Adapting the Crisis Intervention Team (CIT) Model of Police–Mental Health Collaboration in a Low-Income, Post-Conflict Country: Curriculum Development in Liberia, West Africa

Abstract

Objectives. We sought to develop a curriculum and collaboration model for law enforcement and mental health services in Liberia, West Africa.

Methods. In 2013 we conducted key informant interviews with law enforcement officers, mental health clinicians, and mental health service users in Liberia, and facilitated a 3-day curriculum workshop.

Results. Mental health service users reported prior violent interactions with officers. Officers and clinicians identified incarceration and lack of treatment of mental health service users as key problems, and they jointly drafted a curriculum based upon the Crisis Intervention Team (CIT) model adapted for Liberia. Officers’ mental health knowledge improved from 64% to 82% on workshop assessments (t = 5.52; P < .01). Clinicians’ attitudes improved (t = 2.42; P = .03). Six months after the workshop, 69% of clinicians reported improved engagement with law enforcement. Since the Ebola outbreak, law enforcement and clinicians have collaboratively addressed diverse public health needs.

Conclusions. Collaborations between law enforcement and mental health clinicians can benefit multiple areas of public health, as demonstrated by partnerships to improve responses during the Ebola epidemic. Future research should evaluate training implementation and outcomes including stigma reduction, referrals, and use of force.

Violence and other human rights violations against persons with mental illness are major barriers to advancing public health efforts for the prevention and management of noncommunicable diseases such as mental health and substance use disorders,^1–3 which account for 22.5% of the global burden of years lived with disability.⁴ Reducing police violence against persons with mental illness and enhancing the role of law enforcement in promoting other public health initiatives has received increasing attention in the United States and other high-income countries.^5,6 However, there exists a lack of implementation models for involvement of law enforcement in protection of persons with mental illness in low- and middle-income countries, especially in conflict-affected regions such as Sub-Saharan Africa. Our objective was to develop a program to facilitate collaboration between law enforcement and mental health personnel in Liberia, a West African country affected by 14 years of civil war in which an estimated 200 000 Liberians were killed and 1 million were displaced. In addition, Liberia has been afflicted by an outbreak of the Ebola virus, with approximately 8000 cases and 3400 deaths in 2014.⁷

As of the 2003 Comprehensive Peace Agreement in Liberia, the national government, United Nations representatives, and nongovernmental organizations have been working to rebuild infrastructure and establish adequate human resources, including services for law enforcement and mental health care. The Liberian government drafted a National Mental Health Policy in 2009, a National Mental Health Strategic Plan in 2010, and a Mental Health Act in 2012. In 2010, the Ministry of Health and Social Welfare established a mental health unit and technical coordinating committee. Currently, there is 1 psychiatrist and 1 psychiatric facility with 67 inpatient beds and daily outpatient services.

Recognizing the need to develop mental health professional capacity, The Carter Center Mental Health Program (TCC-MHP) partnered with the Liberian government in 2010 to implement components of the Strategic Plan. In Liberia, TCC-MHP is directed and implemented by Liberians. TCC-MHP activities include a professionally accredited 6-month training course for nurses and physician assistants. Between 2010 and 2014, TCC-MHP trained 150 health workers certified as mental health clinicians (MHCs). TCC-MHP also implements a national community-based anti-stigma program, family support and advocacy activities, and facilitates partnerships to advance mental health policy, legislation, and funding. The anti-stigma and advocacy activities involve work with journalists, pharmacists, religious leaders, and other stakeholders. MHCs’ experiences working in prisons and interactions with police officers revealed a need to develop formal collaborations with law enforcement for stigma reduction, service provision, and human rights protection. Therefore, as a part of the nationwide anti-stigma and advocacy program, TCC-MHP engaged leaders in the Liberia National Police (LNP) to identify avenues for collaboration.

The LNP was established in 1956, though the force was ostensibly demobilized during successive civil wars. Woefully inadequate resources, negative public image, insufficient number of officers relative to current population, and corruption in the public sector have substantially impacted the LNP’s ability to fulfill their mandate.⁸ To address this, the LNP has been participating in ongoing training and other quality improvement endeavors supported by the United Nations Police, United States, and Economic Community Of West African States. Top ranking officials in the LNP supported the engagement with TCC-MHP as part of this quality improvement. Their goal was to include mental health issues as an integral part to building an effective law enforcement system. LNP officials selected the National Police Training Academy as the institution to implement collaboration between law enforcement and the mental health field. The academy provides training for patrol officers, corrections officers, immigration officers, and administrators throughout the security sector. All officers complete entrance and certification exams through the academy. Officers receive training based on international standards through expert partners of the academy, inclusive of evaluative processes guided by the United Nations.

Because there is a lack of evidence-based models for law enforcement and mental health collaborations in post-conflict low-income settings, the Liberian staff of TCC-MHP and the National Police Training Academy decided to identify potential models for such collaborations and to conduct formative research to adapt models for implementation in Liberia. They selected Crisis Intervention Team (CIT) as an evidence-based practice that could serve as a starting framework from which to develop a Liberia-specific model.

In the United States and other high-income countries, CIT is a model of collaboration between law enforcement and mental health now celebrating its 25th anniversary.⁹ Initially developed in 1988 in response to a fatal shooting of a man with a serious mental illness in Memphis, Tennessee, CIT has been taken up by an estimated more than 2700 jurisdictions in the United States. CIT is a police-based program to improve safety of officers and persons with psychiatric illnesses or crises; reduce stigma; teach officers how to respond to persons with mental illnesses using verbal de-escalation techniques; and serve as a pre-booking jail-diversion program that directs persons with mental illnesses to treatment rather than incarceration when appropriate.¹⁰ Core CIT elements include partnerships among law enforcement, mental health, and advocacy communities; community ownership of planning, implementation, and networking; CIT training of select police officers; enhancements of policies and procedures within law enforcement and mental health services to facilitate CIT goals; the presence of mental health emergency receiving facilities always available to officers; and in-service courses for advanced training.¹¹

The groundwork for collaborations between law enforcement and mental health providers is facilitated through the CIT training curriculum, a 5-day (40-hour) experience including didactic presentations on mental illnesses, local policies, available resources; site visits to 1 or more mental health treatment facilities where officers can interact with persons with mental illnesses who are stable but who have a history of police encounters; and performance-based training on de-escalation. Trainers include local law enforcement instructors, local mental health professionals, and local advocates (family members and mental health service users), all of whom volunteer their time. A common standard is to train at least 20% of patrol officers in a given agency so that a CIT-trained officer is routinely available. Some police forces have provided training for 100% of officers. Research on CIT in the United States is accumulating,^6,12–16 though implementation and evaluation of CIT in other countries has only just begun. We know of no attempts at adapting CIT for low- and middle-income countries, despite its potential relevance in such settings.

In this report, we describe a series of collaborative activities to develop a program with similar goals to CIT for the evolving mental health system in Liberia. Representatives from the Liberia National Police Training Academy were present from the inception of the project. TCC-MHP and the academy jointly established priorities of the project. All elements of the project design were reviewed by the academy before submission for ethical approval. In this article, we summarize the formative research, curriculum workshop, and follow-up activities (Figure 1); findings are presented based upon (1) key informant interviews and site visits conducted in advance of a 3-day workshop; (2) workshop agenda development; (3) a workshop needs assessment; (4) workshop process, activities, and curriculum development; and (5) pre- and post-workshop assessment of knowledge and attitudes. Though CIT increasingly is implemented by a multitude of diverse law enforcement agencies in the United States, on which substantial research is accumulating, our experiences represent the first attempt at adapting the CIT model for a low-income, post-conflict setting in Africa.

FIGURE 1—

Participatory research process for development of law enforcement and mental health collaborative training program: Liberia, 2010–2014.

METHODS

We employed qualitative, quantitative, and participatory approaches to facilitate development of the curriculum for mental health and law enforcement collaboration. Key informant interviews were used to design a 3-day participatory workshop that was evaluated with qualitative and quantitative methods.

Key Informant Interviews

We conducted key informant interviews with 3 stakeholder groups: MHCs, mental health service users (MHSUs) and their caregivers, and law enforcement officers including police and correctional officers. Interviews provided information on contextual factors that accelerate or impede positive outcomes for MHSUs in the criminal justice system. Interview questions were designed to identify officers’ knowledge and skill gaps, training needs, current curriculum, training infrastructure, and field experiences. Additionally, interview questions highlighted issues of stigma, specifically stakeholders’ knowledge, attitudes, and practices around mental illnesses. Key informant interviews were used to identify appropriate content for the workshop and curriculum development and to select and adapt applicable components of CIT.

Workshop

We conducted a workshop to facilitate collaboration and curriculum development for officers and MHCs. Planning activities began 6 months prior to the workshop with multiple exchanges among TCC-MHP staff, the LNP commandant in charge of training, and US CIT experts, including a psychiatrist, family advocate, and chief of police, all of whom had multiple years of experience designing, implementing, and evaluating CIT programs. CIT experts participated in Liberia site visits of the country’s only psychiatric facility, the central prison, and police headquarters.

Based on key informant interviews and site visits, TCC-MHP staff and CIT experts designed a 3-day workshop in collaboration with LNP. Workshop participants comprised 3 groups: 14 officers from around the country including correctional officers, 17 TCC-MHP-trained MHCs, 2 MHSUs and their caregivers, and National Police Training Academy representatives. The academy selected both patrol and corrections officers as the initial law-enforcement representatives. Participants were informed that the goal was to explore potentials for collaboration among the groups and identify training needs to formalize ongoing partnerships. Training components were included in the workshop to discuss the relevance and format of modules such as “Introduction to Mental Health” and “De-escalation Techniques.” These modules were then discussed and further adapted for implementation in Liberia.

Workshop Needs Assessment

We developed a 26-item needs assessment based on key informant interview content and CIT curriculum elements. Items included working with persons with suicidal behavior, preventing harm among officers interacting with MHSUs, and preventing abuse of MHSUs. Participants scored items on a 3-point scale for level of priority or severity of the problem in their work. We administered this assessment on Workshop Day 1 to select curriculum topics and inform remaining activities in the workshop.

Pre- and Post-Workshop Assessments

A pre- and post-test was developed to pilot assessments of 5 domains among participating law enforcement officers and MHCs: (1) mental health knowledge (23 items, e.g., identification and causes of mental illness); (2) attitudes regarding MHSUs (13 items, e.g., ability to recover from mental illness, appropriateness of chaining MHSUs), which were measured using locally developed tools based on formative research conducted by TCC-MHP¹⁷; (3) perceived functioning of MHSUs (11 items, e.g., caring for personal hygiene, participating in family activities), which were measured using a questionnaire developed in Liberia based on a method for function assessment in Africa and other cross-cultural settings¹⁸; (4) social distance from MHSUs (7 items, e.g., willingness to have a MHSU as a neighbor, coworker, friend); and (5) government restrictions for MHSUs (6 items, e.g., forced medication, forced hospitalization, barred from marriage), measured using Liberia adaptations of items in the Stigma in Global Context–Mental Health Survey.¹⁹ For statistical comparisons, percentages or means were calculated. We used the paired t-test to compare pre- and post-workshop scores.

Six months after the workshop (February-March 2014), we contacted MHCs to obtain qualitative descriptions of collaborations with law enforcement. In addition, in October 2014, we gathered information regarding collaborations between MHCs and security forces in the context of the Ebola outbreak in Liberia.

RESULTS

Through multiple research steps, law enforcement officers, MHCs, and MHSUs actively participated to identify and prioritize training needs, and drafted a curriculum to formalize future collaboration.

Key Informant Interviews

Key informant interviews were conducted with law enforcement officers (n = 10) including administrators, front-line officers, and training officers; MHCs (n = 4); and MHSUs (n = 6, including 2 caregivers). All MHSUs indicated experiencing police brutality in the form of unprovoked beatings, as well as witnessing the brutalization of other MHSUs by law enforcement officers. MHSUs, MHCs, court officials and other officers reported concerns of excessive force, unnecessary restraints, use of derogatory language, and demanding bribes. Two MHSUs stated that older officers with more experience provided counseling and advice, encouraging positive behaviors toward recovery. Two MHSUs reported that problems with law enforcement motivated them toward recovery but interactions with police were not helpful to the recovery process. Only 3 out of 10 officers named the sole mental health hospital, E.S. Grant, by name as a resource. All key informant interview participants indicated that having MHCs, MHSUs, and caregivers participate in training for officers would be beneficial to increasing law enforcement’s capacity to assist MHSUs. All interview participants indicated personal willingness to participate in future trainings. Qualitative data from key informant interviews informed the process and structure of the 3-day CIT workshop.

Workshop

TCC-MHP staff and CIT experts drafted an agenda based on the formative research and site visits. Contents and structure were flexible to accommodate participants’ interests and requests (Table A, available as a supplement to the online version of this article at http://ajph.org). The workshop relied heavily upon group activities in which officers and MHCs worked together to identify needs, propose solutions, and design their recommended curriculum. Engagement with MHSUs and caregivers was a central component.

Forty individuals including officers, MHCs, MHSUs, caregivers, and LNP officials attended the workshop. Seventeen MHCs (71% female; 100% college educated; mean age = 34 years; SD = 3.9 years) and 14 officers (36% female; 21% college educated, 21% completed high school, 57% did not complete high school; mean age = 34 years; SD = 3.6 years) participated in evaluations.

Workshop Needs Assessment

During the needs assessment activity, officers and MHCs identified key problem and priority areas (Table 1). Problems included MHSUs not receiving treatment in jail, MHSUs being inappropriately incarcerated when they should be living at home receiving treatment, and false information provided by MHSUs’ families to officers. Officers included lack of transportation for mental health evaluations in their top 3 problems. Both groups ranked officers’ need for training to care for MHSUs and officers’ need for training to reduce use of force against MHSUs among the top 5 training priorities.

TABLE 1—

Major Problems and Proposed Training Priorities for Law Enforcement Officers Related to Mental Health Issues, Ranked by Order of Priority: Key Informant Interviews, Liberia, 2013

Category and Ranking	Mental Health Clinicians (n = 17)	Law Enforcement Officers (n = 14)
Major problems encountered by people living with mental illness in the law enforcement system
#1	There are people with mental illness in jails or prison who should be receiving treatment in mental hospitals [Item #23]	Families provide false information to police about persons with mental illness [Item #18]
#2	There are people with mental illness in jails or prison who should be living at home receiving treatment [Item #22]	Police officers cannot access transportation to get evaluations for persons with mental illness [Item #21]
#3	Families provide false information to police about persons with mental illness [Item #18]	There are people with mental illness in jails or prison who should be living at home receiving treatment [Item #22]
Proposed training priorities for law enforcement officers to improve engagement with persons living with mental illness
#1	Police need more training on recognizing mental illness [Item #3]	Police need more training on caring for persons with mental illness in jails and prisons [Item #1]
#2	Police need more training on working with suicidal persons [Item #6]	Police officers and mental health clinicians need to work together to help repeat offenders with mental illness [Item #17]
#3	Police need more training on reducing harm to persons with mental illness in the community (e.g., physical abuse, exploitation, mocking) [Item #9]	Police need more training to reduce their use of force and violence against persons with mental illness [Item #2]
#4	Police need more training on caring for persons with mental illness in jails and prisons [Item #1]	Police need more training to reduce personal risk of injury when working with persons with mental illness [Item #5]
#5	Police need more training to reduce their use of force and violence against persons with mental illness [Item #2]	Police need more information on services for persons with mental illness [Item #15]

Note. Item #s refer to 26-item Workshop Needs Assessment developed from key informant interviews with Liberian law enforcement officers, mental health clinicians, and mental health service users. In the assessments, clinicians and officers ranked the major problems encountered and the training priorities.

Workshop Process and Activities

We designed group activities to facilitate development of a training curriculum for officers. Mixed groups were formed with officers, MHCs, and MHSUs. Officers reported wanting training in identifying mental health problems, applying de-escalation techniques, helping persons with suicidal behavior, developing referral pathways, and coordinating treatment in correctional facilities. MHCs wanted officers to help prevent mob violence against MHSUs, to educate families and communities about basic MH issues and resources, and to facilitate follow-up care by notifying MHCs when MHSUs are released from corrections.

Mixed groups independently designed CIT curricula adapted for Liberia. Participants were given no constraints regarding duration, content, or format. After a discussion considering content, transportation issues, and duty schedules, the consensus was for a 5-day schedule (Table 2). All proposed curricula include CIT principles, suicide prevention, de-escalation techniques, and engagement with families and communities.

TABLE 2—

Proposed 5-Day Liberian Mental Health Crisis Intervention Team (CIT) Curriculum for Correctional and Patrol Officers: Liberia, 2013

Time	Day 1	Day 2	Day 3	Day 4	Day 5
8:00 am	Breakfast and introductions	Breakfast and prior day reviews	Breakfast and prior day reviews	Breakfast and prior day reviews	Breakfast and prior day reviews
8:30 am	Pre-Test	CIT principles	Substance abuse disorders	Liberia mental health policy and cultural issues	Review: de-escalation techniques
9:30 am	Definitions of mental health and mental illness	Communication skills and verbal de-escalation	Psychotic disorders	Liberia legal issues and mental health legislation	Review: de-escalation techniques
11:00 am	Signs and symptoms of mental illness	Communication skills and verbal de-escalation	Trauma-related disorders	Liberia legal issues and mental health legislation	Review: suicide prevention
1:00 pm	Lunch	Lunch	Lunch	Lunch	Lunch
2:00 pm	Mental illness myths and facts	Suicide prevention	Mental health facility site visit	Mental health in correctional facilities	Review: CIT principles
3:00 pm	Engagement with consumers and families	Mental health referral processes	Mental health facility site visit	Working with families and communities	Post-test
4:30 pm	Daily review and lessons learned	Daily review and lessons learned	Daily review and lessons learned	Daily review and lessons learned	Graduation

Groups varied in their focus on mental health knowledge, treatment, and specific disorders to be included in the proposed curriculum. Ultimately, 3 classes of disorders (substance abuse, psychosis, and trauma/posttraumatic stress disorder) were considered most relevant because of their association with violence, community disruption, and law enforcement involvement. Discussion of epilepsy was prioritized because of myths that it is contagious and stigma against persons with epilepsy is severe. A site visit to a mental health treatment facility was selected to familiarize officers with local resources and treatment practices. Liberian legal policies and United Nations conventions were also selected content.

We asked groups about potential barriers for effective collaboration. Participants reported that trained MHCs needed to be present throughout the country, and therefore additional MHCs were needed. Access to medications was needed in areas near police stations and correctional facilities. Lack of psychotropic medications in many regions was a major concern. Transportation between law enforcement and health facilities was also deemed necessary. Officers reported not having government-issued mobile phones for work, which impedes contacting MHCs during emergencies.

All groups highlighted need for community partnerships, especially with religious leaders and traditional healers to help educate the public and reduce maltreatment of MHSUs. Maltreatment of MHSUs was often deemed to be justified with religious explanations that mental illnesses result from witchcraft, sinful behavior, and “African science” (e.g., black magic). Law enforcement officers also raised their own mental health as an unmet need. They described mental health problems that they and their colleagues experienced that would benefit from support of MHCs.

Regarding naming the program, participants endorsed the Liberia Mental Health Crisis Intervention Team (MH-CIT). Including the words “mental health” was important because the term “crisis” alone commonly refers to the civil wars, thus MH-CIT clarified a mental health focus rather than political-violence focus.

Pre- and Post-Workshop Assessments

Sixteen MHCs and 14 officers completed both pre- and post-tests. When we analyzed all participants together, we recognized there was a significant increase in knowledge (78% to 88% of items answered correctly), a significant increase in positive attitudes, and a significant decrease in social distance (Table 3). Among only officers, improvement in knowledge was significant. The only significant MHC improvement was in attitudes.

TABLE 3—

Comparison of Pre- and Post-Workshop Assessment Results Among Mental Health Clinicians and Law Enforcement Officers: Liberia, 2013

	Mental Health Clinicians					Law Enforcement Officers					Total Sample
Survey domain	Sample Size	Pretest % or Mean (SD)	Posttest (SD)	Paired t-Test	P Value	Sample Size	Pretest (SD)	Posttest (SD)	Paired t-Test	P Value	Sample Size	Pretest (SD)	Posttest (SD)	Paired t-Test	P Value
Knowledgea	16	90 (0.09)	93 (0.05)	0.99	.34	14	64 (0.11)	82 (0.09)	5.52	< 0.01	30	78 (0.16)	88 (0.09)	3.95	< .001
Attitudesb	16	3.26 (0.46)	3.54 (0.16)	2.42	.03	14	2.82 (0.52)	3.10 (0.31)	1.60	0.13	30	3.05 (0.53)	3.34 (0.33)	2.78	.009
Social distancec	15	1.43 (0.68)	1.22 (0.26)	1.46	.17	13	2.19 (0.92)	1.70 (0.52)	1.94	0.08	28	1.78 (0.87)	1.44 (0.46)	2.43	.02
Functioningd	13	2.52 (0.86)	2.61 (1.06)	0.81	.44	12	2.17 (0.45)	2.50 (0.87)	1.43	0.18	25	2.35 (0.71)	2.56 (0.95)	1.64	.11
Autonomye	15	3.35 (0.55)	3.17 (0.72)	0.96	.35	13	2.29 (0.80)	2.42 (0.54)	0.82	0.43	28	2.86 (0.85)	2.82 (0.74)	0.33	.74

^aKnowledge results based on % correct of 23 items.

^bScores based on 1–4 scale. Higher scores reflect more positive attitudes.

^cScores based on 1–4 scale. Higher scores represent greater social distance.

^dScores based on 1–4 scale. Higher scores represent more independent functioning.

^eScores based on 1–4 scale. Higher scores represent greater autonomy and less government control.

Six months after the workshop, 11 MHCs (69%) reported ongoing engagement with law enforcement, with 7 (44%) participating in weekly prison clinics and correctional facility consultations. Seven MHCs had responded to 1 or more crisis events. MHCs reported collaborations with law enforcement that had not been occurring prior to the workshop. For example, a police officer from the workshop coordinated with an MHC to take a suicidal person to a health facility instead of jail. Another officer intervened after fellow officers beat a psychotic individual. The officer and an MHC took the person for mental health treatment. When a man with bipolar disorder was accused of killing someone, and a mob attempted to kill him, an officer coordinated with MHCs and the United Nations to arrange armored transport to a treatment facility.

As of October 2014, collaborations between MHCs and security forces were also occurring in the context of the Ebola outbreak. One challenge was assisting patients with psychosis and agitated behavior being treated in Ebola treatment units (ETUs). During initial responses to outbreak, a patient with active Ebola infection who also had untreated psychosis became agitated, creating concerns for the safety of health workers wearing personal protective equipment (PPE). At the time, health workers did not know how to engage with patients in a manner that would not breach contact isolation or threaten the integrity of the PPE. Police who did not have PPE and were stationed outside the ETU to secure isolation also did not know how to engage with such patients. This led to collaboration with TCC-MHP for plans to have MHCs train health workers and police in ETUs. Health workers and officers working in ETUs require training on nonviolent de-escalation techniques that could be used for patients with mental illness and other patients who might have psychotic or agitated behavior while in ETUs. Collaborations with law enforcement and ETU health personnel also facilitated referral to MHCs for mental health treatment of traumatized health workers, survivors of Ebola, and family members of patients with Ebola.

DISCUSSION

Law enforcement and health services in Liberia are confronted with numerous current challenges, including rebuilding human and physical resources after 14 years of conflict and responding to public health needs during the current Ebola outbreak. Prior to the Ebola outbreak, the Ministry of Health and Social Welfare and The Carter Center had spent 5 years rebuilding mental health services, which included ensuring effective collaborations between law enforcement and mental health providers. To meet this goal, law enforcement officers and mental health clinicians developed a MH-CIT curriculum to train corrections and patrol officers. The collaboration and resulting curriculum addresses preventing violence against MHSUs by police and the general community, reducing potential harm to law enforcement officers engaging with MHSUs, and preventing self-harm and suicide among MHSUs. As of the summer of 2014, the collaboration also has evolved to address mental health and security issues related to the Ebola outbreak.

Though the goals of Liberia MH-CIT are consistent with the mission of CIT as implemented in the United States, the context in terms of culture, education, and resources necessitates careful adaptation. In addition to disorders related to substance abuse, psychosis, and trauma, participants highlighted the need for training on epilepsy. Epilepsy is considered within the domain of MHCs and is highly stigmatized, leading to high violence risk against persons with epilepsy. In addition to modifying the types of disorders in a CIT curriculum, the content also addresses local myths (e.g., epilepsy is transmitted through bodily fluids, and psychosis results from witchcraft and African science, and as such, helping persons with such conditions places the responding officer at risk, physically, psychologically, and socially).

Participants also recognized that lack of resources and inadequate infrastructure are potential barriers to collaborations between MHCs and officers. Police suffer from limited access to transportation and communication services. Availability of medication is a barrier, with less than 8% of health facilities reporting supply of 1 or more psychiatric medications in 2010.²⁰ However, there have been recent efforts by the government to improve supply nationwide. These and other barriers demonstrate the need for MH-CIT to be conducted alongside other activities to improve human resources, physical and transportation infrastructure, and access to communication and technological services. The Ebola outbreak has further strained health and security resources.

Despite these challenges, there was strong support endorsed by both MHCs and officers. All MHCs at the workshop reported that they would be available 24 hours a day for calls from officers. The National Police Training Academy leadership also committed to piloting MH-CIT. Six months after the workshop, 2-thirds of MHCs had collaborated with law enforcement to intervene with MHSUs. These examples of CIT principles in action demonstrate that Liberia-adapted CIT has potential to work and mobilize other resources (e.g., United Nations involvement) despite gaps in personnel and infrastructure. A potential long-term benefit of the law-enforcement and mental health collaboration is that the groups can jointly advocate for more resources to address these barriers. Moreover, police recognized the importance of caring for their personal mental health. They suggested that MHCs provide mental health support services in police depots during difficult law enforcement cases. Police endorsed increased access to mental health support as an avenue to reduce stress and prevent psychological trauma among the law enforcement community.

The Ebola outbreak in Liberia has highlighted the importance of developing trust and collaborative relationships among the general public, health workers, and law enforcement. The partnerships formed between MHCs and law enforcement officers have been leveraged by governmental and non-governmental organizations during this public health crisis. MHCs have been asked to partner with law enforcement to provide de-escalation training and psychological first aid to improve engagement of health workers and law enforcement with the general public. In both clinical ETUs and at the community level, partnerships between mental health and security forces are imperative in order to prevent discrimination, physical harm, and human rights violations against persons suspected of having Ebola and their family members. The need for human rights protection is especially important for persons impacted by both mental illness and Ebola.

In addition to promoting collaboration and developing a curriculum, the workshop was used to pilot potential pre- and post-tests for trainings. In this small, nonrandom sample of workshop participants, there were significant overall group improvements in knowledge, attitudes, and social distance. Among officers, knowledge improved, which is to be expected given the lack of any prior exposure to mental health education. The change in attitudes among clinicians was an unexpected finding in the context of their extensive prior training. This suggests that collaboration with law enforcement might further sensitize MHCs to the experience of MHSUs. Administration of the pre- and post-tests in actual curriculum implementation is needed to determine changes in these domains for formal MH-CIT.

Strengths and Limitations

Although we attempted to combine diverse methods—qualitative (key informant interviews), quantitative (pre- and post-workshop surveys), and experiential (site visits, field notes, and extensive notes during the 3-day workshop), our sample sizes were limited (e.g., only 12 officers completed pre- and post-tests for the functioning assessment). Though this limits generalizability of specific findings, our processes are relevant to other low- and middle-income countries, especially post-conflict and African settings. The approach to curriculum development was participatory: Liberian law enforcement officers and MHCs dictated programmatic goals and structures. The combination of content developed and adapted for Liberia, personal investment by the officers and MHCs attending the workshop, and endorsement by a national law enforcement training institution are all steps that could be replicated in other settings.

Engagement with MHSUs will likely be a crucial aspect of MH-CIT to reduce stigma among law enforcement officers.²¹ Our workshop included 2 MHSUs, and future trainings should strive to increase MHSU representation as well as consider Liberia-specific video testimonials of MHSUs in recovery to illustrate the potential for and degree of recovery.

Conclusions

Building law-enforcement and mental health collaborations in post-conflict, low resource, and humanitarian settings is a feasible and necessary endeavor to promote public health and human rights. Our activities represent only the first step to address the complex challenges in establishing sustainable effective collaborations in Liberia. Since completion of the workshop, training officers from the National Police Training Academy in collaboration with MHCs have finalized a pilot curriculum. The skills have been used for mental health emergencies and Ebola-related crises. Future efforts will address pilot testing in urban and rural settings, training of trainers, and scaling up the MH-CIT model throughout Liberia. Outcomes to monitor will include health and legal or correctional costs, symptom severity and functioning, and psychosocial measures such as stigma, family engagement, and community participation. Ultimately, culturally acceptable, economically viable, and feasible collaborations between mental health and law enforcement should not be limited to high-income countries. Having these collaborations in place might also help mitigate physical disease, mental illness, and security challenges in humanitarian crises, including environmental disasters, political violence, and communicable disease outbreaks. This collaboration-building and curriculum- development work in Liberia is an important foundation to promote availability of evidence-based services in diverse settings.