In the wake of nationwide demonstrations against police brutality, there has been a surge in interest in making sure mental health providers, not law enforcement, are the ones to respond to a psychiatric crisis.
It’s a strategy that mental health organizations have been sharpening for decades. Dozens of cities across the country have what are known as mobile crisis units, which deploy trained professionals to respond to people experiencing a mental health crisis with compassion and clinical expertise.
Now, with their work thrust into the spotlight, mobile crisis teams have been flooded with calls from other communities hoping to replicate their models.
“I think the timing, the mood of the country is right to take some significant steps,” said Angela Kimball, the national director of advocacy and public policy at the National Alliance on Mental Illness.
Mental health professionals say the need is urgent: A 2016 study estimated that 22% of fatal police encounters followed calls about an individual’s “disruptive behavior” directly due to mental illness or substance abuse. Longtime mental health workers say the models offer a safer, more compassionate way to help those in crisis — and can prevent needlessly violent and traumatic encounters in the process.
“I think if the police didn’t have us and they couldn’t call on us, there would be many, many, many more people who have a mental health issue, or a mental health disorder, in our jails and prisons than there ever, ever should be,” said Rik Cornell, vice president for community relations at the Mental Health Center of Greater Manchester in New Hampshire, which operates a mobile crisis program.
But their experience has also given them an insight that may sit uncomfortably with some advocates of these new models: to work effectively outside the law enforcement system, you still need to have one foot on the inside.
Benjamin Brubaker, who helps lead an Oregon clinic that runs one of the country’s oldest mobile crisis units, said that mental health workers on the ground need police partnerships to fall back on.
“It’s a small fraction of the overall calls we do, but at times, there’s somebody who maybe just doesn’t really understand who we are or is in some kind of psychotic episode,” he said. “We rely on law enforcement to sometimes back us up in those situations.”
Many mental health experts say the police simply aren’t the right people to respond to psychological crises: Officers often aren’t trained in the skills to do so, nor do they have the clinical background that can be crucial in de-escalating a situation.
“People who are already paranoid or fearful or anxious or depressed or agitated — the presence of police for many people increases that agitation,” said Ruth Shim, a clinician and the director of cultural psychiatry at the University of California, Davis.
Shim recalled an incident from her training when she and other clinicians were trying to coax an anxious patient out of the bathroom. The patient was beginning to calm down, until someone called security — and “the whole thing shifted so dramatically.”
“I could feel the tension rise in the space,” she continued. “He felt physically threatened, and the police approached him quite aggressively, and they did end up struggling.”
That dynamic — rooted in a long history of the criminalization of mental illness, a practice which has disproportionately affected Black and Latinx individuals — is only exacerbated by the shortcomings of the country’s fractured mental health system that makes care difficult for many to access.
And experts said that certain police policies — like handcuffing people for transport to psychiatric hospitals — cement the association between mental illness and criminality, encouraging officers to use physical force when responding to people in a psychological crisis.
“We over-rely on the police to manage mental health issues.”
Ruth Shim, psychiatrist and researcher, University of California, Davis
“All of those things have led us to unfairly and incorrectly associate mental illness with criminality and with violence,” Shim said. “And as a result, then we over-rely on the police to manage mental health issues.”
Mobile crisis units are designed to give communities a different — and safer — way to respond to emergencies. One of the longest-running and most prominent programs is known as CAHOOTS, or Crisis Assistance Helping Out on the Streets.
The effort was launched in 1989 by the White Bird Clinic in Eugene, Ore. CAHOOTS is partially funded by the Eugene Police Department, which passes along the calls about noncriminal and nonviolent psychological crises — around 17% of the department’s call volume.
The organization’s teams — each made up of a medic and crisis worker trained in behavioral health — travel to perform welfare checks, emergency counseling, suicide assessments, or nonviolent conflict resolution. They can also offer transportation to clinical care, substance abuse treatment, and shelters — crucially, without the handcuffs. All of these services are trauma-informed, and many CAHOOTS workers themselves have had personal or lived experience with mental illness.
According to data collected between 2014 and 2019, 30% of the people CAHOOTS serves suffer from “severe and persistent mental illness.” Anxiety and depression factor into a quarter of their calls, while situations involving drugs and alcohol account for another 25%.
In 2019, CAHOOTS only requested police backup for 150 out of 24,000 dispatches — a track record that has drawn renewed attention to the group’s work.
“I would say that we have seen a giant uptick in the number of cities reaching out to us from across the nation,” Brubaker said, adding that they’ve heard from a wide range of people. “It’s local grassroots nonprofits, social justice nonprofits, anti-racism activism groups, but also the governors and mayors and councilors and police chiefs.”
The program had already inspired a number of similar efforts in other cities. The Caring for Denver Foundation is currently piloting a mobile crisis team modeled on CAHOOTS. The trial run of STAR — Support Team Assisted Response — began in June after the officials from the community mental health organization went on ride-along calls with CAHOOTS last year. Like that program, the Denver model pairs a paramedic and a mental health professional, who are dispatched by the local police.
“We wanted to create a way that a person could receive care in the right place at the right time by the right trained professional staff, and avoid any encounter with law enforcement if it wasn’t needed,” said Lorez Meinhold, the executive director of the foundation.
Just as challenging as reaching people in crisis: getting those individuals the services they need once they’re out of that crisis. Emergency response systems do little good if they can’t reliably link people to the care they require, and it’s difficult to depend on external resources, which are often sparse and can have lengthy wait lists.
Some of the mobile crisis units, including CAHOOTS, are run by programs with their own robust network of services, including case management, counseling, clinical care, and substance abuse treatment.
Those programs have also had to navigate how to pay for the care they provide. Mobile crisis units that do depend on insurance to be reimbursed for their responses say it can limit their staff size — lengthening the time it can take to respond to a crisis, experts say.
“The mobile crisis teams take 45 minutes to an hour and a half for a clinician to actually arrive on the scene or at the person’s house. … That’s like a decade,” said Annabel Lane, a social worker who works part-time with a Boston-based mobile crisis team.
Other programs, including CAHOOTS, have the capacity to respond much more quickly. But for programs that are short-staffed, some experts said one solution to speed up responses is what’s called the co-responder model, in which mental health workers are dispatched straight from the police station alongside officers.
With faster response times and built-in backup, some mental health leaders say this system is ideal, looping highly trained health professions to situations that are considered particularly high-risk or potentially violent, which the police otherwise might respond to on their own.
The Caring for Denver Foundation has funded 10 co-responder posts for mental health professionals at police stations. Meinhold said the organization hopes to develop a triage system, with co-response teams taking point on highly escalated situations, and STAR managing the less precarious scenes.
To some, the co-responder model might seem like too much of a compromise with the old system. But even mobile crisis programs depend on close relationships with law enforcement for reach and for safety.
“I have appreciated the CAHOOTS program being woven into public safety so directly, specifically with the police, because I feel like that’s really given us access to a lot of calls and to a lot of individuals that we would otherwise not have gotten access to,” Brubaker said.
Without requests patched through from the police, or a dedicated hotline that the public knows to call, it’s exceedingly difficult for mobile crisis units to get the word out about their services.
“Adults are so used to when they’re in crisis either calling 911 or showing up at their ER,” said Karah Kohler, director of children’s mental health at Lutheran Social Services of Illinois. The organization relies on an ad hoc system, in which the local police sometimes divert calls to the area’s NAMI chapter, which knows to re-route the calls to Lutheran Social Services.
And on rare occasions, responding to a crisis might put health workers — who don’t have the power to detain someone and aren’t armed — at risk.
“If we’re in a situation and we develop a sense that this is a situation that’s spinning out of control and is extremely dangerous, and we get on the phone and we say the police, we need you here now — they’re there now,” Cornell said. “I think that only happens when you have these kind of relationships.”
Communities now considering their own alternative models will have to reckon with that dynamic. It’s a divide that Brubaker acknowledged lies within CAHOOTS’ own name: “CAHOOTS was pretty entertaining, tongue-in-cheek,” he said. “We’re kind of working with the cops, but we’re not the cops.”
But some experts said it’s not a question of immediately — or entirely — removing police officers from the equation. Rather, there’s a need to build an infrastructure that can respond to people in crisis and get them the help that might be needed.
It’s a system that will take time – and buy-in from the whole community — to build.
“These gray hairs today helped me understand that the solution is going to be collective,” said Bill Carruthers, a member of the board of directors for NAMI Georgia.
Carruthers once suffered from a substance abuse disorder that led to frequent run-ins with the police and time in prison.
“I had bought into the fact that the only way that I was going to be able to survive on this planet was to be chained,” he said. Now, Carruthers works in psychiatric rehabilitation and serves as a peer support specialist. His goal is to keep people with mental health conditions out of the prison system — and to hone the support system that makes that possible.
“Instead of just saying, ‘You guys don’t do it right,’ what can we do to support, educate, participate, advocate, and generate?” he said. “It can’t be perfect. We can’t wait forever.”