Police are ill-equipped to safely and effectively serve people experiencing behavioral health crises. With more than 240 million 911 calls made each year, police have become the default first responders for a wide range of social issues, from mental illness to substance use to homelessness.^[]For 911 call volume, see National Emergency Number Association (NENA),”9-1-1 Statistics,” https://www.nena.org/page/911Statistics. The dire shortcomings of this approach are reflected in the disproportionate number of people with mental illnesses and substance use disorders killed by police every year and the disproportionate numbers held in jails and prisons.^[]Amam Z. Saleh, Paul S. Appelbaum, Xiaoyu Liu et al. “Deaths of People with Mental Illness During Interactions with Law Enforcement,” International Journal of Law and Psychiatry 58 (2018), 110-116; Jennifer Bronson and Marcus Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12 (Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics (BJS), 2017), https://www.bjs.gov/content/pu...; and Jennifer Bronson, Jessica Stroop, Stephanie Zimmer, and Marcus Berzofsky, Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009 (Washington, DC: BJS, 2017), https://www.bjs.gov/content/pu.... Although many officers may possess de-escalation skills, the mere presence of armed, uniformed officers with police vehicles can exacerbate feelings of distress and escalate mental health-related situations, particularly in Black communities and other communities of color, where relationships with police are historically characterized by tension and distrust.^[]See for example Substance Abuse and Mental Health Services Administration (SAMHSA), National Guidelines for Behavioral Health Crisis Care—A Best Practice Toolkit (Washington, DC: U.S. Department of Health and Human Services, SAMHSA, 2020), 68-69, https://www.samhsa.gov/sites/d...; Drew DeSilver, Michael Lipka, and Dalia Fahmy, “10 Things We Know about Race and Policing in the U.S.,” Pew Research Center, June 3, 2020, https://www.pewresearch.org/fa.../. Too often, encounters between the police and people in crisis end in handcuffs with an enforcement action or emergency department transport. Too often, they do not end in voluntary assessment and referral to the long-term supports people with mental illnesses and substance use disorders need to thrive.

Police themselves have been saying for years that they are asked to do too much. Why do we continue to ask them to respond to crisis calls that health professionals could address more safely and effectively?

For communities to shift away from police-led responses to people experiencing behavioral health crises, they must engage and fund new partners who can plan and implement different approaches. But developing alternatives that reduce police involvement in crisis response and divert people from jail does not require reinventing the wheel. There are many existing examples of community-based, health-centered responses that can lead to better outcomes for people with behavioral health issues. This report provides an overview of crisis response programs, including a typology of approaches organized by the involvement of law enforcement, before examining the efforts of three communities—Eugene, Oregon; Olympia, Washington; and Phoenix, Arizona—to reduce the number of crisis calls directed to police. Although these efforts involve varying degrees of police participation and collaboration, and each reflects different stages of program implementation, they all promote the use of alternative first responders who can intercept calls concerning mental health and substance use that would have otherwise gone to police. Finally, the report offers key considerations to aid communities in planning and implementing programs that shift responses from police to community.

Crisis response programs in context

Recent decades have seen severe reductions in behavioral health services due to a series of events, including deinstitutionalization and the failure to fund promised community-based services and supports.^[]William H. Fisher, Jeffrey L. Geller, and John A. Pandiani, “The Changing Role of the State Psychiatric Hospital,” Health Affairs 28, no. 3 (2009), 676-684, https://perma.cc/Z3SS-ZKA7. Because of this failure, increasing numbers of people with mental illness and substance use disorders have come into contact with the police, experiencing trauma during these encounters and even ending up in jail, where they stay longer than people without behavioral health conditions facing similar charges.^[]Serious Mental Illness (SMI) Prevalence in Jails and Prisons (Arlington, VA: Treatment Advocacy Center, 2016), 2, https://www.treatmentadvocacyc.... Many communities have increased both funding for correctional facilities and mental health treatment in jails; Rikers Island in New York City, Cook County Jail, and Los Angeles County Jail hold more people with behavioral health conditions than the dedicated mental health treatment facilities across the country.^[]Ibid., 1.

At the same time, some communities have introduced crisis response programs designed to address urgent concerns. These concerns include repeat encounters with police, poor connections to care, incarceration of people with mental illness for low-level offenses, and deaths of people with behavioral health conditions at the hands of police. The resulting programs, including Crisis Intervention Team (CIT) and co-responder models, often involve ongoing collaboration among police, advocates, and health and social service providers; extensive crisis scenario training for officers that includes de-escalation practice; and diversion from arrest to appropriate services and supports.

Unfortunately, many existing programs are hindered by an overreliance on police, limited community collaboration, and underinvestment in community-based resources. Communities must pursue new approaches that minimize trauma and distress, promote dignity and autonomy, and reduce repeat encounters with police for people who experience behavioral health crises. Reducing law enforcement involvement in crisis calls is a critical step toward these goals.

Current crisis response approaches are wide ranging, with varying degrees of police involvement, and communities might pursue multiple approaches simultaneously. Why, then, do communities choose one strategy over another or adopt multiple, layered approaches? These decisions are typically based on the specific problems that communities face and the resources available to address them. A lack of non-police resources often demonstrates how much local governments have prioritized criminal justice investments to address public health problems.^[]Vera Institute of Justice, What Policing Costs: A Look at Spending in America’s Biggest Cities, dataset (New York: Vera Institute of Justice), accessed August 18, 2020, https://www.vera.org/publicati....

As the following typology illustrates, existing approaches to crisis response are designed to handle a wide variety of situations, and multiple approaches may be needed to build a robust crisis response system that meets local needs. As communities rethink the role of police in crisis response, they must seek out and invest in community-based solutions.

Police-based responses

• Crisis Intervention Team (CIT) model—Police officers with 40 hours of specialized training respond to behavioral health crisis calls, de-escalate the situation, and direct people to services when appropriate.^[][] CIT International, Crisis Intervention Team (CIT) Programs: A Best Practice Guide for Transforming Community Responses to Mental Health Crises (Memphis, TN: CIT International, 2019), https://www.citinternational.o.... The model is based on strong community partnerships.

• Case management teams—Police convene multidisciplinary teams that use law enforcement and health data to identify people who frequently use emergency and behavioral health services and develop individualized response plans to connect them to services and other supports. The teams might involve proactive outreach of co-responding clinician/police officer teams, with the goal of developing solutions that reduce repeat interactions.

Police-based co-responses

• Primary co-response teams—Behavioral health clinicians co-respond with officers in patrol cars as first responders to situations involving someone in behavioral health crisis. These teams may include peer specialists. Clinicians may also co-respond remotely via phone or telehealth support.

• Secondary co-response teams—Behavioral health clinicians co-respond with officers in patrol cars at the request of police officers who respond first to situations involving someone in behavioral health crisis. Clinicians may also co-respond remotely via phone or telehealth support.

Community-based responses

• Crisis and “warm” lines—Crisis telephone lines are staffed by trained call-takers who provide remote counseling to people in crisis as an alternative to calling police. Warm lines are staffed by specially trained peers, who have lived experience with mental illness and provide phone support to people who are not in crisis.
• Peer navigator programs—Programs in which peers support recovery for people with behavioral health disorders. These programs hire and train peers who have lived experience with mental illness and/or substance abuse.^[]SAMHSA, “Peers,” April 16, 2020, https://www.samhsa.gov/brss-ta.... Programs may focus on people at risk of criminal justice involvement, offering them direct peer-to-peer support to avoid calls to police or trips to the emergency department.
• Mobile crisis teams (MCTs)—Teams composed variously of medics, crisis workers, and/or peers available to respond to people in crisis and provide immediate stabilization and referral to community-based mental health services and supports. When available, police may coordinate with MCTs for an alternative to police response, or community members can request them by calling appropriate service providers.
• EMS-based responses—Teams consisting of licensed counselors, clinical social workers, physicians, and EMTs who respond to people in crisis instead of police. The goal is to reduce arrests. These teams can transport people to services other than the emergency department to facilitate more appropriate treatment.^[]See for example Stein Bronsky, Robin Johnson, and Kristin Giordano, “Mobile Integrated Healthcare Program Changing How EMS Responds to Behavioral Health Crises,” Journal of Emergency Medical Services 41, no. 10 (2016), https://www.jems.com/2016/09/3....
• 911 diversion programs—Procedures used by police, fire, and EMS dispatchers to divert eligible non-emergency, mental health-related calls to behavioral health specialists. These specialists manage the behavioral health crisis by telephone and offer referrals to needed services.

This report highlights three communities—Eugene, Oregon; Olympia, Washington; and Phoenix, Arizona—that employ unique approaches to reduce police involvement in crisis calls and have layered several approaches in their efforts to address multiple problems:

• In Eugene, Oregon, the Crisis Assistance Helping Out on the Streets (CAHOOTS) program, housed in the White Bird Clinic, dispatches teams of mental health clinicians with a medic to respond to calls involving someone in crisis when safety is not an issue.
• Olympia, Washington, has introduced complementary initiatives to help people in crisis, including the Crisis Response Unit (CRU), which is modeled after CAHOOTS, and Familiar Faces, which provides peer outreach to people who are repeatedly coming to the attention of police.
• In Phoenix, Arizona, which has a comprehensive crisis response apparatus as well as a CIT program, 911 call-takers and dispatchers can refer crisis-related calls to a crisis line specialist who manages crises and makes referrals over the phone or deploys mobile crisis teams as needed, instead of police.

The case studies in this report are based on a review of the literature on police responses to people in behavioral health crisis, interviews with experts, and interviews with stakeholders in the highlighted communities. Communities were selected for their innovative approaches to reducing on-scene police response and shifting responsibility to behavioral health experts. You can read more about the methodology below.

Amid national conversation in recent months about reducing policing’s footprint in behavioral health matters, the Crisis Assistance Helping out on the Streets (CAHOOTS) program in Eugene, Oregon, has received particular attention as a successful and growing alternative to on-scene police response. Staffed and operated by Eugene’s White Bird Clinic, the program dispatches two-person teams of crisis workers and medics to respond to 911 and non-emergency calls involving people in behavioral health crisis—calls that in many other communities are directed to police by default. CAHOOTS units are equipped to deliver “crisis intervention, counseling, mediation, information and referral, transportation to social services, first aid, and basic-level emergency medical care.”^[]White Bird Clinic, “CAHOOTS FAQ,” accessed August 18, 2020, https://whitebirdclinic.org/ca.... All services are voluntary. If the situation involves a crime in progress, violence, or life-threatening emergencies, police will be dispatched to arrive as primary or co-responders.^[]Ibid. CAHOOTS teams deliver person-centered interventions and make referrals to behavioral health supports and services without the uniforms, sirens, and handcuffs that can exacerbate feelings of distress for people in crisis. They reduce unnecessary police contact and allow police to spend more time on crime-related matters. Eugene police may also request assistance if they arrive on-scene and determine that a CAHOOTS team can help resolve a situation.

This case study explains how CAHOOTS teams are funded, dispatched, staffed, and trained—and how a long-term commitment between police and community partners has cemented the program’s success.

Funding CAHOOTS through the police

The City of Eugene has long supported CAHOOTS through the Eugene Police Department (EPD) budget as an essential part of the community’s crisis response system, beginning in 1989 when EPD funded the first CAHOOTS shift.^[]Tatiana Parafiniuk-Talesnick, “In Cahoots: How the Unlikely Pairing of Cops and Hippies Became a National Model,” The Register-Guard, October 20, 2019, https://www.registerguard.com/.... In June 2016, the Eugene City Council increased the program’s funding by $225,000 per year to allow for 24/7 service.^[]Ellen Meny, “CAHOOTS Starts 24-Hour Eugene Service in January 2017,” KVAL, December 12, 2016, https://kval.com/news/local/ca.... Funding increases have continued over the last few years to allow for overlapping, two-van coverage as the call volume for CAHOOTS has grown.^[]City of Eugene Police Department, “CAHOOTS,” https://www.eugene-or.gov/4508/CAHOOTS.

After years of working with police in Eugene, White Bird expanded CAHOOTS services to the neighboring community of Springfield in 2015, when Lane County administered an Oregon Health and Human Services grant for the program.^[]Parafiniuk-Talesnick, “In Cahoots,” 2019; Tim Black, operations coordinator, CAHOOTS, April 17, 2020, telephone call. Between Eugene and Springfield, CAHOOTS is now funded at around $2 million annually—about 2 percent of their police departments’ budgets.^[]Anna V. Smith, “There’s Already an Alternative to Calling the Police,” High Country News, June 11, 2020, https://www.hcn.org/issues/52.....

Dispatching CAHOOTS for ‘better customer service’

A key element of White Bird’s partnership with police is that CAHOOTS staff carry a police radio that emergency dispatchers use to request their response to people in crisis on a special channel. The channel can get “overwhelmed,” Eugene officer Bo Rankin explained, by the increasing number of requests for CAHOOTS teams.^[]Officer Bo Rankin, Eugene Police Department, February 25, 2020, telephone call. Of the estimated 24,000 calls CAHOOTS responded to in 2019, only 311 required police backup, and in Eugene, CAHOOTS teams resolved almost 20 percent of all calls coming through the city’s public safety communications center.^[]Black, September 10, 2020, email; and Trevor Bach, “One City’s 30-Year Experiment with Reimagining Public Safety,” U.S. News & World Report, July 6, 2020, https://www.usnews.com/news/ci....

The center is housed in EPD and tasked with receiving and dispatching all police, fire, and CAHOOTS calls.^[]Marie Longworth, communications supervisor, Eugene Police Department, May 4, 2020, telephone call. With the CAHOOTS program embedded in Eugene’s communications system, Eugene dispatchers are empowered to use this non-police alternative to handle non-police issues.

The police department and CAHOOTS staff collaboratively developed criteria for calls that might prompt a CAHOOTS team to respond primarily, continuing to adapt them based on experience; the protocol is used as a guide rather than a rule. For example, when a call arrives at Eugene’s communications center, through either 911 or the community’s non-emergency line, call-takers listen for details that might fit these criteria. As Eugene communications supervisor Marie Longworth put it, sending CAHOOTS rather than police is often regarded as “better customer service” for community members requesting assistance for themselves or others.^[]Ibid.

Longworth also notes that CAHOOTS’s relationships in the community help dispatchers connect people with appropriate responders. The communications center sometimes gets direct requests for CAHOOTS. In other cases, because of their familiarity with community members and their specific needs, CAHOOTS teams have demonstrated comfort taking on calls that would otherwise go to police.^[]Ibid.

Although most EPD officers receive CIT training, CAHOOTS staff take on a more specialized set of issues and benefit from extensive field training focused on crisis incidents.^[]Rankin, February 25, 2020, call; Rankin, September 10, 2020, email. The CAHOOTS training process is incremental, ranging from field observation to de-escalation to the nuts and bolts of working with police radios, writing reports, coordinating with service partners, and starting and ending shifts.^[]Black, April 17, 2020, call.

White Bird also engages CAHOOTS trainees in a mentorship process that lasts throughout their careers with the organization, with the understanding that they take on difficult work and need outlets to process experiences together to carry out their jobs.^[]Ibid. The practice demonstrates the importance of wellness for first responders and community members alike.

In addition to bringing expertise in behavioral health-related de-escalation to a scene, CAHOOTS teams can drive a person in crisis to the clinic or hospital. This transportation, which must be voluntary, eliminates the indignity of a police transport, which necessitates the use of handcuffs per standard police protocols.^[]Rankin, February 25, 2020, call.

More rarely, CAHOOTS teams may determine that police involvement is needed when they gather more information, or as a situation evolves on-scene. If they respond to calls involving people who pose a danger to themselves or others, CAHOOTS teams may see the need for an involuntary hold without the authority to carry one out.^[]Black, April 17, 2020, call. For example, a person may be so severely intoxicated that they cannot care for themselves and will not consent to a sobering center.^[]American College of Emergency Physicians, “Sobering Centers,” https://www.acep.org/by-medica.... In this case, CAHOOTS staff might call in patrol officers to execute an emergency custody order. For mental health calls that end in involuntary hospitalizations such as these, CAHOOTS vans follow patrol vehicles to the emergency department to share their transfer sheet, which lists observations of and items discussed with the community member. This facilitates continuity of care for the client.^[]Black, April 17, 2020, call.

Collaboration between EPD and CAHOOTS extends beyond emergency response. Over the last few years, EPD has introduced the Community Outreach Response Team program to deliver case management for people experiencing homelessness who often come to the attention of emergency services.^[]Rankin, February 25, 2020, call; see also Cameron Walker, “Police Collaboration Effort Works to Keep Downtown Eugene Safe,” KVAL-TV, August 10, 2016, https://kval.com/news/local/po.... As part of this program, the police have partnered with CAHOOTS to bring their behavioral health expertise to bear on community members who continue to experience frequent contact with the police. EPD has found that this collaborative problem-solving work complements Eugene’s ongoing efforts to support alternative first responders.^[]Sergeant Julie Smith, Eugene Police Department, March 11, 2020, telephone call.

Close collaboration among government and community partners—including schools, shelters, and behavioral health providers—enables CAHOOTS to respond to a wide variety of situations and to assist police and other agencies with behavioral health emergencies when appropriate.^[]White Bird Clinic, “CAHOOTS FAQ.” Such partnerships during program planning and throughout program implementation are essential to the success of efforts to improve local crisis response systems. CAHOOTS Operations Coordinator Tim Black stressed that the organization’s success did not happen overnight; there were many small, but important, details to address and a wide range of stakeholders to engage for effective implementation. “You want to make sure you have everyone who could possibly have an opinion about this topic at the table,” he explained.^[]Black, April 17, 2020, call. It is important to include detractors of the police department in program planning, as getting these partners’ input is critical to program success. Officer Rankin noted that CAHOOTS staff themselves can be “strongly against police in many ways,” but it is “nice having all the line people trying to come up with solutions together.”^[]Rankin, February 25, 2020, call.

Still, the Eugene and Springfield communities are more than 80 percent white, making them racially homogeneous compared to many cities.^[]United States Census Bureau, “Quickfacts Eugene, Oregon,” https://www.census.gov/quickfacts/eugenecityoregon; and United States Census Bureau, “Quickfacts Springfield, Oregon,” https://www.census.gov/quickfa.... “There’s a lot of privilege that comes along with having a healthy enough relationship with police that you can contact them,” Black acknowledged, and Eugene is now exploring a separate phone line for CAHOOTS that would be disconnected from the police department.^[]Black, April 17, 2020, call; and Molly Harbarger, “Police Cuts Give Portland Alternative First Responder Program a Boost—But Can it Respond to the Moment?” The Oregonian, July 4, 2020, https://www.oregonlive.com/cri.... This is a vital consideration for implementing crisis response programs where relationships between police and communities of color are historically characterized by tension and distrust. Programs may find success by grappling with this distrust directly and engaging a wide variety of partners to reach communities with the greatest need.^[]See for example Jumaane D. Williams, Improving New York City’s Responses to Individuals in Mental Health Crisis (New York: New York City Public Advocate, 2019), https://www.pubadvocate.nyc.go....

CAHOOTS credits being embedded in the community’s emergency communications and public safety infrastructure for much of its impact, while stressing that the program’s ultimate objective is to reduce policing’s overall footprint. White Bird’s website states, “CAHOOTS is designed to provide an alternative to police action whenever possible for non-criminal substance abuse, poverty, and mental health crisis.”^[]White Bird Clinic, “CAHOOTS FAQ.” According to Black, the program aims to reduce opportunities for people to become justice-involved and lose their rights. Working with the police has made this possible: “By no means do we [ignore] what other public safety personnel are doing,” he explains. “We try to use our privilege in the public safety system to fight for compassionate and responsive services.”^[]Black, April 17, 2020, call.

As communities across the country reconsider enforcement-led approaches to social issues with renewed urgency, efforts to address crises among people experiencing homelessness and the broader community in Olympia, Washington, stand out. In fact, more than 20 percent of people experiencing homelessness in the United States have a serious mental health condition, and roughly a third have a substance use disorder.^[]For more on mental illness, see U.S. Department of Housing and Urban Development (HUD), HUD 2018 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations (Washington, DC: HUD, November 13, 2018), 1, https://files.hudexchange.info.... For more on substance use disorders, see SAMHSA, “Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States,” (North Bethesda, MD: SAMHSA, 2011), 2, https://www.samhsa.gov/sites/d.... Recent Olympia Police Department (OPD) initiatives have started to reduce officer involvement in these matters. Building on standard CIT training, these initiatives include a Crisis Response Unit (CRU) loosely modeled after CAHOOTS and a Familiar Faces program that provides peer outreach to people who repeatedly come to the attention of police.

This case study examines Olympia’s efforts in recent years to launch new alternative responder and peer navigator programs. Key steps in program development have included securing initial funding, determining when and how CRU members are dispatched, shaping strategies for CRU members and Familiar Faces peers to support people with behavioral health needs, and engaging a wide variety of stakeholders to address challenges as they arise.

Funding Olympia’s layered approach

Olympia, Washington, has relied on a combination of local tax revenue and grant funding to support its crisis response initiatives. In November 2017, voters in Olympia, Washington, passed a public safety levy that included funds for an enhanced crisis response, with a focus on improving conditions in Olympia’s downtown area.^[]Abby Spegman, “Olympia Police Prepare for ‘Year of Transition’ after Voters Approve Public Safety Levy,” The Olympian, January 25, 2018, https://www.theolympian.com/ne.... Then-Chief of Police Ronnie Roberts had been an officer and sergeant in Eugene, Oregon, and he had advocated for a similar approach in Olympia.^[]Amelia Dickson, “Does Olympia Need a Tax Hike to Support Public Safety? Or Can Money Be Found Elsewhere?” The Olympian, October 1, 2017, https://www.theolympian.com/ar.... The levy allocated $110,100 and $497,000 in startup and annual costs, respectively, for OPD to contract with a behavioral health partner that would staff CRU as an alternative-to-police response led by unarmed civilian behavioral health specialists.^[]Abby Spegman, “Olympia’s Crisis Response Team Had Nearly 700 Calls in Its First Two Months,” The Olympian, June 1, 2019, https://www.theolympian.com/ne....

While planning for CRU was underway, OPD launched the Familiar Faces program in late 2018 with $106,000 in state grant funding awarded through the Washington Association of Sheriffs and Police Chiefs (WASPC).^[]Washington Association of Sheriffs and Police Chiefs (WASPC), “Mental Health Field Response Teams Program,” https://www.waspc.org/index.ph...; Anne Larsen, outreach services coordinator, Olympia Police Department, and Lt. Amy King, Olympia Police Department, April 13, 2020. Familiar Faces assigns peer navigators with lived experience to conduct outreach with clients recommended by downtown officers and city staff based on frequent contact with emergency services.^[]Abby Spegman, “Olympia’s Crisis Response Team Coming in January: ‘Our Goal is to Divert People From Jail’,” The Olympian, December 7, 2018, https://www.theolympian.com/ne...; Larsen and King, April 13, 2020, call. In early 2020, WASPC awarded Olympia an additional $804,000 grant to expand the program, providing funding for four more peer navigators, a mental health professional, and a program manager.^[]City of Olympia, “One Community Plan—Focus Area 3,” June 29, 2020, accessed on September 10, 2020, http://olympiawa.gov/community...

Rather than dispatching CRU directly based on specific criteria, TCOMM 911 shares all potentially eligible calls coming through 911 or Olympia’s non-emergency line over the shared police frequency. CRU teams hear all the calls on the police frequency while they are working and may decide to respond, or officers may refer calls to CRU if they determine a health-centered response is more appropriate and the apparent threat for first responders is minimal. Callers have also increasingly requested CRU as the unit has established itself in the community.^[]Wendy Hill, deputy director, and Jonnica Elkins, operations supervisor, Thurston 9-1-1 Communications, July 2, 2020, telephone call. OPD reports 511 contacts between CRU and community members in the second quarter of 2020, 175 of which were initiated by CRU members themselves.^[]Larsen, August 24, 2020, email.

In addition to proactively engaging with people who appear to be experiencing a crisis or more minor behavioral health issue, CRU can provide a secondary response at the request of first-responding officers. However, OPD officers were only on-scene with CRU 86 of the 511 times the unit engaged with community members in the second quarter of 2020.^[]Ibid. Although some situations involving a police and CRU response resemble co-responder approaches in other communities, OPD says its objective remains reducing police presence altogether in crisis responses unless police involvement is needed.^[]Larsen and King, March 12, 2020, call. According to OPD and TCOMM 911 representatives, CRU members have increasingly responded to calls on their own as officers have demonstrated increased comfort relying on CRU to address pressing behavioral health needs in the community.^[]Hutnik, May 22, 2020, call; and Hill and Elkins, July 2, 2020, call.

Much of CRU’s day-to-day activity involves building relationships in the community, like those with people who live in encampments. According to OPD’s Outreach Services Coordinator Anne Larsen, “They [CRU teams] have great de-escalation skills, but don’t always need them.”^[]Larsen and King, March 12, 2020, call. Larsen stressed the importance of flexibility in service criteria and delivery, explaining, “If you define crisis to the minute, people won’t use you.”^[]Ibid.

Beyond responding to crisis situations, CRU’s interactions with community members are wide-ranging in service of building trust. Staff see many of the same people every day, and much of their work involves developing relationships so they can effectively respond when crises arise.^[]Spegman, “700 Calls,” 2019. CRU members are asked to always do what’s best for clients’ health. “They are not snitches; they are not used to gather information to get someone arrested,” Larsen said in a 2019 interview with The Olympian. “We address the behavioral health, not the criminal aspect of people’s behavior.”^[]Ibid.

In addition to completing required state training for behavioral health specialists, CRU members are expected to engage with a wide variety of people, including police officers and vulnerable community members, as well as a range of service providers. As part of their training, CRU members spent time with police on patrol, learned about resources in downtown Olympia, and built relationships with the people they would end up serving. Further, given their role in monitoring the police radio, CRU members established familiarity with police radios and navigating through town.^[]Larsen and King, March 12, 2020, call.

Early in the program, officers introduced the peers to people on the list so they could begin developing a sense of trust and a better understanding of those people’s specific needs. Soon after those initial introductions, the peers began working with clients independently of police, which gave them the space they needed to build meaningful relationships, and it was not long before their phones saw an influx of requests. “Once consumers saw they were showing up regardless of weather and without judgment,” Larsen explains, “there was more engagement.”^[]Ibid. As of June 2020, the two peers had reported 2,387 contacts with clients since July 2019 and were providing varying degrees of sustained support to a caseload of 24 people.^[]Larsen, August 24, 2020, email.

Peers provide wide-ranging services. Because they are not funded through Medicaid, peer navigators face fewer restrictions than clinicians around how—and for how long— they engage with clients. They have the flexibility to assess situations themselves and tailor interventions, operating together and independently as needed. Services include problem-solving with clients to address housing transitions and childcare challenges; transporting clients to and from treatment and department stores for necessities; supporting clients with haircuts, laundry, and showers; and providing a listening ear.^[]Larsen and King, April 13, 2020, call. Melissa Mckee, one of the program’s current peer navigators, explained that there is “no typical day” in the role, and the people they work with are often resistant to typical service provision.^[]Mckee and Whiteman, April 23, 2020, call.

But program stakeholders also note that the systems and services set up to serve people in crisis often defy accessibility. “We do this stuff every day,” peer navigator Keith Whiteman said, “and it’s still super challenging to navigate through the mazes of the mental health system.”^[]Ibid. Keeping up with the level of need in the community has been a persistent challenge, according to Lieutenant King, and the program’s peers have had to “figure out a [sustainable] pace and how you work within the system and obstacles that system presents.”^[]Larsen and King, April 13, 2020, call. OPD recently expanded the program in an effort to meet this need, adding four peers to its Familiar Faces team in August 2020 with the goal of providing peer-led case management services for more than 60 community members.^[]Larsen, August 24, 2020, email.

‘Same goal, same team’ collaboration

As peer navigators, Mckee and Whiteman carry out their work through both active outreach and collaborative problem-solving alongside system stakeholders. Ongoing stakeholder meetings in Olympia convene Familiar Faces peers, CRU members, OPD leaders, behavioral health partners, the county public defender, and other community representatives, who review difficult cases together as they arise.^[]Larsen and King, April 13, 2020, call. As Larsen explained, the perspectives represented in this stakeholder group are wide-ranging, but they are ultimately “working toward the same goal and on the same team.”^[]Ibid.

The meetings have provided for meaningful learning opportunities and conversations across disciplines and experiences. “They don’t know everything about police work,” Lieutenant King said of the peers, “and I don’t know everything about being incarcerated and addicted.”^[]Ibid. Mckee described the experience of transitioning into her role with a criminal history as “huge” and “groundbreaking” for shifting culture within the agency as well as in her own “internal landscape.”^[]Mckee and Whiteman, April 23, 2020, call. Whiteman echoed this sentiment, saying the collaboration is “changing the culture on both sides of the fence.”^[]Ibid. Larry Jefferson, a longtime public defender and fellow stakeholder in OPD’s roundtable discussions, agreed, noting that participating officers become more likely to refer people to CRU and Familiar Faces as they observe positive changes in the lives of these programs’ clients.^[]Larry Jefferson, public defender, Olympia, Washington, July 21, 2020, telephone call.

Based on his personal experience, Jefferson also grounded the community’s efforts in national conversations about the need for public safety and health systems that equitably serve and protect Black lives. “My goal is for every Black family to feel supported by the OPD,” Jefferson said, and programs like Familiar Faces are “the tip of the spear for that.”^[]Ibid. But, he added that more must be done to get everyone the help they need, and OPD’s layered approach cannot overcome every obstacle to finding appropriate housing and health care for clients.^[]Ibid. When encounters between first responders and community members are safely resolved, communities must then come together to provide low-barrier, long-term supports and services for people navigating periods of crisis.

In Phoenix, Arizona, which has a comprehensive crisis response apparatus as well as a CIT program, dispatchers in the Phoenix Police Department (PPD) Communications Bureau can refer eligible 911 calls to Crisis Response Network (CRN), a nonprofit organization providing crisis call center services across the state.^[]Crisis Response Network, “About Crisis Response Network,” accessed September 9, 2020, https://www.crisisnetwork.org/.... In Phoenix and the wider Maricopa County area, CRN’s Central Arizona crisis line resolves many crises over the phone or, if an on-scene response is appropriate, sends a mobile crisis team (MCT) of clinicians trained in crisis intervention rather than police.^[]Crisis Response Network, “Services,” accessed September 9, 2020, https://www.crisisnetwork.org/.... Phoenix is also piloting a co-response approach that pairs officers with MCTs for crisis-related calls that prompt a police response but nonetheless indicate a need for behavioral health assessment and de-escalation.^[]Paul Galdys, deputy CEO, RI International, and Sabrina Taylor, CIT training coordinator, Phoenix Police Department, March 4, 2020, telephone call.

This case study describes how Medicaid funding in Arizona supports Phoenix police collaboration with crisis care providers to connect more people to treatment, including a co-response pilot and efforts to divert crisis-related 911 calls to the crisis system rather than sending police.

Ensuring a well-funded crisis care continuum

The funding of crisis care in Arizona has roots in a decades-long lawsuit settled in 2014. Arnold v. Sarn alleged that the Arizona Department of Health Services and Maricopa County had failed to sufficiently fund a comprehensive community mental health system as required by state statute. The settlement of the case secured the guaranteed provision of community-based services and programs for people with serious mental illness. Arizona is now unique in how it braids local, state, and federal funding sources to ensure a broad range of community-based services are widely accessible and meet the settlement’s standards.^[]Christine Vestal, “‘Arizona Model’ for Behavioral Health Crisis Care Gains Attention from Other States,” azcentral, February 21, 2020, https://www.azcentral.com/stor...; Shelley Curran, director of crisis, cultural, prevention, and court services, Mercy Care, September 8, 2020, email.

The lawsuit’s legacy has important implications for collaboration between police and behavioral health partners. According to Paul Galdys, deputy CEO of Maricopa County behavioral health care provider RI International, the partnership between law enforcement, the Regional Behavioral Health Authority, and Arizona Medicaid has created the expectation that “crisis providers, including mobile crisis teams and our crisis facilities, [must] say ‘yes’ every time we get a referral.”^[]Galdys and Taylor, March 4, 2020, call. Galdys described the positive result of this expectation as a “no wrong door” approach for people with mental illness. Designated drop-off areas for law enforcement help facilitate swift handoffs between police and crisis care providers, encouraging officers to continue bringing people in crisis to appropriate facilities rather than the emergency department, or even jail.^[]Vestal, “Arizona Model,” 2020. PPD’s partnerships with these facilities are among the program elements that set the department’s CIT efforts apart from those focused solely on training for police. Crisis care providers, meanwhile, do not have to worry about the type of health care coverage someone has when they arrive at their door because of Arizona’s braided funding approach.^[]Shelley Curran, director of Crisis, Cultural, Prevention, and Court Services, and Tenasha Hildebrand, crisis and veteran services administrator, Mercy Care, April 29, 2020, telephone call.

The service delivery expectations that emerged in the aftermath of Arnold v. Sarn, paired with Arizona Medicaid’s managed care approach, have amounted to significant funding for CRN, whose Central Arizona crisis line and 27 mobile crisis teams (MCTs) operated by other local providers give Maricopa County comprehensive mobile crisis response capacity.^[]Galdys and Taylor, March 4, 2020, call. Tenasha Hildebrand, crisis and veteran services administrator at Mercy Care, a managed care organization that helps fund CRN, underlined the success of crisis lines in referring people to care outside of the crisis system without the need for an on-scene response altogether, and the significant majority of situations CRN manages are stabilized over the phone.^[]Curran and Hildebrand, April 29, 2020, call; Crisis Response Network, “About,” database (Tempe, AZ: CRN), https://www.crisisnetwork.org/.... However, for crisis-related calls that come through 911, 911 dispatchers now work with CRN to ensure these situations do not receive police responses by default.

Within this group, about 150 MCT dispatches per month result from police referrals after officers have arrived on-scene and determined that one of CRN’s mobile teams can help de-escalate a situation and provide transportation to appropriate crisis services.^[]Galdys and Taylor, March 4, 2020, call. If PPD decides a mobile team is needed, CRN has agreed to deliver one within an hour—and without the standard screening process that might slow down a response. CRN’s average response time is in the range of 30 to 45 minutes.^[]Matthew Moody, manager of Contact Center Operations, Crisis Response Network, June 18, 2020, telephone call.

PPD and CRN have explored opportunities to integrate CRN’s mobile crisis teams with 911 dispatch to reduce the time required for an MCT to arrive on-scene. In early 2020, a co-dispatch pilot program began serving a specific Phoenix neighborhood among those that have seen the highest volume of CIT calls.^[]Ibid. When a 911 call in that neighborhood includes a behavioral health issue but also requires a police response, 911 dispatchers simultaneously notify police and CRN so that CRN can dispatch a co-responding mobile team.^[]Ibid. There is limited data thus far to draw conclusions about the pilot’s impact, but PPD CIT Training Coordinator Sabrina Taylor said officers are reporting MCT response times that “feel faster,” and the police incur no additional cost from the effort because it complements CRN’s ongoing work.^[]Galdys and Taylor, March 4, 2020, call; and Moody, June 18, 2020, call.

However, these partners have also come to agree that forgoing police involvement when appropriate and sending more 911 calls to CRN is an important priority with the potential to improve outcomes for people in crisis. To get “upstream” from police contact, as Crisis Response Network’s Manager of Contact Center Operations Matthew Moody put it, CRN developed a plan for 911 dispatchers to relay calls to a CRN specialist instead of first dispatching an officer for the many calls that do not require police intervention and may not require any kind of on-scene response.^[]Moody, June 18, 2020, call. CRN specialists, clinicians with a bachelor’s or master’s degree and four to eight years of experience, conduct in-depth risk assessments to screen these calls. Based on these assessments, the specialists can resolve situations through phone support and referrals or send an MCT to the scene.^[]Ibid. Yet there is still work to be done to overcome existing policies and practices that default to sending police rather than directing calls to CRN.

“When you call 911, 911 deals with it,” he explained. “If you start with 911, you’re starting with a justice lens.”^[]Galdys and Taylor, March 4, 2020, call. Many people have been taught to call 911 to handle all emergencies, and like many communities, Phoenix will send police when police are asked for. Terry McDermott, a Phoenix advocate with mental illness who presents at CIT trainings with PPD officers, praised the work of CRN’s crisis line specialists and MCTs but believes most people are unaware of these resources and are more likely to turn to 911 during a crisis.^[]Terry McDermott, advocate, Phoenix, Arizona, July 16, 2020, telephone call.

PPD and CRN have taken action to begin changing this culture. “We knew we needed our [911] operators to trust the crisis operators,” Dispatch Supervisor Myla Marovich explained, “in order to be able to hand the calls over and trust they’ll do the right thing for that caller.”^[]Myla Marovich, shift supervisor, Phoenix Police Department, and Sabrina Taylor, CIT training coordinator, Phoenix Police Department, June 4, 2020, telephone call. After conducting a survey of Phoenix’s 911 operators, PPD determined that persistent dispatcher concerns around liability made them less likely to send a call to CRN. These dispatchers feared that threats to safety could emerge and they might be reprimanded for not sending patrol.^[]Galdys and Taylor, March 4, 2020, call; and Moody, June 18, 2020, call. Indeed, CRN specialists concerned about risk assessment findings gathered over the phone can send calls back to 911 within a few minutes to dispatch police as necessary.^[]Moody, June 18, 2020, call. A growing number of people in the department recognize that, if they want to encourage more diversion, they need to develop a policy that explicitly directs dispatchers to divert calls to CRN in certain circumstances, rather than just presenting it as an option.^[]Marovich and Taylor, June 4, 2020, call.

Collaboration and cross-center learning

Training between PPD and CRN has been a key strategy in encouraging the diversion of more 911 calls. Through February and March 2019, the police department coordinated with CRN to roll out a new dispatcher training for this purpose. The training consisted of 30-minute videos on mental health and PPD’s broader CIT efforts, as well as a two-hour in-person meeting with a CRN manager to discuss the evolution of Arizona’s crisis system.^[]Galdys and Taylor, May 7, 2020, call. The manager fielded questions about how the crisis line works and what they can or cannot handle. Moody recounted that “even veteran 911 dispatchers learned there were call types that CRN could take that they didn’t know of before.”^[]Moody, June 18, 2020, call. In early 2020, a CRN manager returned to meet with dispatch supervisors in three training sessions so they could raise any questions that had come up about diverting calls to CRN. Supervisors were also briefed on a pilot that would have placed the CRN manager in the PPD communications center for 20 hours per week. After the CRN manager participated in two days of observation and answering dispatchers’ questions, the COVID-19 pandemic put the pilot on hold, but CRN and PPD nonetheless observed a temporary increase in the number of calls diverted to CRN shortly after the training sessions. The following graph captures mental health–related 911 calls in Phoenix that did not receive a police response and demonstrates an increase in referrals.^[]Taylor, September 2, 2020, email.

The brief uptick underscores the value of ongoing education and engagement between the communications centers, as well as what might be gained from a formal departmental policy requiring greater call diversion.

Phoenix partners understand that rethinking how emergency communications responds to crisis calls will play an integral role in driving change. Consequently, PPD’s Communications Bureau increasingly serves as a key stakeholder in Phoenix’s crisis response efforts. PPD and CRN now routinely exchange feedback as they review calls together to determine how they might be handled differently.^[]Moody, June 18, 2020, call. Phoenix’s crisis response program engages a wide variety of partners and includes law enforcement–friendly crisis services and trainings tailored for diverse stakeholders, among other program elements. Although the Communications Bureau’s efforts to rethink Phoenix’s crisis system and push responses upstream from police are still relatively new—“We have a lot of catching up to do,” as dispatch supervisor Marovich put it—they point toward crisis response programs that broaden their focus to include not only improved police responses but also improved community-based responses and reduced police contact.^[]Marovich and Taylor, June 4, 2020, call.

To reduce police involvement in crisis calls, communities have had to surmount challenges and work together to determine how best to meet their goal of providing the right response at the right time for the right person. Ultimately, they have worked together creatively—police, behavioral health, advocacy, community residents, and others—to create programs that use existing resources and source funding for new ones to promote health and safety for all.

Identifying funding, configuring on-scene responses (who does what, when) while maintaining safety for everyone, and training needed personnel will form the backbone of any effort to replicate these models.

Funding

Programmatic efforts to reform police responses to people in behavioral health crisis around the country have been touted as adding few new costs to policing budgets.^[]Dave McClure, Ellen Paddock, Rayanne Hawkins, and Mayookha Mitra-Majumdar, Pay for Success and the Crisis Intervention Team Model (Washington, DC: Urban Institute, 2017), https://www.urban.org/sites/default/files/publication/94741/pay-for-success-and-the-crisis-intervention-team-model_1.pdf. See also Larry Thompson and Randy Borum, "Crisis Intervention Teams (CIT): Considerations for Knowledge Transfer," Mental Health Law & Policy Faculty Publications, 2006, 548, https://scholarcommons.usf.edu.... Though this may have been true for police agencies, communities often need additional funds for the behavioral health services that would augment or replace police responses. The three communities Vera researchers studied each required significant funding (see case studies), and acquired it through a combination of grants, levies, and federal and state funds. Communities looking to implement new models should consider the following possible funding sources:

• police department budgets, which can be reallocated to support more comprehensive non-police response approaches;
• state grants, including police association grants that support non-police first responders or peer outreach;
• braided funding pooled together from local, state, and federal sources, as demonstrated in Arizona; and
• public safety levies that explicitly carve out funding for enhanced non-police crisis response.

911 call diversion

To truly reduce the police response to scenes involving people with mental illness, dispatchers must divert calls to 911 (and non-emergency numbers) to non-traditional responders. At the heart of the ability to divert 911 calls are two important needs. Departments must establish policies in conjunction with agency legal staff and train police department staff—and communications personnel—to understand that they are not going to be held liable for situations in which they do not respond to the call. Communities looking to implement new models should consider the following possibilities for 911 diversion practices:

• alternative first responders carry police radios so they can be dispatched to the scene or monitor and proactively intercept calls that might benefit from their behavioral health expertise; and
• legal staff address any potential liability for police or mental health service personnel by developing clear guidelines to determine which calls will be dispatched to mental health services or transferred to a mental health expert at the 911 call center.

On-scene response models

The task of removing the police from encounters with people in crisis requires extensive coordination among various responders to reduce potentially dangerous situations and foster connections to services for people with a wide range of needs. The sites Vera talked with have creatively managed to place the right person at the scene of a crisis to help manage a person’s ongoing needs outside of the crisis and establish long-term solutions. Communities looking to implement new models should consider the following possible on-scene response approaches:

Recruiting and training personnel

The case studies reveal that people with certain traits and abilities are needed to do the work of compassionately and patiently helping people in crisis get the help they need. In addition, extensive training is needed because job responsibilities may be new to staff in these roles. Communities looking to implement new models should consider the following strategies for recruiting and training alternative responders and dispatchers:

• Rather than prioritizing responders with graduate-level training, programs like CAHOOTS identify team members based on their passion for serving people with behavioral health conditions and their ability to learn about the full range of community resources, work with police, engage people during crisis, and connect them to appropriate services;
• Training for line-level crisis workers features cross-training with officers to learn about police experiences in their communities, as well as building relationships with community-based organizations to learn about specific treatments and supports;
• Officers themselves dedicate time to learning about behavioral health outreach strategies and treatment approaches; and
• Dispatcher trainings include information about the crisis response system and the activities of behavioral health partners to ensure dispatcher confidence in those partners as they conduct their own assessments to deliver alternatives to police response.

Many community partners clearly have a role to play in supporting safe responses to people in crisis that center their dignity and long-term health outcomes. This report highlights important strategies and approaches to help communities navigate ways to reduce police involvement in situations involving someone in behavioral health crisis. Reducing police involvement in crisis response hinges on a robust and flexible crisis continuum that enables access to effective and appropriate treatments, services, and supports for a wide range of clients. Ultimately, creating alternatives to police responses will connect people in the community with the services they need, reduce arrest rates and the potential for violent police encounters, and promote the health and safety of community members.