Coercion in Mobile Crisis: An Exploratory Factor Analysis of Eight Interventions

Background & Purpose: Police involvement in behavioral health crises (BHCs) can result in harmful, even fatal outcomes, for people in crisis. In response, the 988 Suicide & Crisis Hotline was launched in 2020 to redirect crisis calls from police to mental health professionals, including mobile crisis (MC) teams. While MC teams are framed as a safer alternative to police, they may still deploy coercive interventions. Presently, MC workers’ intervention decisions are poorly understood and their potential for reproducing harm via purportedly alternative interventions remains. As coercion in mental healthcare encompasses a wide variety of practices across diverse service contexts and jurisdictions, it is necessary to describe which interventions constitute coercion during MC response.

Methods: We conducted secondary analysis of an experimental 2x2 factorial vignette survey examining the impact of race and prior-criminal legal involvement on MC workers’ use of involuntary hospitalization and calling the police in a national sample of MC workers (n = 369). Participants were randomly assigned to one of four crisis vignettes. Language for each vignette was the same apart from independent variables. To assess stability of decision-making across varying levels of agitation, participants were presented low- and high-agitation scenarios and rated appropriateness, likelihood, and supervisor’s recommendation of deploying eight different interventions. Intervention endorsement was binarized (low vs. high endorsement) for de-escalation, referral to community-based services (CBS), voluntary crisis stabilization services (CSS), voluntary CSS with involuntary hospitalization if caller declined, involuntary hospitalization, calling specially-trained law enforcement, calling any law enforcement, and calling a support person/peer. We conducted exploratory factor analysis (EFA) with varimax rotation to group MC interventions in both low- and high-agitation scenarios.

Results: Data suitability for EFA was confirmed via Kaiser-Meyer-Olkin and Bartlett’s testing. Scree plot analysis indicated two latent factors in both low- and high-agitation scenarios: coercive and collaborative interventions. In the low-agitation scenario, collaborative interventions included de-escalation (Factor Loading [FL]: 0.53), referral to CBS (FL: 0.68), and referral to CSS (FL: 0.60), while coercive interventions included voluntary CSS with involuntary hospitalization if caller declined (FL: 0.75), involuntary hospitalization (FL: 0.80), and calling specially-trained (FL: 0.70) or any law enforcement (FL: 0.73). In the high-agitation scenario, collaborative interventions included de-escalation (FL: 0.63), referral to CBS (FL: 0.70), referral to CSS (FL: 0.80), and pursuit of involuntary hospitalization if voluntary CSS were declined (FL: 0.48), while coercive interventions included pursuit of involuntary hospitalization if voluntary CSS were declined (FL: 0.59), involuntary hospitalization (FL: 0.75), and calling specially-trained (FL: 0.62) or any law enforcement (FL: 0.57).

Conclusions and Implications: Across both scenarios, involuntary hospitalization and police involvement (specially-trained and general) were classified as coercive interventions, while collaborative interventions included de-escalation, referrals to CBS, and voluntary CSS. Voluntary CSS services with pursuit of involuntary hospitalization if caller declined cross-loaded onto both factors in the high-agitation scenario, highlighting ethical tensions providers experience: such interventions may increase immediate safety while also inducing potential harm. Further exploration on circumstances providers deploy collaborative and coercive interventions is needed to reduce the use of coercion on people experiencing BHCs when possible.