted but refusing help.” Symptom categories were not mutually exclusive, and individuals sometimes exhibited symptoms from multiple categories. To contextualize symptoms, BHPs briefly noted whether clients or their families reported diagnosed behavioral health disorders; the most common of these included depression, anxiety, schizophrenia, bipolar disorder, and post-traumatic stress disorder. BHPs also indicated whether the client had relevant recent and/or historic trauma. Finally, co-responders noted important information related to whether clients were receiving behavioral health treatment, including whether they had established providers and whether they were taking any prescribed psychotropic medications. BHPs often indicated whether clients belonged to a range of populations associated with important behavioral health risk. For example, BHPs noted when clients were elderly, had developmental or intellectual disabilities, were veterans, or victims of domestic violence. BHPs also noted important sociodemographic characteristics associated with risk, including whether a client was a sexual or gender minority, was currently unsheltered or unstably housed, or spoke limited or no English. Provision of Supports After assessing behavioral health symptoms, co-responding BHPs provided a range of supports to meet the needs of both the clients and other community members with whom they interacted. Our analyses indicated that these supports fit into three categories: clinical response, police assistance, and other supports. BHPs often provided multiple supports in the context of one encounter. Table 3 provides examples of each category of support, as described in the clinical notes. Table 3 Supports provided during co-response encounters Support Clinical Response De-escalation “Client was de-escalated and brought to [hospital] under Section 12.” “Client was de-escalated and referred back to a previous outpatient provider. Co-responder worked with client and her family on some short term strategies to reduce stress.” “Client seemed agitated following an altercation with store security over a shoplifting incident. This writer de-escalated the client while the policer officer was running his driver’s license. Client left the area calmly following the encounter.” Psychosocial support “Provided emotional support to mother of client. She declined further services.” “This writer called client’s mother to offer support. Client’s mother really just needed someone to listen and support her.” Provision of psychoeducation or resources “This writer explained to client’s mother the process after a client is brought to the emergency department on a section 12. This writer assisted mother in calling the hospital to obtain more info.” “Informed client of services provided by BEST and other area mental health resources.” “This writer gave client info regarding assisted outpatient treatment and mental health court and told him to talk with his attorney.” Recommendation for voluntary services “Recommended BEST urgent care center.” “Attempted to engage client in pursuing voluntary substance use treatment.” “Attempted to engage client in voluntary dual diagnosis services. Client refused referrals, but took information on BEST urgent care center.” Referral or connection to voluntary services “Referred client to peer support. Confirmed upcoming appointment with psychiatrist.” “Referred client to partial hospitalization program.” “Made arrangements for mobile crisis team to respond without the police.” Admission to voluntary services “This writer contacted community crisis stabilization and spoke to the nurse practitioner, who accepted the client into their program. This writer and street outreach officer dropped the client off there.” “Reached out to mother and provided assistance securing medication and bringing client to partial hospitalization program.” “Client accepted voluntary dual diagnosis treatment.” Follow-up (scheduled or proactive) “Patient to contact therapist and BEST follow-up scheduled for next week.” “This writer called mother to follow-up and ensure that the call center had reached out to the family.” “This writer followed up with client with a phone call to check in. Client stated she is doing the same, but will be ok. This writer followed up with an email to client with resources; client also gave permission for this writer to make a referral to [local services agency]. Alert placed in medical records system “When client couldn’t be located, placed alert in BEST.” “Entered BEST alert to connect with Department of Mental Health homeless outreach team for stabilization.” “This writer connected with [BHP] to do outreach once client is released from the hospital and entered an alert into BEST system.” Police Assistance Providing information from medical record “Provided summary of known BEST history to officer, in case client returns.” “Provided officer information about client’s frequent utilization of BEST.” “Provided mental health history and information to officers.” Clinical recommendation “Advised that client did not meet the criteria for involuntary services.” “Recommended Section 35 to detectives.” “This writer advised BPD to issue a section 12 should another call of threats or harassment come in regarding client.” Support for Section 12 (Emergency restraint and hospitalization of individual posing risk of serious harm by reason of mental illness) “This writer assisted with getting the section 12 to the street outreach unit, safety assessment, and coordinating issuing the section.” “This writer assisted officers with issuing a Section 12 to a client who has been off her medications.” “Provided a pre-filled Section 12 to officers.” Support for Section 35 (Involuntary commitment of individual with an alcohol or substance use disorder when there is likelihood of serious harm as a result of that substance use) “Assisted officers in locating client for transport to hospital for Section 35 evaluation.” “Assisted with affidavit for Section 35 petition by providers.” “Assisted with completion of Section 35 affidavit and supplemental paperwork.” Section 18A consult (Evaluation to determine whether an individual who has been arrested but not yet arraigned requires hospitalization for mental health) “Explained 18A process to detectives in case that is needed.” “Section 18A evaluation; evaluation determined client was not suicidal or homicidal and can remain in police custody.” Other requested supports “This writer provided consultation over the phone for officers who were on scene with a client who was displaying signs of paranoia.” “This writer assisted BPD with developing custody plans for client when discharged from hospital.” “Well-being check requested for client. This writer and BPD arrived. Client stated she wanted to die because she is grieving her son.” General Assistance Information or connection to social services “Assisted mother with resources for guardianship.” “Assisted with SNAP application and emailed shelter worker.” “Referred to elder services.” Other “Assisted with arranging childcare with children’s grandmother.” “Delivered some clothing to client while they were a medical inpatient.” “Client walked in to file a domestic violence report. This writer assisted with translation and domestic violence referrals.” Clinical Response One of the most common supports that co-response BHPs provided was de-escalation. For example, BHPs frequently described attempting to calm clients and/or their families and encouraging them to work with emergency medical services or police to resolve the crisis. BHPs sometimes described techniques used during escalation: e.g., “De-escalated client with grounding techniques for anxiety.” BHPs also described providing psychosocial support to clients and their families. Co-responding BHPs attempted to “reassure and comfort the client” and provided “support to client’s mother who is frustrated her son does not meet Section 12 [involuntary hospitalization] criteria.” De-escalation and psychosocial support were also used by BHPs when it was determined that a client needed potentially involuntary evaluation at a hospital: e.g., “Client was still agitated when this writer was speaking to him, but he agreed to be transported to the hospital.” Depending on client symptoms, need, and willingness to engage in treatment, BHPs provided information about and connection to voluntary services along a service linkage continuum (Fig. 2 ). On the left of this continuum are psychoeducation and resources about local services, which BHPs frequently share with clients and families. For example, one BHP described providing “psychoeducation regarding potential for relapse if client maintains social connections to actively using friends.” BHPs also helped clients and families prepare and plan how to connect with care during if a crisis should reoccur: e.g., “This writer gave mother a BEST pamphlet in case she needed to call for a future evaluation.” BHPs recommended a range of voluntary behavioral health services for clients and families, including psychiatric urgent care, mobile crisis services, substance use treatment, and outpatient providers; in these situations, clients could decide whether to immediately engage services. For example, one BHP, “Offered BEST urgent care services. Client took brochure and will seek care on his own.” When appropriate, BHPs connected clients to potential providers or made referrals: e.g., “Client willing to engage in outpatient therapy. Referral to [provider] made.” In some cases, BHPs described walking patients to potential providers and initiating a warm handoff: e.g., “Made introduction to the community behavioral health center team.” In these cases, BHPs may not know whether patients engage in services after the referral as made. BHPs also facilitated client admission to voluntary services, including community crisis stabilization (unlocked 24/7 care) and detox placements; this often included escorting patients to their placement, e.g., “Walked patient to [substance use program] for detox placement.” BHPs could schedule follow-up encounters for clients and families by BEST mobile BHPs, who then contacted the client and/or their family in the following days or at a specified time to check-in and offer additional services if needed. These follow-up encounters did not involve the police and were intended to help ensure clients engaged with needed services: e.g., “Patient to contact therapist and BEST follow-up scheduled for next week.” Co-response BHPs also reported proactively following up with clients, families, and other members of the community to ensure that a client received adequate support in the days or weeks following a co-response encounter. Sometimes, BHPs also placed alerts in the BEST electronic medical records system. Alerts inform BEST providers (including those in the emergency department, mobile crisis teams, and other co-response BHPs) of important information about a client should that individual present for services anywhere within the BEST system. For example, a BHP placed an alert after trying to create a safety plan with a client who was adamant they did not need one: “Client’s mother was told to call 911 immediately if she feels it is necessary. This writer made an alert in the BEST system.” Police Assistance In addition to clinical responses, co-response BHPs provided multiple forms of assistance to police personnel. One of the most common forms of assistance provided was the provision of health information to police from the BEST electronic health record. At the request of police, BHPs shared limited information about an individual from the BEST electronic health record either during an encounter or as part of a threat assessment prior to an encounter. For example, a BHP might share information from a client’s recent BEST encounters: “Client is somewhat familiar to BEST- last encounter was [date] with disposition to detox.” Another common form of assistance provided by BHPs was a recommendation about client behavioral health needs. Most often, BHPs advised whether a client required involuntary hospitalization: “advised them [police officers] to complete a Section 12 for client.” BHPs also supported officers with filing and serving mental health-related orders, including Section 12 (emergency restraint and hospitalization of individual posing risk of serious harm by reason of mental illness) and Section 35 orders (involuntary commitment of individual with an alcohol or substance use disorder when there is a likelihood of serious harm as a result of that substance use). BHPs reported assisting with paperwork and accompanying officers to execute the orders. Although less common, co-response BHPs also consulted at the request of police during Section 18A evaluations, which occur when individuals who have been arrested but not yet arraigned may need hospitalization for a mental health concern. BHPs additionally described providing a wide range of supports as requested by police personnel, both on-scene and via radio/phone. These included accompanying police officers during well-being checks and offering officers support or guidance during interactions with clients. Co-response BHPs also helped with evaluation and planning (e.g., threat assessments, developing custody plans). General Assistance BHPs provided miscellaneous assistance to clients and community members beyond police assistance and clinical responses. For instance, BHPs provided information and resources to clients and their families about local social services (e.g., housing services, homeless shelters, elder services). When appropriate, BHPs connected clients directly to these services or made referrals. BHPs also described helping clients organize things like childcare and transportation, as well as obtaining and supplying material resources (e.g., clothing). Occasionally, BHPs acted as interpreters to facilitate interactions between police officers and community members with limited English proficiency, whether these related to mental health or not. Discussion Although previous research has examined the effectiveness of the embedded co-response model (Marcus & Stergiopoulos, 2022 ), less is known about the role of behavioral health professionals within that model. This study fills this gap by characterizing how BHPs operate within the Boston Police Department’s co-response program. Our analysis yielded a conceptual framework that depicts the multi-faceted role of co-response BHPs in the community, with important implications for practice, policy, and research. BHPs interacted with a wide range of community members beyond clients and police officers. To assess behavioral health needs, BHPs communicated with clients’ family and friends, healthcare providers, and social services providers, as well as individuals working within the criminal justice and school systems. These interactions highlighted common behavioral health symptoms of clients, including suicidal ideation, psychosis, mania, disorganized behavior, and substance use. Our analysis provides a rich description of the supports provided by BHPs during and after co-response encounters, including clinical responses and assistance to police officers. Psychiatric disorders have risen in prevalence among the United States population in the years following the COVID-19 pandemic. This has led to more frequent interactions between police and individuals experiencing behavioral health crises (Crichlow & Atkin-Plunk, 2024 ). Our findings highlight the potential mechanisms through which the co-response model may promote criminal justice diversion and address behavioral health needs within the community. The co-response pair primarily interfaces with community members who face structural vulnerabilities in addition to their psychiatric distress. BHPs recorded when clients belonged to populations associated with important behavioral health risk (e.g., clients who were elderly, had developmental or intellectual disabilities, were veterans, or were victims of domestic violence). BHPs also noted important sociodemographic characteristics associated with risk (e.g., sexual or gender minorities, individuals unstably housed or unsheltered, or individuals with limited or no English). While we could not report demographics for the full study period, data from 2023 indicate that co-responders interact with people of color at higher rates than the general Boston population. Identifying opportunities for prevention could mitigate disproportionate interaction with individuals who are already at risk for negative outcomes. Findings from this study also illustrate mechanisms through which co-response models may impact mental health service outcomes. The continuum of clinical responses provided by the behavioral health professionals in our study (educating clients and families about available services, making provider referrals, securing voluntary treatment placements, and providing follow-up care) fall far beyond the scope of police officers’ duties and skillsets (Telep & Weisburd, 2016). The presence of this expertise and police encounters may increase the likelihood that clients and families access behavioral health services. It may also reduce unnecessary use of higher-acuity settings (e.g., emergency department) and involuntary commitment. Through on-scene intervention and referrals to voluntary treatment, BHPs support lower-threshold care in the community and help direct clients to accessible resources, such as community health centers. Including BHPs in police encounters can shift the experience and outcomes for individuals experiencing behavioral health crisis; however, BHPs in an embedded model, such as in BPD’s program only have the opportunity to de-escalate situations when police officers determine that the scene is safe and request a BHP’s support. Further, the model used by BPD requires police to voluntarily participate in co-response, proactively engage a BHP, and integrate a BHP’s recommendations; buy-in and trust on the part of police are therefore critical to success of the program. Relationship-building between BHPs and police personnel may take time, and outcomes like police use of force or injury may reflect the quality of these relationships (Haugstvedt & and Tuastad, 2023). Our study has some important limitations that may affect the transferability of results to other contexts. First, our study examined one co-response program in an urban area. Findings should be interpreted cautiously in relation to the role of BHPs in other co-response programs and models. The researchers did not have access to police data or client/family perceptions to triangulate the roles BHPs played. Additionally, the content of clinical notes varied widely, and it was up to individual BHPs to determine whether information was important enough to be included. Due to the structure of the clinical notes and the consistency of BHP reporting, we were unable to provide demographic information about the study sample. Finally, the study period (July 2019- March 2022) included the COVID-19 pandemic. Although the co-response program operated during the pandemic, with police and BHPs using appropriate personal protective equipment (e.g., masks) in accordance with CDC guidelines, there was increased use of phone consultations to decrease the risk of infection. The emergence of common themes across the study period suggests that data saturation was reached (Strauss & Corbin, 1998 ), despite any impacts of the lockdown and subsequent phases of the pandemic. Despite these limitations, our findings have implications for practice and policy. The rich description of co-responder roles that emerged from our study aligns well with the objectives of the co-response model: facilitating rapid assessment, de-escalation, and service referrals (Shapiro et al., 2015 ). Our findings detail the emerging role that BHPs play in police response to vulnerable people in the community. As we move towards the goal of reducing justice involvement for individuals experiencing behavioral health crises, detailing the variety of encounters in which co-response pairs engage can be a useful way to both measure and track how BHPs are part of achieving this goal. Our framework may inform police departments considering co-response adoption. We offer a more complete understanding of the types of services and referrals that BHPs provide and subsequent resolutions. This can be helpful for communities who want to adopt co-response but are unsure how to define the role of co-response pairs in their community. Adopting and implementing co-response can be an enormous task. Cross-training can be an avenue to relate these opportunities for collaboration to both police officers and BHPs who will be part of or are already serving on co-response pairs. Future research should explore the mechanisms through which co-response models impact specific outcomes. Much of the existing research has relied solely on police data and points to positive criminal justice outcomes, such as reductions in both arrest and use of force (Lamanna et al., 2018; Morabito et al., 2018 ). However, less is known about short- and long-term mental health outcomes. Using data collected from BHPs may provide a more complete understanding of how effective co-response programs are at linking those with behavioral health need to community services. These data may also help explain mixed findings on the efficacy of co-response and identify the most effective aspects of existing programs. Co-response programs are growing in popularity across the country as police departments work to meet the needs of the communities they serve (Crichlow & Atkin-Plunk, 2024 ). It is therefore critical to define the roles and responsibilities of mental health professionals within these programs. BHPs in our study described playing a multi-faceted role within Boston Police Department, interacting with a wide range of community members to assess and respond to clients in crisis. Our findings suggest potential mechanisms by which embedded co-response programs may reduce negative interactions between police and the community, divert individuals experiencing behavioral health crises from the criminal justice system, and connect these individuals with supports and mental health care. Declarations Ethics approval and consent to participate: All research procedures were approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board. We conducted the study in accordance with ethical standards as detailed in the Helsinki Agreement. This study involved the secondary data analysis of electronic health records; a waiver of consent was granted as the research involved minimal risk, did not adversely affect the rights and welfare of individuals, and could not practicably be carried out without a waiver. Funding: This research was supported by the Bureau of Justice Assistance’s Justice and Mental Health Collaboration Program [grant number 15PBJA-23-GG-01466-MENT] and in part by a philanthropic donor. Author Contribution RO, CNH, GG, DCH, JS, and MSM were involved in the conception of the study. RO, CAB, CNH, JS, and MSM were involved in the design of the study. RO and DCH were involved in the acquisition of data. RO, CAB, CNH, CX, SS, CS, AD, GG, SK, FK, JS, and MSM were involved in the analysis of data. RO, CAB, CNH, AD, GG, EP, TF, JS, and MSM were involved in the interpretation of data. All authors were involved in drafting and/or substantively revising the work. Data Availability The data used in this study is from electronic medical records and therefore cannot be shared openly, to protect the privacy of the individuals included. References American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596 Bailey, K., Hofer, M., Sightes, E., Lowder, E. M., Grommon, E., & Ray, B. (2023). Study protocol and stakeholder perceptions of a randomized controlled trial of a co-response police-mental health team. Journal of Experimental Criminology . https://doi.org/10.1007/s11292-023-09598-2 Bailey, K., Lowder, E. M., Grommon, E., Rising, S., & Ray, B. R. (2022). Evaluation of a police–mental health co-response team relative to traditional police response in Indianapolis. Psychiatric Services , 73 (4), 366–373. https://doi.org/10.1176/appi.ps.202000864 Balfour, M. E., Hahn Stephenson, A., Delany-Brumsey, A., Winsky, J., & Goldman, M. L. (2022). Cops, clinicians, or both? Collaborative approaches to responding to behavioral health emergencies. Psychiatric Services , 73 (6), 658–669. https://doi.org/10.1176/appi.ps.202000721 Blais, E., & Brisebois, D. (2021). Improving police responses to suicide-related emergencies: New evidence on the effectiveness of co-response police-mental health programs. Suicide and Life-Threatening Behavior , 51 (6), 1095–1105. https://doi.org/10.1111/sltb.12792 Braun, V., & Clarke, V. (2012). Thematic Analysis. APA handbook of research methods in psychology, Vol 2: Research designs: Quantitative, qualitative, neuropsychological, and biological (pp. 57–71). American Psychological Association. https://doi.org/10.1037/13620-004 Bronson, J., & Berzofsky, M. (2017). Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12 . Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/imhprpji1112.pdf Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis . sage. Creswell, J. W. (with, & Poth, C. N. (2025). Qualitative Inquiry & Research Design: Choosing Among Five Approaches (Fifth edition.). Sage. Crichlow, V. J., & Atkin-Plunk, C. A. (2024). Meshing into one: An assessment of law enforcement and clinician perspectives on professional roles and the embedded co-responder model. Criminal Justice and Behavior , 00938548241298695. https://doi.org/10.1177/00938548241298695 Dempsey, C., Quanbeck, C., Bush, C., & Kruger, K. (2020). Decriminalizing mental illness: Specialized policing responses. CNS Spectrums , 25 (2), 181–195. https://doi.org/10.1017/S1092852919001640 Every-Palmer, S., Kim, A. H. M., Cloutman, L., & Kuehl, S. (2023). Police, ambulance and psychiatric co-response versus usual care for mental health and suicide emergency callouts: A quasi-experimental study. Australian & New Zealand Journal of Psychiatry , 57 (4), 572–582. https://doi.org/10.1177/00048674221109131 Gonzalez Miranda, L. A., Shetty, A., & Ehlke, D. (2024). Analyzing alternative behavioral crisis response models in the u.s. Journal of Community Health , 49 (2), 324–329. https://doi.org/10.1007/s10900-023-01299-1 Haugstvedt, H.,and, & Tuastad, S. E. (2023). It gets a bit messy: Norwegian social workers’ perspectives on collaboration with police and security service on cases of radicalisation and violent extremism. Terrorism and Political Violence , 35 (3), 677–693. https://doi.org/10.1080/09546553.2021.1970541 Koziarski, J., Ferguson, L., & Huey, L. (2022). Shedding light on the dark figure of police mental health calls for service. Policing: A Journal of Policy and Practice , 16 (4), 696–706. https://doi.org/10.1093/police/paac006 Lamin, S. A.,and, & Teboh, C. (2016). Police social work and community policing. Cogent Social Sciences , 2 (1), 1212636. https://doi.org/10.1080/23311886.2016.1212636 Marcus, N., & Stergiopoulos, V. (2022). Re-examining mental health crisis intervention: A rapid review comparing outcomes across police, co-responder and non-police models. Health & Social Care in the Community , 30 (5), 1665–1679. https://doi.org/10.1111/hsc.13731 Meehan, T., Brack, J., Mansfield, Y., & Stedman, T. (2019). Do police–mental health co-responder programmes reduce emergency department presentations or simply delay the inevitable? Australasian Psychiatry , 27 (1), 18–20. https://doi.org/10.1177/1039856218797424 Morabito, M. S., & Savage, J. (2021). Examining proactive and responsive outcomes of a dedicated co-responder team. Policing: A Journal of Policy and Practice , 15 (3), 1802–1817. https://doi.org/10.1093/police/paab029 Morabito, M. S., Savage, Jenna, Sneider, Lauren,and, & Wallace, K. (2018). Police response to people with mental illnesses in a major u.s. city: The boston experience with the co-responder model. Victims & Offenders , 13 (8), 1093–1105. https://doi.org/10.1080/15564886.2018.1514340 National Institute of Mental Health (2024, September). Mental Illness . https://www.nimh.nih.gov/health/statistics/mental-illness Oblath, R., Herrera, C. N., Were, L. P. O., Syeda, H. S., Duncan, A., Ferguson, T., Kalesan, B., Perez, D. C., Taglieri, J., Borba, C. P. C., & Henderson, D. C. (2022). Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team. Community Mental Health Journal . https://doi.org/10.1007/s10597-022-01015-8 Puntis, S., Perfect, D., Kirubarajan, A., Bolton, S., Davies, F., Hayes, A., Harriss, E., & Molodynski, A. (2018). A systematic review of co-responder models of police mental health ‘street’ triage. Bmc Psychiatry , 18 (1), 256. https://doi.org/10.1186/s12888-018-1836-2 Shapiro, G. K., Cusi, A., Kirst, M., O’Campo, P., Nakhost, A., & Stergiopoulos, V. (2015). Co-responding police-mental health programs: A review. Administration and Policy in Mental Health and Mental Health Services Research , 42 (5), 606–620. https://doi.org/10.1007/s10488-014-0594-9 Strauss, A., & Corbin, J. (1998). Basics of Qualitative Research Techniques . https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=18c7cfe7a46c7771b60dc384b1b4e350f65b13e2 United States Census Bureau (2020). Boston—Census Bureau Search . https://data.census.gov/all?q=boston Yang, S. M., Gill, C. E., Lu, Y. F., Azam, M., & Kanewske, L. C. (2024). A police-clinician co-response team to people with mental illness in a suburban-rural community: A randomized controlled trial. Journal of Experimental Criminology . https://doi.org/10.1007/s11292-023-09603-8 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Health & Justice → Version 1 posted Editorial decision: Revision requested 26 Sep, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers invited by journal 25 Jul, 2025 Editor assigned by journal 23 Jul, 2025 Submission checks completed at journal 23 Jul, 2025 First submitted to journal 16 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7136266","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491988501,"identity":"ff90a701-8b82-4183-bdbf-166e07941095","order_by":0,"name":"Rachel 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06:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7136266/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7136266/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40352-025-00381-1","type":"published","date":"2025-11-25T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87819717,"identity":"49491616-68f1-48d0-95ad-94cad8cbcb8c","added_by":"auto","created_at":"2025-07-29 10:43:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":309517,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Framework: The Role of BHPs in Co-Response\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7136266/v1/07cd0195ef242bf21788fb66.jpeg"},{"id":87820339,"identity":"8e59560c-40e3-496c-b5d7-f4a5feb78b49","added_by":"auto","created_at":"2025-07-29 10:51:07","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":290041,"visible":true,"origin":"","legend":"\u003cp\u003eBehavioral Health Service Linkage Continuum\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7136266/v1/c429fe91a63285b9600f813c.jpeg"},{"id":97178307,"identity":"119274e5-8e14-49e3-a0d3-305bf335e6b8","added_by":"auto","created_at":"2025-12-01 16:07:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1409252,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7136266/v1/e7714f6f-7b5d-4309-ace3-5279203f4c4b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging Crisis and Care: Exploring the Role of Behavioral Health Professionals in a Police Co-Response Model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 23% of all U.S. adults, or 59.3\u0026nbsp;million people, meet criteria for a psychiatric disorder, with 15.4\u0026nbsp;million of them having a serious mental illness (National Institute of Mental Health, 2024). Police officers are often the first to respond when people with SMI are in distress (Balfour et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Gonzalez Miranda et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Research indicates that upwards of 7% of calls for service to the police involve people experiencing behavioral health crises (Koziarski et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and 20–25% of people who have been arrested also experience some behavioral health condition (Bronson \u0026amp; Berzofsky, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Over one-third of incarcerated individuals (37% of those in state/federal prisons and 44% of those in local jails) have a history of mental illness, over twice the prevalence in the general population (Bronson \u0026amp; Berzofsky, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). As a result, programs involving collaboration between law enforcement and mental health professionals are increasingly being implemented across the nation to support the behavioral health needs of individuals in crisis within the context of police encounters (Dempsey et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCo-response programs are one such collaboration. In this model, behavioral health professionals are embedded within police departments to foster a cohesive and collaborative response to incidents involving behavioral health (Lamin \u0026amp; and Teboh, 2016; Shapiro et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Co-response pairs (i.e., one officer and one behavioral health professional) perform street triage with the primary goal of safely stabilizing individuals in crisis while reducing unnecessary emergency department (ED) utilization or hospitalization and diverting individuals from criminal justice system involvement when appropriate (Bailey et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Morabito et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResearch evaluating co-response programs has demonstrated mixed effectiveness of the approach (Marcus \u0026amp; Stergiopoulos, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Some studies suggest that co-response pairs have positive criminal justice outcomes in that they resolve the immediate crisis for most individuals (Meehan et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) while also reducing the risk of incarceration (Bailey et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)) and police use of force (Blais \u0026amp; Brisebois, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Every-Palmer et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Marcus \u0026amp; Stergiopoulos, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Less research has defined or examined the clinical outcomes associated with co-response. For example, there are mixed findings on how co-responder pairs impact transfer to emergency room; in some studies, co-response is associated with increased transfer while in others, it is associated with decreased transfer (Blais \u0026amp; Brisebois, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Every-Palmer et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Meehan et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExisting co-response research largely focuses on the outcomes of these interactions for people experiencing behavioral health crises in the community (Puntis et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) or officer perceptions of the approach (Bailey et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), largely ignoring the role and perceptions of co-responding behavioral health professionals. Lack of understanding about the role of behavioral health professionals within the co-responder model limits understanding of the mechanisms by which programs may impact both police (e.g., use of force, service user injury, arrest rate, resolution on scene) and clinical outcomes (e.g., transportation to emergency department, referral to mental health services, engagement with mental health services). Given the growing popularity of these partnerships and mixed findings as to their efficacy (Marcus \u0026amp; Stergiopoulos, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), increased understanding of the role of co-response behavioral health professionals (BHPs) is critical to inform ongoing practice, policy, and research.\u003c/p\u003e\u003cp\u003eTo address this gap in the literature, we analyzed almost three years of clinical notes from co-responding behavioral health professionals within the Boston Police Department’s co-response program. Our objective was to describe the role of the behavioral health professionals within the co-response program. The analysis yielded a conceptual framework with three domains, which highlights mechanisms by which co-response may impact both police and behavioral health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn 2011, the Boston Police Department (BPD) launched an embedded co-response program to support the stabilization of individuals experiencing behavioral health crises (“clients”) and to address their needs outside of the criminal justice system when possible (Morabito et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Morabito \u0026amp; Savage, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Co-response pairs are comprised of one police officer and one BHP; these pairs are intended to respond to calls that are generally classified by the emergency response system as involving an “EDP” (i.e., emotionally disturbed person).\u003c/p\u003e\u003cp\u003eBehavioral health professionals in the program are Master’s-level behavioral health professionals (BHPs; e.g., licensed mental health counselors, licensed clinical social workers) hired and supervised through the Boston Emergency Services Team (BEST), the public psychiatric emergency services program for the Boston metropolitan area (Oblath et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). During the study period (July 2019 through March 2022), BEST BHPs were available to assist BPD officers Monday-Friday from 7:30 AM to 11 PM and on weekends from 10 AM to 6 PM.\u003c/p\u003e\u003cp\u003eIn BPD’s co-response program, police officers participate in the co-response program on a volunteer basis and may engage co-response BHPs at their discretion. Officers and BHPs have different shift schedules and do not work in regular pairs. During a co-response shift, a BHP is typically assigned to accompany (i.e., ride along with) one officer. A co-response pair can then be dispatched to specific scenes or can proactively respond to radio calls that they identify as having a probable behavioral health component. For example, co-response pairs may respond to calls involving known individuals or addresses that have benefited from co-response in the past. When BHPs ride along with officers, they remain in the car until the scene is deemed safe and secured by officers. Once a call is deemed safe, co-responding BHPs can assist with de-escalation, assessment, and determination of whether the individual requires diversion, transportation, or other mental health services. Co-response BHPs may also be assigned to spend their shift at a designated district station, where they provide consultations as requested by dispatch or on-scene officers. BHPs provided consults over the phone or in-person (after being transported by an officer to the scene).\u003c/p\u003e\u003cp\u003e\u003cb\u003eData\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll study procedures were approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board. This study involved the secondary analysis of electronic health records. We analyzed clinical notes from 4,111 co-response encounters occurring between July 2019 and March 2022. After each encounter, BHPs completed a brief form with two open-text fields where they described the complaint (i.e., details about the client and the problem) and the disposition (i.e., any actions they took in response to the situation and the clinical outcome, if available). The length of notes in the complaint field ranged from one to 135 words (M = 10.8, SD = 10.7). The length of notes for the disposition field ranged from one to 374 words (M = 24.5, SD = 33.0).\u003c/p\u003e\u003cp\u003eDemographic data were not systematically collected on the post-encounter form until late 2022, when discrete fields pertaining to age, race, sex and housing stability were added. Prior to that—including for our entire study period—BHPs inconsistently reported demographic details in the two open-text fields. As a result, we cannot provide demographic information about clients served during the study period. For context, we did examine the demographics of all clients served in calendar year 2023 (the first full year for which we had demographic data), which we expect was comparable to prior years. In 2023, 12.0% of clients served by the co-response program were under age 18 (M = 13.2, SD = 3.1) and 88.0% were adults (M = 41.5, SD = 15.3). In terms of gender, clients were 50.8% male, 47.5% female, and 1.3% transgender or non-binary (0.4% missing). Clients were 38.5% Black, 25.8% White, 18.1% Hispanic, and 4.9% another race/ethnicity (12.7% missing). This differs substantially from racial and ethnic characteristics of Boston’s general population as reported in the 2020 census (United States Census Bureau, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)44.6% non-Hispanic White, 19.1% non-Hispanic Black, 18.7% Hispanic).\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used an inductive approach to data analysis incorporating aspects of grounded theory and thematic analysis (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Charmaz, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). To reduce bias, our initial coding team was multi-disciplinary, including: a developmental psychologist [redacted], a postdoctoral fellow with a background in public health [redacted], an emergency psychiatrist [redacted], two psychiatry residents [redacted], and two undergraduate research assistants [redacted]. Details about the complaint were often included in the disposition field, so we did not distinguish between these two fields during the coding process. Instead, we focused on all available information related to each encounter.\u003c/p\u003e\u003cp\u003eDuring open coding, team members reviewed each complaint and disposition narrative and assigned codes to meaningful chunks of data. Codes were recorded and the team met weekly to collapse and define them, as well as to identify and discuss emerging themes. After each complaint or disposition field was coded, a second team member reviewed the assigned codes and noted any questions or disagreements. The team discussed and resolved these issues at the weekly meetings and revised the codebook accordingly. After all of the encounters had been coded by at least two team members, the team continued to meet weekly to define, organize, and name the themes that had emerged. Additionally, the coding team met bi-weekly with a team of advisors with expertise related to the program consisting of criminologist [redacted], the BPD deputy director of research and development [redacted], and the clinical supervisor for the co-responders [redacted] to ask questions and discuss emerging themes.\u003c/p\u003e\u003cp\u003eThis process ultimately yielded a conceptual framework with three themes. We then verified the credibility of this framework using three methods. First, we shared the framework with our advisory team, who evaluated whether it was in alignment with the program as understood by BPD and BEST clinical leadership. Second, we had two members of the research team who did not participate in the open coding process evaluate whether the conceptual framework accurately reflected a random sample of 50 encounters. Our auditors were a postdoctoral fellow with a background in social work [redacted] and a graduate student in nursing [redacted]. Finally, using an adapted version of member checking (Creswell, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), one team member [redacted] attended a clinical supervision meeting with current co-responders to evaluate how well the framework reflected their experiences in the field and their understanding of their role. Our final framework was refined and revised based on feedback received during these three processes.\u003c/p\u003e\u003cp\u003eThe quality of BHP reporting varied widely, and some notes did not include complete information about the encounter. As we are not confident that the frequencies of codes accurately reflect how often events occurred, we do not report frequencies of codes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur analyses of clinical notes from over 4,000 co-response encounters yielded a conceptual framework describing the role of the co-response BHP in assessing and responding to mental health needs within the context of police encounters (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Our framework includes three domains. First, our analysis highlighted how BHPs interacted with a wide range of community members during co-response encounters. Second, we identified common behavioral symptoms and characteristics of clients. Finally, we were able to describe specific types of supports provided by BHPs during co-response encounters.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCommunity Interactions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBHPs reported interacting with a wide range of community members during co-response calls (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Prior to an encounter, police personnel were the primary source of information for co-response BHPs. During encounters, BHPs interacted with a wide range of community members to assess the behavioral health needs of clients and provide support in relation to those needs. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e highlights BHP interactions with specific types of community members, both for the purposes of assessment and provision of support.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInteractions between co-response BHPs and community members\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEntity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTypes of Interactions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssessment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSupport\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolice personnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments, provide recommendations, collaborate to develop supports for client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Responding officer stated client\u0026rsquo;s home is uninhabitable from hoarding but she is refusing to leave.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Officer highlighted client who has had many recent encounters with Boston Police Department and appears to be homeless and mentally ill\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;Consulted with FBI and offered potential support during an outreach encounter.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Clinician suggested officers document all contacts with client to facilitate possible future Section 35.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments and provide supports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer evaluated client; client endorsed audial hallucinations and showed evidence of visual hallucinations. Client was upset regarding the food that was given to him in the holding cell, so he made statements about suicidal intent\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer face timed client and was able to get client to open the door after an hour of speaking with client.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;After speaking with the client for awhile, this writer was able to get the client to agree to go the hospital in order to get an evaluation.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer spoke with the client and informed her that she will be going to the hospital for an evaluation. Client was then transported without issues.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily of client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments and provide supports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer spoke to client\u0026rsquo;s cousin who has many concerns, including that client is unable to take care of herself\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer met with the client\u0026rsquo;s wife who reported that the client is off his medication, stays up all night, and appears to be going into a manic state.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;This writer spoke with client\u0026rsquo;s family and informed them that the client is not appropriate for a section 12 but he may need to have a medical evaluation with his doctors to address his pain.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;De-escalated mother of client and provided information about Section 35 process.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare Provider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments, provide recommendations, and collaborate to develop supports for client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer spoke with the client\u0026rsquo;s clinician who reported that the client has a history of making statements that people are stealing from her. The clinician reported that the client has just recently started back on her medications\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer called the primary clinician; clinician stated that client is currently not taking his meds and clinician is concerned about client\u0026rsquo;s aggressive behavior escalating and potentially becoming violent.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;This writer and nurse case manager were able to collaborate regarding the needs and service options of the client and her husband.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer spoke with provider at [hospital], who then made contact with the client about getting them a recovery coach and any other needed services.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Services Provider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments, provide recommendations, and collaborate to develop supports for client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer spoke with the client\u0026rsquo;s group home who reported the client\u0026rsquo;s behaviors were her normal baseline. The group home staff reported that the client is okay and usually comes back to the program without any issues.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Per [shelter] staff, earlier that morning the client had refused to leave the bathroom when other guests needed to use it. Client was suspended for 30 days for being disruptive but refused to leave.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;This writer made several phone calls to shelters to see if any of them had beds available today.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer contacted elder services due to concern for the client\u0026rsquo;s well-being.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCriminal Justice System\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvide recommendations and collaborate to develop supports for client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Court clinician called co-responder requesting a well-being check on client\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client\u0026rsquo;s parole officer contacted this writer to ask for a follow-up with the client. Per parole officer, client contacted parole officer through text message stating he wanted to kill himself.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;Consulted with assistant district attorney who will request mental health and substance abuse evaluation through open case.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Provided attorney with release of information to seek records.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Referred to mental health court.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool Staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments and collaborate to develop supports for client\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Client\u0026rsquo;s school contacted this writer to report that the client was dysregulated in school today.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer contacted school personnel for info. School staff reported that at the end of the school day the client talked about killing himself when he got home.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;Connected with school staff to develop a safe re-entry plan for client.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer informed the school of the safety plan.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConduct assessments and provide recommendations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer was able to speak to a neighbor who helps client out and states that client has food and is able to take care of herself.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer met with the client\u0026rsquo;s friend who stated that the client texted him stating that she was going to go to the beach and overdose on pills due to him forgetting to pick her up. Client\u0026rsquo;s friend reported that he has been trying to get the client to calm down but was unsuccessful.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;This writer coordinated with client\u0026rsquo;s friend and came to the agreement that client would stay with her friend for a few days.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Provided resources to landlord and suggested she call 911 next time problems arise with tenant.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePolice Personnel\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePolice personnel and BHPs interacted frequently both prior to and during encounters. In alignment with the structure of the co-response program, police initiated almost all co-response encounters: e.g., \u0026ldquo;responding officers requesting consultation and on-scene assistance with emotionally disturbed person off of her meds on a recent drug binge.\u0026rdquo; Police officers were an important source of information as BHPs assessed client behavioral health, offering their own direct observations of client behavior and symptoms: e.g., \u0026ldquo;Officer reports client is very upset and made statements about suicidal ideation.\u0026rdquo;\u003c/p\u003e\u003cp\u003e Information sharing between BHPs and officers was bi-directional, and BHPs sometimes communicated important information about a client\u0026rsquo;s mental health history to officers: e.g., \u0026ldquo;Provided mental health history and information to officers.\u0026rdquo; This sharing is in compliance with Health Insurance Portability and Accountability Act (HIPAA) guidelines, which permit a HIPAA-covered entity to disclose personal health information to law enforcement without an individual\u0026rsquo;s signed authorization to protect the individual or another person from serious harm (Department of Health and Human Services, 2025). The clinical notes also highlighted how BHPs and police officers worked together to determine the best response to client behavioral health needs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis writer and BPD officers discussed next steps. This writer stated that based on the client\u0026rsquo;s apparent manic and paranoid behavior, numerous false reports against his roommates made to 911, and previous mental health history, it would be best for client to be seen at hospital for a psychiatric evaluation. This writer also advised officers that client does not want to go to the hospital and will likely be non-compliant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eClients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBHPs typically interacted with clients themselves, although there were encounters where clients were not present. Typical initial interactions with clients reflected BHPs\u0026rsquo; direct observations of behavioral health symptoms: e.g., \u0026ldquo;This writer spoke with the client who had pressured speech and was very manic.\u0026rdquo; Clients also shared important information about their mental state: e.g., \u0026ldquo;The client was tearful and emotional and disclosed to this writer that he suffers from depression and feels like there\u0026rsquo;s no point in living.\u0026rdquo; In some cases, BHPs needed to de-escalate a situation prior to assessment and the provision of supports: e,g., \u0026ldquo;This writer spoke with the client and was able to calm him down. This writer also spoke to the client about seeking assistance for his mood swings.\u0026rdquo; After assessing the situation, BHPs provided a range of supports for clients, which we discuss in more detail in a later section. In cases where BHPs did not interact directly with clients, other individuals provided information (e.g., family members)\u003c/p\u003e\u003cp\u003e\u003cb\u003eOther Community Members\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn addition to police officers and clients, co-response BHPs gathered information from and provided support to concerned family members. BHPs interacted with healthcare providers to obtain information to help the client and coordinate care. Interactions with healthcare providers typically occurred over the phone, and included the client\u0026rsquo;s existing providers (e.g., primary care physicians, mental health care providers) and/or potential new providers for referral purposes. BHPs also collaborated with emergency medical personnel (EMTs and paramedics) at the scene of an encounter. Similar to collaborating with healthcare providers, BHPs interacted both in-person and over the phone with existing or potential social service providers, including shelter staff and social workers. In some situations, BHPs interacted with agents of the criminal justice system, most commonly lawyers and parole officers. During encounters involving youth, co-response BHPs sometimes interacted with school staff. Finally, BHPs sometimes interacted with friends, roommates, neighbors, or other members of the public who had contacted police or emergency services about clients. Examples of BHP interactions with a wide range of community members are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBehavioral Health Symptoms\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCo-responding BHPs identified a range of client behavioral health symptoms, the most common of which are highlighted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, with examples from clinical notes. Some of the most common symptoms noted by co-response BHPs were suicidal ideations, intentions, or behaviors. For example,\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBehavioral health symptoms of co-response clients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCode\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExample\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBehavioral health symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntent to harm self/suicidal intent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClient has either passive or active thoughts of harming themselves. Includes suicidal ideation or behaviors.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Client is homeless and reports he is choosing to live outside in the elements to die. He stated that he would like to find a gun and kill himself.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer met with the client who reported that he was having feelings of suicidal intent. Due to language barrier the client could not report whether he had a plan or not. Client does have a history of self harm.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer met with the client who reported that she self-harmed by cutting her wrist yesterday after getting into a verbal disagreement with her mother. Client is endorsing recurring thoughts of sucidial intent and has a history of cutting (last time 2 years ago).\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClient appears to be under the influence or reports substance use.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer met with client who admitted that she used substances the night before which caused her to yell and scream and act erratically.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer spoke to client, who denied drug use but showed signs of impairment from stimulants.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client was intoxicated (alcohol) and stated twice that she would kill her grandson\u0026rsquo;s father, who lives in the apartment above. \u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClient exhibits a loss of touch with reality, including hallucinations, delusions, paranoia, and/or disorganized thinking.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Client exhibiting delusion and paranoia. Client\u0026rsquo;s apartment was barricaded all vents were sealed with cardboard.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client reported that he is hearing voices and that they are telling him to hurt people.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Grossly disorganized decompensated psychosis. Client is tearful and unable to effectively communicate.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClient exhibits euphoria, grandiosity, rapid speech, impulsivity, and/or reckless behavior.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This writer met with the client who was manic, had disorganized thought process. Client admitted to this writer that she had stopped taking her medications due to them making her feel strange.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Upon arrival client was agitated but was able to calm down. Client denies any suicidal or homicidal intent at this time. Client\u0026rsquo;s family reported that [he] is manic, has been off his meds for at least a year, and has been decompensating ever since.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisorganized behavior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClient exhibits thoughts, actions, or speech that is incoherent or illogical. Includes inappropriate or bizarre behaviors and emotional dysregulation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Client was walking around naked in public this morning. Upon arriving at her home, opened her door fully naked. Client stated that she did not want to wear clothes and has suicidal intent.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client is making bizarre and threatening comments to strangers in the community.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer met with client who reported that he became dysregulated after he and his mother got into a verbal argument over a mess in the kitchen. Client stated that he was unable to control his behaviors and started to destroy his mother\u0026rsquo;s home.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis writer met with the client who stated that he wanted to kill himself and he had a plan to obtain a gun and shoot himself. Client stated that he has been dealing with these thoughts for a while and he believes that he is going to act on them at some point soon.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSubstance-related calls were also common, and BHPs recorded whether clients appeared intoxicated at the time of the encounter: e.g., \u0026ldquo;Client was drunk and refused EMS services. Client denied any suicidal or homicidal intentions. Client had a bottle of gin in his hand and did allow this writer to put the bottle in the freezer.\u0026rdquo; Other common symptom categories included psychosis, mania, and/or disorganized behaviors. For example, one BHP noted, \u0026ldquo;Client is having active paranoia and delusions regarding her family being out to get her. Per mom, client has not slept in days. No mental health history, but client is 2 months postpartum.\u0026rdquo; We defined disorganized behaviors as behaviors generally considered socially unacceptable or irreconcilable with normal/expected behavior, including dysregulated or out-of-control behavior (American Psychiatric Association, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e): e.g., \u0026ldquo;Client was walking throughout city in leather coat with several layers of clothing in 100 degree heat; delusional thinking, profusely sweating, exhausted but refusing help.\u0026rdquo; Symptom categories were not mutually exclusive, and individuals sometimes exhibited symptoms from multiple categories.\u003c/p\u003e\u003cp\u003eTo contextualize symptoms, BHPs briefly noted whether clients or their families reported diagnosed behavioral health disorders; the most common of these included depression, anxiety, schizophrenia, bipolar disorder, and post-traumatic stress disorder. BHPs also indicated whether the client had relevant recent and/or historic trauma. Finally, co-responders noted important information related to whether clients were receiving behavioral health treatment, including whether they had established providers and whether they were taking any prescribed psychotropic medications.\u003c/p\u003e\u003cp\u003eBHPs often indicated whether clients belonged to a range of populations associated with important behavioral health risk. For example, BHPs noted when clients were elderly, had developmental or intellectual disabilities, were veterans, or victims of domestic violence. BHPs also noted important sociodemographic characteristics associated with risk, including whether a client was a sexual or gender minority, was currently unsheltered or unstably housed, or spoke limited or no English.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvision of Supports\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter assessing behavioral health symptoms, co-responding BHPs provided a range of supports to meet the needs of both the clients and other community members with whom they interacted. Our analyses indicated that these supports fit into three categories: clinical response, police assistance, and other supports. BHPs often provided multiple supports in the context of one encounter. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides examples of each category of support, as described in the clinical notes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSupports provided during co-response encounters\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical Response\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDe-escalation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Client was de-escalated and brought to [hospital] under Section 12.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client was de-escalated and referred back to a previous outpatient provider. Co-responder worked with client and her family on some short term strategies to reduce stress.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client seemed agitated following an altercation with store security over a shoplifting incident. This writer de-escalated the client while the policer officer was running his driver\u0026rsquo;s license. Client left the area calmly following the encounter.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychosocial support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Provided emotional support to mother of client. She declined further services.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer called client\u0026rsquo;s mother to offer support. Client\u0026rsquo;s mother really just needed someone to listen and support her.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProvision of psychoeducation or resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;This writer explained to client\u0026rsquo;s mother the process after a client is brought to the emergency department on a section 12. This writer assisted mother in calling the hospital to obtain more info.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Informed client of services provided by BEST and other area mental health resources.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer gave client info regarding assisted outpatient treatment and mental health court and told him to talk with his attorney.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecommendation for voluntary services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Recommended BEST urgent care center.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Attempted to engage client in pursuing voluntary substance use treatment.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Attempted to engage client in voluntary dual diagnosis services. Client refused referrals, but took information on BEST urgent care center.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReferral or connection to voluntary services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Referred client to peer support. Confirmed upcoming appointment with psychiatrist.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Referred client to partial hospitalization program.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Made arrangements for mobile crisis team to respond without the police.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdmission to voluntary services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;This writer contacted community crisis stabilization and spoke to the nurse practitioner, who accepted the client into their program. This writer and street outreach officer dropped the client off there.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Reached out to mother and provided assistance securing medication and bringing client to partial hospitalization program.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client accepted voluntary dual diagnosis treatment.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up (scheduled or proactive)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Patient to contact therapist and BEST follow-up scheduled for next week.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer called mother to follow-up and ensure that the call center had reached out to the family.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;This writer followed up with client with a phone call to check in. Client stated she is doing the same, but will be ok. This writer followed up with an email to client with resources; client also gave permission for this writer to make a referral to [local services agency].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlert placed in medical records system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;When client couldn\u0026rsquo;t be located, placed alert in BEST.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Entered BEST alert to connect with Department of Mental Health homeless outreach team for stabilization.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer connected with [BHP] to do outreach once client is released from the hospital and entered an alert into BEST system.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePolice Assistance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProviding information from medical record\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Provided summary of known BEST history to officer, in case client returns.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Provided officer information about client\u0026rsquo;s frequent utilization of BEST.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Provided mental health history and information to officers.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical recommendation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Advised that client did not meet the criteria for involuntary services.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Recommended Section 35 to detectives.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer advised BPD to issue a section 12 should another call of threats or harassment come in regarding client.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport for Section 12 (Emergency restraint and hospitalization of individual posing risk of serious harm by reason of mental illness)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;This writer assisted with getting the section 12 to the street outreach unit, safety assessment, and coordinating issuing the section.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer assisted officers with issuing a Section 12 to a client who has been off her medications.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Provided a pre-filled Section 12 to officers.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport for Section 35\u003c/p\u003e\u003cp\u003e(Involuntary commitment of individual with an alcohol or substance use disorder when there is likelihood of serious harm as a result of that substance use)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Assisted officers in locating client for transport to hospital for Section 35 evaluation.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Assisted with affidavit for Section 35 petition by providers.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Assisted with completion of Section 35 affidavit and supplemental paperwork.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSection 18A consult\u003c/p\u003e\u003cp\u003e(Evaluation to determine whether an individual who has been arrested but not yet arraigned requires hospitalization for mental health)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Explained 18A process to detectives in case that is needed.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Section 18A evaluation; evaluation determined client was not suicidal or homicidal and can remain in police custody.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther requested supports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;This writer provided consultation over the phone for officers who were on scene with a client who was displaying signs of paranoia.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;This writer assisted BPD with developing custody plans for client when discharged from hospital.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Well-being check requested for client. This writer and BPD arrived. Client stated she wanted to die because she is grieving her son.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral Assistance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation or connection to social services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Assisted mother with resources for guardianship.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Assisted with SNAP application and emailed shelter worker.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Referred to elder services.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Assisted with arranging childcare with children\u0026rsquo;s grandmother.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Delivered some clothing to client while they were a medical inpatient.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Client walked in to file a domestic violence report. This writer assisted with translation and domestic violence referrals.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Response\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne of the most common supports that co-response BHPs provided was de-escalation. For example, BHPs frequently described attempting to calm clients and/or their families and encouraging them to work with emergency medical services or police to resolve the crisis. BHPs sometimes described techniques used during escalation: e.g., \u0026ldquo;De-escalated client with grounding techniques for anxiety.\u0026rdquo; BHPs also described providing psychosocial support to clients and their families. Co-responding BHPs attempted to \u0026ldquo;reassure and comfort the client\u0026rdquo; and provided \u0026ldquo;support to client\u0026rsquo;s mother who is frustrated her son does not meet Section 12 [involuntary hospitalization] criteria.\u0026rdquo; De-escalation and psychosocial support were also used by BHPs when it was determined that a client needed potentially involuntary evaluation at a hospital: e.g., \u0026ldquo;Client was still agitated when this writer was speaking to him, but he agreed to be transported to the hospital.\u0026rdquo;\u003c/p\u003e\u003cp\u003eDepending on client symptoms, need, and willingness to engage in treatment, BHPs provided information about and connection to voluntary services along a service linkage continuum (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). On the left of this continuum are psychoeducation and resources about local services, which BHPs frequently share with clients and families. For example, one BHP described providing \u0026ldquo;psychoeducation regarding potential for relapse if client maintains social connections to actively using friends.\u0026rdquo; BHPs also helped clients and families prepare and plan how to connect with care during if a crisis should reoccur: e.g., \u0026ldquo;This writer gave mother a BEST pamphlet in case she needed to call for a future evaluation.\u0026rdquo; BHPs recommended a range of voluntary behavioral health services for clients and families, including psychiatric urgent care, mobile crisis services, substance use treatment, and outpatient providers; in these situations, clients could decide whether to immediately engage services. For example, one BHP, \u0026ldquo;Offered BEST urgent care services. Client took brochure and will seek care on his own.\u0026rdquo; When appropriate, BHPs connected clients to potential providers or made referrals: e.g., \u0026ldquo;Client willing to engage in outpatient therapy. Referral to [provider] made.\u0026rdquo; In some cases, BHPs described walking patients to potential providers and initiating a warm handoff: e.g., \u0026ldquo;Made introduction to the community behavioral health center team.\u0026rdquo; In these cases, BHPs may not know whether patients engage in services after the referral as made. BHPs also facilitated client admission to voluntary services, including community crisis stabilization (unlocked 24/7 care) and detox placements; this often included escorting patients to their placement, e.g., \u0026ldquo;Walked patient to [substance use program] for detox placement.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBHPs could schedule follow-up encounters for clients and families by BEST mobile BHPs, who then contacted the client and/or their family in the following days or at a specified time to check-in and offer additional services if needed. These follow-up encounters did not involve the police and were intended to help ensure clients engaged with needed services: e.g., \u0026ldquo;Patient to contact therapist and BEST follow-up scheduled for next week.\u0026rdquo; Co-response BHPs also reported proactively following up with clients, families, and other members of the community to ensure that a client received adequate support in the days or weeks following a co-response encounter. Sometimes, BHPs also placed alerts in the BEST electronic medical records system. Alerts inform BEST providers (including those in the emergency department, mobile crisis teams, and other co-response BHPs) of important information about a client should that individual present for services anywhere within the BEST system. For example, a BHP placed an alert after trying to create a safety plan with a client who was adamant they did not need one: \u0026ldquo;Client\u0026rsquo;s mother was told to call 911 immediately if she feels it is necessary. This writer made an alert in the BEST system.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cb\u003ePolice Assistance\u003c/b\u003e\u003c/p\u003e\u003cp\u003e In addition to clinical responses, co-response BHPs provided multiple forms of assistance to police personnel. One of the most common forms of assistance provided was the provision of health information to police from the BEST electronic health record. At the request of police, BHPs shared limited information about an individual from the BEST electronic health record either during an encounter or as part of a threat assessment prior to an encounter. For example, a BHP might share information from a client\u0026rsquo;s recent BEST encounters: \u0026ldquo;Client is somewhat familiar to BEST- last encounter was [date] with disposition to detox.\u0026rdquo; Another common form of assistance provided by BHPs was a recommendation about client behavioral health needs. Most often, BHPs advised whether a client required involuntary hospitalization: \u0026ldquo;advised them [police officers] to complete a Section 12 for client.\u0026rdquo;\u003c/p\u003e\u003cp\u003eBHPs also supported officers with filing and serving mental health-related orders, including Section 12 (emergency restraint and hospitalization of individual posing risk of serious harm by reason of mental illness) and Section 35 orders (involuntary commitment of individual with an alcohol or substance use disorder when there is a likelihood of serious harm as a result of that substance use). BHPs reported assisting with paperwork and accompanying officers to execute the orders. Although less common, co-response BHPs also consulted at the request of police during Section 18A evaluations, which occur when individuals who have been arrested but not yet arraigned may need hospitalization for a mental health concern.\u003c/p\u003e\u003cp\u003eBHPs additionally described providing a wide range of supports as requested by police personnel, both on-scene and via radio/phone. These included accompanying police officers during well-being checks and offering officers support or guidance during interactions with clients. Co-response BHPs also helped with evaluation and planning (e.g., threat assessments, developing custody plans).\u003c/p\u003e\u003cp\u003e\u003cb\u003eGeneral Assistance\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBHPs provided miscellaneous assistance to clients and community members beyond police assistance and clinical responses. For instance, BHPs provided information and resources to clients and their families about local social services (e.g., housing services, homeless shelters, elder services). When appropriate, BHPs connected clients directly to these services or made referrals. BHPs also described helping clients organize things like childcare and transportation, as well as obtaining and supplying material resources (e.g., clothing). Occasionally, BHPs acted as interpreters to facilitate interactions between police officers and community members with limited English proficiency, whether these related to mental health or not.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough previous research has examined the effectiveness of the embedded co-response model (Marcus \u0026amp; Stergiopoulos, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), less is known about the role of behavioral health professionals within that model. This study fills this gap by characterizing how BHPs operate within the Boston Police Department\u0026rsquo;s co-response program. Our analysis yielded a conceptual framework that depicts the multi-faceted role of co-response BHPs in the community, with important implications for practice, policy, and research.\u003c/p\u003e\u003cp\u003eBHPs interacted with a wide range of community members beyond clients and police officers. To assess behavioral health needs, BHPs communicated with clients\u0026rsquo; family and friends, healthcare providers, and social services providers, as well as individuals working within the criminal justice and school systems. These interactions highlighted common behavioral health symptoms of clients, including suicidal ideation, psychosis, mania, disorganized behavior, and substance use. Our analysis provides a rich description of the supports provided by BHPs during and after co-response encounters, including clinical responses and assistance to police officers.\u003c/p\u003e\u003cp\u003ePsychiatric disorders have risen in prevalence among the United States population in the years following the COVID-19 pandemic. This has led to more frequent interactions between police and individuals experiencing behavioral health crises (Crichlow \u0026amp; Atkin-Plunk, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Our findings highlight the potential mechanisms through which the co-response model may promote criminal justice diversion and address behavioral health needs within the community. The co-response pair primarily interfaces with community members who face structural vulnerabilities in addition to their psychiatric distress. BHPs recorded when clients belonged to populations associated with important behavioral health risk (e.g., clients who were elderly, had developmental or intellectual disabilities, were veterans, or were victims of domestic violence). BHPs also noted important sociodemographic characteristics associated with risk (e.g., sexual or gender minorities, individuals unstably housed or unsheltered, or individuals with limited or no English). While we could not report demographics for the full study period, data from 2023 indicate that co-responders interact with people of color at higher rates than the general Boston population. Identifying opportunities for prevention could mitigate disproportionate interaction with individuals who are already at risk for negative outcomes.\u003c/p\u003e\u003cp\u003eFindings from this study also illustrate mechanisms through which co-response models may impact mental health service outcomes. The continuum of clinical responses provided by the behavioral health professionals in our study (educating clients and families about available services, making provider referrals, securing voluntary treatment placements, and providing follow-up care) fall far beyond the scope of police officers\u0026rsquo; duties and skillsets (Telep \u0026amp; Weisburd, 2016). The presence of this expertise and police encounters may increase the likelihood that clients and families access behavioral health services. It may also reduce unnecessary use of higher-acuity settings (e.g., emergency department) and involuntary commitment. Through on-scene intervention and referrals to voluntary treatment, BHPs support lower-threshold care in the community and help direct clients to accessible resources, such as community health centers.\u003c/p\u003e\u003cp\u003eIncluding BHPs in police encounters can shift the experience and outcomes for individuals experiencing behavioral health crisis; however, BHPs in an embedded model, such as in BPD\u0026rsquo;s program only have the opportunity to de-escalate situations when police officers determine that the scene is safe and request a BHP\u0026rsquo;s support. Further, the model used by BPD requires police to voluntarily participate in co-response, proactively engage a BHP, and integrate a BHP\u0026rsquo;s recommendations; buy-in and trust on the part of police are therefore critical to success of the program. Relationship-building between BHPs and police personnel may take time, and outcomes like police use of force or injury may reflect the quality of these relationships (Haugstvedt \u0026amp; and Tuastad, 2023).\u003c/p\u003e\u003cp\u003eOur study has some important limitations that may affect the transferability of results to other contexts. First, our study examined one co-response program in an urban area. Findings should be interpreted cautiously in relation to the role of BHPs in other co-response programs and models. The researchers did not have access to police data or client/family perceptions to triangulate the roles BHPs played. Additionally, the content of clinical notes varied widely, and it was up to individual BHPs to determine whether information was important enough to be included. Due to the structure of the clinical notes and the consistency of BHP reporting, we were unable to provide demographic information about the study sample. Finally, the study period (July 2019- March 2022) included the COVID-19 pandemic. Although the co-response program operated during the pandemic, with police and BHPs using appropriate personal protective equipment (e.g., masks) in accordance with CDC guidelines, there was increased use of phone consultations to decrease the risk of infection. The emergence of common themes across the study period suggests that data saturation was reached (Strauss \u0026amp; Corbin, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1998\u003c/span\u003e), despite any impacts of the lockdown and subsequent phases of the pandemic.\u003c/p\u003e\u003cp\u003eDespite these limitations, our findings have implications for practice and policy. The rich description of co-responder roles that emerged from our study aligns well with the objectives of the co-response model: facilitating rapid assessment, de-escalation, and service referrals (Shapiro et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Our findings detail the emerging role that BHPs play in police response to vulnerable people in the community. As we move towards the goal of reducing justice involvement for individuals experiencing behavioral health crises, detailing the variety of encounters in which co-response pairs engage can be a useful way to both measure and track how BHPs are part of achieving this goal. Our framework may inform police departments considering co-response adoption. We offer a more complete understanding of the types of services and referrals that BHPs provide and subsequent resolutions. This can be helpful for communities who want to adopt co-response but are unsure how to define the role of co-response pairs in their community. Adopting and implementing co-response can be an enormous task. Cross-training can be an avenue to relate these opportunities for collaboration to both police officers and BHPs who will be part of or are already serving on co-response pairs.\u003c/p\u003e\u003cp\u003eFuture research should explore the mechanisms through which co-response models impact specific outcomes. Much of the existing research has relied solely on police data and points to positive criminal justice outcomes, such as reductions in both arrest and use of force (Lamanna et al., 2018; Morabito et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, less is known about short- and long-term mental health outcomes. Using data collected from BHPs may provide a more complete understanding of how effective co-response programs are at linking those with behavioral health need to community services. These data may also help explain mixed findings on the efficacy of co-response and identify the most effective aspects of existing programs.\u003c/p\u003e\u003cp\u003eCo-response programs are growing in popularity across the country as police departments work to meet the needs of the communities they serve (Crichlow \u0026amp; Atkin-Plunk, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). It is therefore critical to define the roles and responsibilities of mental health professionals within these programs. BHPs in our study described playing a multi-faceted role within Boston Police Department, interacting with a wide range of community members to assess and respond to clients in crisis. Our findings suggest potential mechanisms by which embedded co-response programs may reduce negative interactions between police and the community, divert individuals experiencing behavioral health crises from the criminal justice system, and connect these individuals with supports and mental health care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003e All research procedures were approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board. We conducted the study in accordance with ethical standards as detailed in the Helsinki Agreement. This study involved the secondary data analysis of electronic health records; a waiver of consent was granted as the research involved minimal risk, did not adversely affect the rights and welfare of individuals, and could not practicably be carried out without a waiver.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research was supported by the Bureau of Justice Assistance\u0026rsquo;s Justice and Mental Health Collaboration Program [grant number 15PBJA-23-GG-01466-MENT] and in part by a philanthropic donor.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRO, CNH, GG, DCH, JS, and MSM were involved in the conception of the study. RO, CAB, CNH, JS, and MSM were involved in the design of the study. RO and DCH were involved in the acquisition of data. RO, CAB, CNH, CX, SS, CS, AD, GG, SK, FK, JS, and MSM were involved in the analysis of data. RO, CAB, CNH, AD, GG, EP, TF, JS, and MSM were involved in the interpretation of data. All authors were involved in drafting and/or substantively revising the work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used in this study is from electronic medical records and therefore cannot be shared openly, to protect the privacy of the individuals included.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2013). \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e (Fifth Edition). American Psychiatric Association. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.books.9780890425596\u003c/span\u003e\u003cspan address=\"10.1176/appi.books.9780890425596\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBailey, K., Hofer, M., Sightes, E., Lowder, E. M., Grommon, E., \u0026amp; Ray, B. (2023). Study protocol and stakeholder perceptions of a randomized controlled trial of a co-response police-mental health team. \u003cem\u003eJournal of Experimental Criminology\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11292-023-09598-2\u003c/span\u003e\u003cspan address=\"10.1007/s11292-023-09598-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBailey, K., Lowder, E. M., Grommon, E., Rising, S., \u0026amp; Ray, B. R. (2022). Evaluation of a police\u0026ndash;mental health co-response team relative to traditional police response in Indianapolis. \u003cem\u003ePsychiatric Services\u003c/em\u003e, \u003cem\u003e73\u003c/em\u003e(4), 366\u0026ndash;373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ps.202000864\u003c/span\u003e\u003cspan address=\"10.1176/appi.ps.202000864\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBalfour, M. E., Hahn Stephenson, A., Delany-Brumsey, A., Winsky, J., \u0026amp; Goldman, M. L. (2022). Cops, clinicians, or both? 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M., Gill, C. E., Lu, Y. F., Azam, M., \u0026amp; Kanewske, L. C. (2024). A police-clinician co-response team to people with mental illness in a suburban-rural community: A randomized controlled trial. \u003cem\u003eJournal of Experimental Criminology\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11292-023-09603-8\u003c/span\u003e\u003cspan address=\"10.1007/s11292-023-09603-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-and-justice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"heju","sideBox":"Learn more about [Health \u0026 Justice](https://healthandjusticejournal.biomedcentral.com/)","snPcode":"40352","submissionUrl":"https://submission.springernature.com/new-submission/40352/3","title":"Health \u0026 Justice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Co-responder model, mental health, policing, diversion","lastPublishedDoi":"10.21203/rs.3.rs-7136266/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7136266/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePolice co-responder programs are collaborations between law enforcement and healthcare institutions where behavioral health professionals are embedded within police departments to support officers responding to incidents involving mental health and/or substance use. Research suggests that co-responder programs, which have existed for over 20 years in the United States and have become particularly popular in recent years, have the potential to decrease police use of force and divert individuals experiencing behavioral health crises from the criminal justice system. However, scant knowledge exists about the role of behavioral health professionals in these programs. This qualitative study examines nearly three years of clinical notes from the Boston Police Department\u0026rsquo;s co-response program. Using an inductive approach incorporating aspects of grounded theory and thematic analysis, we analyzed notes from 4,111 co-response encounters between July 2019 and March 2022. Our study yielded a conceptual framework with three domains. First, behavioral health professionals interacted with a wide range of community members, including: police personnel; individuals experiencing behavioral health crises; family members of individuals in crisis; and healthcare and social services providers. Second, and through these interactions, behavioral health professionals assessed behavioral health symptoms, behavioral health history, and indicators of risk. Finally, and in response to their assessments, behavioral health professionals provided clinical supports, police assistance, and general assistance to multiple community members. Our findings suggest potential mechanisms by which co-response programs impact both police and behavioral health outcomes. Implications for practice, policy, and future research are discussed.\u003c/p\u003e","manuscriptTitle":"Bridging Crisis and Care: Exploring the Role of Behavioral Health Professionals in a Police Co-Response Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 10:43:03","doi":"10.21203/rs.3.rs-7136266/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-26T13:19:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T00:07:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164764581026178246618065400487897995377","date":"2025-07-28T12:37:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234127272378939706121885900877713194747","date":"2025-07-27T11:03:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-25T09:05:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-23T23:53:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-23T23:52:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health \u0026 Justice","date":"2025-07-16T06:01:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-and-justice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"heju","sideBox":"Learn more about [Health \u0026 Justice](https://healthandjusticejournal.biomedcentral.com/)","snPcode":"40352","submissionUrl":"https://submission.springernature.com/new-submission/40352/3","title":"Health \u0026 Justice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ae15f00-7437-404f-ac0c-326ba295c3cb","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:00:52+00:00","versionOfRecord":{"articleIdentity":"rs-7136266","link":"https://doi.org/10.1186/s40352-025-00381-1","journal":{"identity":"health-and-justice","isVorOnly":false,"title":"Health \u0026 Justice"},"publishedOn":"2025-11-25 15:57:23","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-07-29 10:43:03","video":"","vorDoi":"10.1186/s40352-025-00381-1","vorDoiUrl":"https://doi.org/10.1186/s40352-025-00381-1","workflowStages":[]},"version":"v1","identity":"rs-7136266","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7136266","identity":"rs-7136266","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}