When psychiatrists discuss behavioral health diversion, we usually mean redirecting a person away from arrest, jail, or prosecution and toward treatment. Mental health courts, crisis-response programs, and alternatives to incarceration are essential; yet if diversion begins only after criminal-legal contact, it has begun too late.
Before the police encounter or courtroom appearance, there may have been an unanswered outreach visit, an appointment that was never rescheduled, an escalating symptom interpreted only as misconduct, or a recurring crisis that never led to a sustained therapeutic relationship.
At Intercept 0, engagement is what makes early diversion possible.
Making Intercept 0 Work
The Sequential Intercept Model correctly begins with Intercept 0: community services and crisis responses before law-enforcement involvement. It identifies additional opportunities for diversion throughout the criminal legal system and reentry (Substance Abuse and Mental Health Services Administration [SAMHSA], 2024). The earliest opportunities for diversion therefore exist at Intercept 0. Yet services alone do not guarantee diversion. A referral, appointment, and clinically sound recommendation may all exist while the person remains disconnected from care. Intercept 0 succeeds only when people can be reached, relationships established, and services made acceptable and usable. In other words, engagement does not precede Intercept 0; it is a clinical process that makes Intercept 0 effective.
Behavioral health systems often assume a familiar sequence: a person recognizes a need, accepts a referral, attends an appointment, and follows a treatment plan. Those with the greatest needs, however, may be least able to move through that sequence.
Some have experienced coercion, stigma, institutionalization, discrimination, homelessness, or abandonment. Others live with paranoia, cognitive impairment, active substance use, trauma, or serious medical illness.
From the clinician’s perspective, the person may appear resistant, unmotivated, or nonadherent. From the person’s perspective, refusal may be protective, avoidance may reflect fear, and anger may be an effort to preserve dignity. What appears to be a failure to engage may be a predictable response to how treatment or authority more broadly has previously been experienced.
When this response is met with case closure, fragmented referrals, or escalating pressure, untreated needs do not disappear. They may instead reemerge as an emergency department visit, a 911 response, an involuntary intervention, or an arrest.
Engagement Is a Clinical Intervention
Psychiatry often treats engagement as a preliminary task: first persuade the person to enter treatment, then begin the real clinical work. Yet engagement is not merely the prelude to treatment; rather, it is part of treatment.
Research identifies therapeutic alliance, accessibility, and confidence that treatment will address the person’s goals as important influences on participation (Dixon et al., 2016). Street-outreach research similarly indicates that people experiencing homelessness and serious mental illness may require more time to engage than those reached in traditional settings (Lam & Rosenheck, 1999).
Disengagement should not automatically be treated as a final decision or fixed patient characteristic. It is clinical information about symptoms, cognition, trauma, survival needs, prior coercion, cultural difference, the therapeutic relationship, or service design.
Psychiatrists have a particular responsibility here. Diagnostic formulation should help us understand barriers to engagement without reducing the person to a diagnosis. Risk assessment should guide proportionate intervention without allowing every refusal to become evidence of dangerousness. Respect for autonomy should not mean abandoning a person whose capacity to trust or organize care develops slowly. Conversely, concern for safety should not become a rationale for unnecessary coercion.
The clinical question must shift from “How do we make this patient comply?” to “What is preventing this person from experiencing care as safe, relevant, and usable?” That shift does not minimize illness or risk. It makes our formulation more complete.
Match the Intervention to the Relationship
Even an appropriate intervention can fail when offered at the wrong stage of the relationship. A person who does not yet feel safe may experience problem-solving as pressure. Someone who does not feel heard may experience psychoeducation as dismissal. A treatment plan developed before trust exists may be clinically appropriate and relationally unusable.
A practical sequence is to:
- Establish safety: reduce threat, preserve dignity, and clarify that the immediate purpose is neither punishment nor control.
- Listen: understand the person’s account of the problem, including what the person wants, fears, distrusts, or believes has gone wrong before.
- Convey empathy: demonstrate that the person’s experience has been understood before attempting to redirect it.
- Collaborate: identify the smallest next step the person is willing to take rather than insisting on the entire preferred treatment plan.
These functions are consistent with trauma-informed principles emphasizing safety, trustworthiness, peer support, collaboration, and empowerment (SAMHSA, 2023). They also apply beyond the consulting room. Research involving people with mental illness who experienced police contact suggests that perceived procedural justice, including voice, dignity, and fairness, can influence cooperation and resistance during those encounters (Watson & Angell, 2013).
Engagement is rarely linear. A person may collaborate one day and withdraw the next. A crisis may require returning to safety. A missed appointment may reflect ambivalence, cognitive difficulty, substance use, competing needs, or a rupture in trust. Sometimes the appropriate response is not discharge or another generic referral, but renewed engagement.
Treat Disengagement as an Early Warning
Behavioral health and criminal-legal systems typically measure events after engagement has deteriorated: hospitalizations, emergency calls, arrests, incarceration, missed appointments, or program discharge. These outcomes matter, but they are lagging indicators.
If engagement is an upstream component of diversion, we should also observe its trajectory. Is trust growing or shrinking? Are interactions becoming more or less reciprocal? Is the person expressing needs, accepting small forms of support, or participating in decisions? Are clinicians, crisis teams, hospitals, shelters, and community programs communicating consistently? Where does continuity repeatedly break down?
Increasing avoidance, shorter interactions, missed visits, growing mistrust, escalating conflict, or withdrawal from previously accepted support should prompt clinical curiosity and coordinated action. The team might reconsider who conducts outreach, when and where contact occurs, what the person identifies as urgent, whether peer involvement would help, and whether previous interventions have inadvertently increased threat.
Needless to say, engagement alone cannot prevent every crisis or arrest. Persistent outreach cannot substitute for emergency intervention when imminent risk is present. Nor can relationships compensate for inadequate housing, unavailable treatment, workforce shortages, fragmented systems, or insufficient alternatives to incarceration.
Research on mental health courts and jail-diversion programs shows potential benefits, but outcomes vary, and referral into nominal treatment is not the same as sustained connection to effective care (Steadman et al., 2011; Broner et al., 2004). Diversion policy should therefore measure not only whether a referral was made, but whether the person was reached, remained connected, participated meaningfully, and received care matched to actual needs.
Engagement is the connective tissue that makes the rest of the diversion continuum usable.
The First Diversion Decision
The criminal legal system should not become the default behavioral health system for people whose needs are complex, whose trust is fragile, or whose acceptance of care develops slowly.
Psychiatry must remain centrally involved in crisis services, pre-arrest diversion, mental health courts, treatment alternatives to incarceration, and reentry planning. However, our contribution cannot begin only after the legal system has assumed responsibility. We must help build clinical systems capable of recognizing deteriorating engagement and responding before symptoms become crises, crises become public-safety events, and public-safety events become criminalization.
True diversion begins before the courtroom, before the police encounter, and often before the crisis call. It begins when we decide whether to interpret withdrawal as refusal, anger as dangerousness, ambivalence as failure, or mistrust as a reason to change our approach.
The first diversion decision is not made by a judge. It is made when a person begins to disengage and the behavioral health system decides whether to close the door or find another way to remain present.
Mardoche Sidor, MD, is Chief Medical Officer at Urban Pathways.
References
Broner, N., Lattimore, P. K., Cowell, A. J., & Schlenger, W. E. (2004). Effects of diversion on adults with co-occurring mental illness and substance use: Outcomes from a national multi-site study. Behavioral Sciences & the Law, 22(4), 519–541. https://doi.org/10.1002/bsl.605
Dixon, L. B., Holoshitz, Y., & Nossel, I. (2016). Treatment engagement of individuals experiencing mental illness: Review and update. World Psychiatry, 15(1), 13–20. https://doi.org/10.1002/wps.20306
Lam, J. A., & Rosenheck, R. (1999). Street outreach for homeless persons with serious mental illness: Is it effective? Medical Care, 37(9), 894–907. https://doi.org/10.1097/00005650-199909000-00006
Steadman, H. J., Redlich, A., Callahan, L., Robbins, P. C., & Vesselinov, R. (2011). Effect of mental health courts on arrests and jail days: A multisite study. Archives of General Psychiatry, 68(2), 167–172. https://doi.org/10.1001/archgenpsychiatry.2010.134
Substance Abuse and Mental Health Services Administration. (2023). Practical guide for implementing a trauma-informed approach. https://library.samhsa.gov/product/practical-guide-implementing-trauma-informed-approach/pep23-06-05-005
Substance Abuse and Mental Health Services Administration. (2024). The Sequential Intercept Model (SIM). https://www.samhsa.gov/communities/criminal-juvenile-justice/sequential-intercept-model
Watson, A. C., & Angell, B. (2013). The role of stigma and uncertainty in moderating the effect of procedural justice on cooperation and resistance in police encounters with persons with mental illnesses. Psychology, Public Policy, and Law, 19(1), 30–39. https://doi.org/10.1037/a0027931
