People experiencing behavioral health crises are in urgent need of compassion, care, and support—to ease their distress, to keep them safe, and to plan for their ongoing wellbeing.

In the vast majority of jurisdictions, police officers—as default first responders for 911 calls—are tasked with meeting these needs. They are often ill-equipped to do so.

Indeed, officer involvement can make these situations worse; this is particularly true in Black communities and other communities of color, which have disproportionately shouldered the harms of policing.¹ Research conducted nationwide shows that most Black people, in contrast to most white people, live with the fear that police will hurt them or their family members.² The tragic police killings of Daniel Prude, Deborah Danner, Walter Wallace Jr., Joseph DeWayne Robinson, and far too many others experiencing behavioral health crises have driven community demands for systemic change.³

In turn, an increasing number of jurisdictions are developing civilian–led crisis response programs. Staffed by unarmed teams of clinicians, peers, and other specially trained civilian responders, such programs are demonstrating that they can safely act as an alternative to police for people in crisis.⁴ However, to truly address the needs of people most harmed by the status quo, jurisdictions must work to eliminate racial disparities and improve outcomes for everyone as they plan, implement, and evaluate these programs. In other words, crisis response programs must prioritize antiracism and equity.

But what does an antiracist and equitable crisis response program look like?

To answer this question, researchers from the Vera Institute of Justice (Vera) interviewed national subject matter experts and local program stakeholders, including people with direct experience in establishing and managing crisis response operations. Vera used the findings of these interviews to produce this toolkit. Vera hopes that it will provide guidance to advocates and practitioners alike who aspire to design and deliver more equitable crisis response services in their communities.

Methodology

The strategies and promising practices highlighted in this report draw on interviews conducted with advocates, practitioners, and researchers, as well as a review of program materials.

Vera researchers completed 35 interviews with a total of 44 national subject matter experts and local program stakeholders with professional and lived experience in behavioral health and crisis intervention, policing, 911 communications, peer support, research, and advocacy. Vera aimed to learn from local programs at different stages of planning and implementation and to include programs with novel approaches and innovations. Vera researchers included communities with diversity in size, geographic location, and demographic composition. Vera also sought to include stakeholders with subject matter expertise in areas relating to equity, such as racial equity, immigration, disability justice and access, and peer advocacy and workforce development.

From March to November 2021, Vera researchers conducted 35 interviews with a total of 44 national subject matter experts and local program stakeholders. Background research, outreach to partners, and referrals and recommendations from other interviewees informed recruitment and selection. (See the full list of interviewees and an overview of the programs included.)

Interviews were conducted over Zoom and were audio recorded and transcribed for analysis. The researchers did not record two of the 35 interviews, based on the preference of interview participants. For these interviews, a Vera researcher took detailed notes during the interview. Advocates and other interviewees who were not speaking with Vera in their professional capacities were offered a $50 prepaid credit card for participating in the interview.

Vera researchers followed a semi-structured interview question guide tailored to each participant. The guide included questions on defining and measuring antiracism and equity for crisis response programs and identifying strategies and recommendations to advance antiracism and equity during program planning, implementation, and evaluation.

A team of three Vera researchers used Dedoose qualitative data analysis software to organize and analyze the qualitative interview data. Through an iterative process during regular team meetings, the researchers developed a set of codes to identify the key themes and findings of the interviews.

Vera researchers also requested and reviewed relevant materials from local programs. Examples of these included program evaluation reports, data dashboards, and program planning materials and documentation.

Read More

Decision-making and equity: From caller to crisis response

When someone in crisis needs immediate support, there are numerous decision points that may produce inequities. At each point, local practitioners, depending on the action they take, can help reduce disparities and ensure that all people in crisis receive the care and support they need.

Overview of recommendations

Through their interviews with subject matter experts and program stakeholders, Vera researchers identified seven key areas where communities can take action to develop antiracist, equitable crisis response programs. The table below summarizes Vera’s recommendations for each program area.

Local programs must be shaped by the perspectives and recommendations of community members. It is particularly important to hear from people who have direct, lived experience of current services and responses; people who have experienced behavioral health crises; and Black, Indigenous, and other people of color that have been disproportionately harmed by policing. Without these perspectives, programs risk perpetuating distrust and reproducing the inequities of status quo approaches.

Even with the best of intentions, community engagement and consultation efforts can be ineffective when they are one-off or infrequent, when they ask for input only and do not share opportunities for decision-making, or when stakeholders with institutional power are not open to critical feedback. People with lived experience should be in leadership and decision-making roles, contributing fully to programmatic and strategic decisions.⁵

Key recommendations

• Partner and collaborate with people with lived experience
• Allocate time and resources to integrate feedback

Partner and collaborate with people with lived experience

From the earliest stages of planning and development, crisis response programs should be designed in partnership and collaboration with stakeholders who have direct, lived experience of local services and behavioral health needs.

In Portland, Oregon, for example, a 2018 report revealed that the majority of arrests the prior year involved people identified as homeless, highlighting the particular impact of policing on this community.⁶ The campaign to establish a civilian crisis response service—Portland Street Response (PSR)—began in 2019 and was led by Street Roots, a local nonprofit organization that leads media, advocacy, and community outreach initiatives for people experiencing homelessness and poverty.⁷ Executive Director Kaia Sand recounted that when the Portland City Council began planning for the PSR pilot, “it became clear that we needed a large-scale way to bring unhoused voices into the plan development.”⁸ To guide the planning and implementation of the pilot, the Portland City Council allocated $500,000, hired a program manager, and formed several workgroups, including a group dedicated to community engagement.⁹ Street Roots helped lead listening sessions and a survey of 184 unhoused community members that informed recommendations for the launch and implementation of the pilot program.¹⁰

Similarly, in Toronto, a group of community stakeholders—the Reach Out Response Network (RORN)—engaged community members who were “most likely to be impacted by current and future crisis services” to inform their proposal for a new, civilian-led crisis response service.¹¹ This included Black, Indigenous, and other communities of color; people experiencing houselessness; LGBTQ+ people; Deaf community members; people with developmental disabilities; neurodivergent people; youth; mental health service consumers and peer workers; family members; and advocates. Through a series of town halls, surveys, focus groups, and interviews, RORN ultimately engaged more than 800 community members; this work culminated in a report and proposal to the City of Toronto.¹² The city was receptive and committed to continued community engagement and contracted with RORN and other Black-, Indigenous, and LGBTQ+-led organizations.¹³

Local program stakeholders shared many more examples of people with lived experience providing knowledge and guidance to the development of crisis response programs. In some places, people with lived experience were engaged in ongoing consultation with program leadership and, in others, they were embedded in core planning teams.¹⁴ Beyond the development of programs, people with lived experience are actively participating in state and local legislative advocacy. Through such efforts—writing op-eds and providing testimony to legislators, for example—they seek to improve the funding and infrastructure needed to support non-police responses.¹⁵

Read More

Allocate time and resources to integrate feedback

To be successful, programs must ensure that there are time, resources, and processes to meaningfully include the feedback provided by community stakeholders in program planning and development.

Local government stakeholders have reported that this can be a challenge amidst the many competing priorities that are required to launch and implement new programs. In New York City, a representative from the Mayor’s Office of Community Mental Health (OCMH) explained how the planning of the Behavioral Health Emergency Assistance Response Division (B-HEARD) pilot was on a short timeline to launch the program.¹⁶ OCMH representatives highlighted that advocates, experts, and community members were involved in the planning process for the B-HEARD pilot, but OCMH did not have the ability to meet with as many community advocates as they would have liked prior to the pilot program’s launch.¹⁷

Local challenges point to the need for collaboration processes that are clearly structured and well-resourced. Chacku Mathai, an ex-patient advocate and board member for the National Association for Rights Protection and Advocacy (NARPA), shared the insight that “the need to get money out the door oftentimes supersedes the quality of how to get that money out of the door” for government procurement processes; community involvement and racial equity concerns can become an afterthought as a result.¹⁸ Shannon Scully, the senior advisor for justice and crisis response policy at the National Alliance on Mental Illness (NAMI), added “what we always know about collaboration efforts is, if it's not funded, it's really kind of hard to keep people there continuing to do the work, because it tends to be the thing that falls to a lesser priority because people aren't paid to be there.”¹⁹

As these examples illustrate, community engagement and collaboration cannot be an afterthought in the planning process; this work requires resources and time to be successful.

Read More

Hesitancy, skepticism, and fear of calling 911 are prevalent in Black and other communities of color.²⁰ Built in the aftermath of civil rights protests in the late 1960s, the centralized 911 system we know today can trace its history to the Kerner Report, which envisioned it as one way to increase the deployment of police to quell civil unrest in Black communities.²¹ In the decades since, 911 has become an extension of a public safety system that perpetuates racial injustice and a tool that has entrenched police as the first—and often only—responders to nearly every social problem or request for assistance, further criminalizing communities of color. Yet it remains the most visible and widely available resource for emergency response.²²

If someone decides to call 911, there are still several critical decision points that influence whether the person in crisis receives the care they need. Importantly, operators must be able to build interpersonal trust to communicate effectively with callers. This often requires engaging in cultural humility, fostering emotional connection, and navigating language barriers and challenges around immigration status, race, ethnicity, and other features of a caller’s identity.²³

Below, Vera presents recommendations on how to increase the likelihood that people in need will call for crisis assistance and that 911 operators will connect them with the support they need. By July 2022, 988 will be in operation nationwide as a number to call for mental health, substance use, and suicide crises, and there are considerable funding and capacity-building efforts underway to support its implementation.²⁴ These recommendations apply not only to 911 systems, but also to 988 systems.

Key recommendations for increasing access for callers

• Create additional access points beyond 911
• Train and support operators to address communication barriers and gaps in technology

Key recommendations for program criteria, call-taking, and dispatching

• Identify the types of 911 calls that are appropriate for civilian crisis response beyond those narrowly defined as behavioral health crises
• Embed behavioral health experts in 911 call centers
• Refine assessments of safety and violence
• Support operators through program piloting and expansion

Increase access for callers

Create additional access points beyond 911

Many marginalized communities have long been distrustful of police involvement and, by extension, hesitant to call 911. To overcome the fear of a police response, jurisdictions can consider increasing access to mobile crisis responses through crisis lines, non-emergency lines, and other alternative numbers that are disconnected from traditional public safety systems. In Eugene and Springfield, Oregon, CAHOOTS, a mobile crisis intervention program, is accessible via 911, as well as via a 10-digit non-emergency line that is connected to the same communications center.²⁵ Portland Street Response (PSR) is currently only accessible via 911, but a six-month evaluation of the program included a recommendation to provide access for community members via Portland’s 311 number, 988, or another direct line.²⁶

In Rochester, New York, the Person in Crisis (PIC) team is accessible via 911 and through 211, the region’s 24/7 crisis line.²⁷ 211 operators can also make connections and referrals to all of the city’s local health and human services.²⁸ By partnering with the existing 211 system, operators can assess whether PIC is the most appropriate response, whether other community-based health and social services are more appropriate, and whether to transfer the call to 911 if there are more immediate health and safety risks.²⁹ PIC has focused on publicizing and raising awareness of 211 as the number to call for PIC because, as former Commissioner Daniele Lyman-Torres explained, “[people feel that] no matter what they do or no matter what they say, they end up with the police . . . and people don’t want the police [to respond].”³⁰

Read More

Train and support operators to address communication barriers and gaps in technology

Callers may face communication barriers navigating 911 systems and crisis lines that are not tailored to serve their needs.

Daniela Hernández Chong Cuy, an immigration lawyer and mental health advocate, emphasized that communicating the nuance of a crisis situation can be very challenging for those who did not learn English as their first language: “[W]e have a particular language to speak about these mental and emotional states that, when it’s not your first language, it can be a huge issue.”³¹ Pat Strode, a leader of Crisis Intervention Team (CIT) programs and trainings in Georgia, explained that their 911 operator trainings have included a focus on navigating language barriers, “how to listen to the emotions and ask questions based on the emotions that they hear, versus sometimes the words that they hear, because people may not have the vocabulary to articulate exactly what it is they need.”³²

Advocates have also noted where gaps in technology and infrastructure can contribute to inequity in access and outcomes. For example, Toronto’s Reach Out Response Network consulted Deaf community members on how they would like to be able to access crisis response services; they recommended that services be available through multiple avenues, including text, video relay, or via an app.³³ Video relay calls establish three-way video links between 911 callers, an ASL communication assistant, and the 911 operators.³⁴ Such calls require access to the technology for the caller and training for 911 operators. Similarly, even though text-to-911 capability is expanding, there are gaps in coverage across the United States.³⁵ Importantly, advocates have successfully pushed for texting capability to be a requirement for the upcoming national implementation of 988.³⁶

Read More

Program criteria, call-taking, and dispatching

Identify the types of 911 calls that are appropriate for civilian crisis response beyond those narrowly defined as behavioral health crises

Vera’s analysis of publicly available 911 call data, spanning nine cities and more than 23 million calls, suggests that an average of 19 percent of calls for service could be handled by unarmed civilian crisis response programs.³⁷

Communities that are implementing crisis response programs must define which call types their program teams should be dispatched to. Importantly, many calls that might not meet a jurisdiction’s criteria to be considered a “behavioral health crisis” might still involve an underlying behavioral health need—call types involving “disorderly behavior,” for example.³⁸ Broadening the criteria for crisis response effectively narrows the scope of police response, a common goal of civilian crisis response programs, and increases access to unarmed responders. To inform this process, jurisdictions should undertake an expansive assessment of their 911 call data. This analysis can also be used to refine the screening questions and protocols 911 operators follow.

The Community Assistance Life Liaison (CALL) program in St. Petersburg, Florida, has adopted this expansive and data-driven approach. Indeed, about 30 percent of calls the program responds to are not coded as mental health–related; rather, they are calls concerning nuisance complaints (related to issues such as panhandling and homelessness), neighborly disputes, and child/juvenile matters. These are calls that often involve an underlying mental health condition.³⁹ The chief of the St. Petersburg Police Department, Anthony Holloway, championed the decision to include a broader range of calls for service than other crisis response programs. Chief Holloway operated from the assumption that community members use 911 as a 24/7 general assistance line and may not always want or need police assistance. The department identified high-volume call types that law enforcement officers were ill-suited to address and planned for them to be diverted to CALL.⁴⁰

Read More

Embed behavioral health experts in 911 call centers

Identifying and triaging behavioral health–related calls is a key part of how 911 operators can contribute to more effective and equitable crisis responses. However, one recent survey of 911 call centers revealed that the majority of 911 operators do not receive specialized training to handle behavioral health crisis calls or have access to behavioral health experts.⁴¹ Of the call centers that implemented specialized crisis training, more than three-quarters were in regions where at least 75 percent of the population is white.⁴²

Call centers with embedded behavioral health experts—Harris County, Texas, and Phoenix, Arizona, for example—have seen improvements in the appropriate triaging of behavioral health–related 911 calls.⁴³ Former Commissioner Lyman-Torres, who oversaw the PIC team in Rochester, has advocated for embedding clinicians in call centers and notes that mental health professionals can play a role in defining the types of calls that are coded as “violent” in the first place, undoing the harms caused by the stigmatization of mental illness and other biases.⁴⁴

Ultimately, embedding behavioral health clinicians in call centers could drive culture change in dispatching. It would promote greater attention to the specific behaviors displayed by people in crisis rather than assessments that they are “violent” or “dangerous,” which disproportionately impact people of color.⁴⁵

Read More

Refine assessments of safety and violence

911 and crisis line operators are tasked with assessing risk in all the calls they receive, including behavioral health crisis calls. Operators must assess the risk of the caller harming themselves or others on scene, including the first responders. As such, dispatching systems nationwide must create protocols that determine whether the risk of violence or harm merits sending an armed first response.⁴⁶ These considerations are critical to ensure calls are resolved as safely as possible.

Risk determinations are critical decision points that can introduce bias and inequity. Some 911 operators may be more alarmist than others when processing the same types of calls.⁴⁷ The race and class of a neighborhood or subject of a call can shape the level of risk both 911 callers and 911 operators perceive.⁴⁸ Crisis response programs, therefore, face a challenge: dispatchers may be less likely to send alternative responses to neighborhoods that are subject to an intensive police presence and that are most in need of non-police responses.⁴⁹ Screening protocols may inadvertently reproduce these inequities. For example, 911 dispatchers in St. Petersburg have implemented a series of screening questions to ensure that the calls triaged to CALL are limited to nonviolent matters and that the people involved do not have active warrants. CALL program manager Megan McGee recognizes this is most likely to affect people who are from overpoliced communities and acknowledged that it is a practice that could perpetuate racial inequities.⁵⁰ CALL has collected program data throughout its nine-month pilot and has partnered with a local university to evaluate its operations and identify processes that may contribute to inequity.⁵¹

The appropriate dispatch of calls by 911 operators has been an early implementation challenge for the B-HEARD program in New York City.⁵² Jason Hansman of the Mayor‘s Office of Community Mental Health (OCMH) explained that assessing risk of violence can be a key issue for operators: “What is your definition of violence versus someone else's definition of it?”⁵³ To support operators, OCMH is regularly reviewing call logs and dispatch decisions and providing operators with coaching, support, and re-training on how to implement protocols. Hansman notes that, while independent judgement by operators will always be a core feature of 911 triage, programs can work to identify recurring patterns in call types and situations that should receive a civilian response.⁵⁴

Read More

Support operators through program piloting and expansion

Many crisis response programs start as smaller-scale pilots that are restricted to specific geographic areas and/or specific times and days. Eventually, these programs may scale up their capacity to serve the entire community over a greater number of hours and days. Pilot programs often launch in neighborhoods with a high volume of behavioral health-related 911 calls. Although this is an opportunity to get resources to those most in need, it also presents logistical and management challenges. To be successful, 911 operators must have clear protocols, training, and support on how and when to dispatch crisis response teams throughout different phases of program implementation.

For example, San Francisco’s Street Crisis Response Team (SCRT) launched in November 2020 with one team available 12 hours per day in the city’s Tenderloin area. The program added a second team serving the Mission-Castro neighborhood in February 2021 and four more teams later that year to achieve city-wide and overnight coverage.⁵⁵ Each phase of SCRT’s expansion was paired with updated decision trees and protocols to guide operators in dispatching calls to the new program.⁵⁶

Read More

Many communities have made progress in reducing police involvement in crisis response, but there remains no clear consensus around exactly who, if not police, should be answering 911 calls involving behavioral health needs.⁵⁷

Experts caution against the notion that replacing police alone will eliminate inequities arising from interactions between first responders and people in crisis. “We know that there’s a huge amount of bias within the mental health system as well, so the danger is still there,” explained Amy Watson, professor of social work at the University of Wisconsin-Milwaukee. She pointed to the potential for bias in how responders interpret a situation, interact with a person in crisis, assess that person’s needs, and rely on involuntary hospitalization to connect them to care.⁵⁸ In fact, Black people are disproportionately subject to such coercive mechanisms, which can exacerbate trauma and sow distrust in the very services and supports meant to facilitate recovery.⁵⁹ Vinnie Cervantes, organizing director with the Denver Alliance for Street Health Response, stressed the importance of crisis responders who have lived experience with behavioral health concerns and reflect the communities they serve.⁶⁰ The behavioral health workforce is still disproportionately white, and a preference for professional designations such as licensed clinicians may present barriers to employing more people with lived experience in both frontline and leadership roles.⁶¹

Hiring

Civilian crisis response programs are taking shape against a backdrop of workforce shortages and the underrepresentation of people of color and people with lived experience (known as “peers”) across the behavioral health field. As local stakeholders navigate these challenges, strategic hiring will play an important role in meeting community needs.

Key recommendations

• Recruit responders who reflect the communities they serve
• Focus on skills and experience
• Integrate peers into crisis response

Recruit responders who reflect the communities they serve

Jurisdictions have pursued a variety of strategies to assemble teams that reflect the communities they serve. The Person in Crisis (PIC) Team in Rochester, New York, launched in January 2021 out of the Department of Recreation and Human Services (DRHS). It was developed amid community demands for “culturally competent health professionals” as an alternative to police.⁶² As such, the program made residency in the city, which is about 40 percent Black, a prerequisite for employment.⁶³ Daniele Lyman-Torres, former commissioner of DRHS, explained that they needed staff who have “cultural understanding and relevance . . . as opposed to being afraid to drive down the street, or any street in the city, which our suburban counterparts are [afraid to do].”⁶⁴ She noted that Rochester successfully realized its goal of creating a PIC Team that is largely made up of clinicians of color. To illustrate the importance of this, Lyman-Torres recounted a 911 call in which a white clinician suggested that his Black male client was violent and needed to be involuntarily hospitalized. Although multiple police cars were directed to the scene, a PIC Team clinician—who is a Black man and was simultaneously dispatched—was able to engage and connect the community member to treatment “without any issue.”⁶⁵ The Community Assistance and Life Liaison (CALL) program in St. Petersburg, Florida, initially struggled to attract a diverse pool of candidates and ultimately expanded its hiring process to surrounding cities to recruit more responders of color.⁶⁶ CALL’s other strategies included placing employment ads in more than 70 local newspapers, hosting community meetings, and connecting with smaller neighborhood associations.

Read More

Focus on skills and experience

Recruitment for civilian response teams requires careful consideration of the specific skills and experience that the program work demands and recognition that these might not be reflected in formal qualifications. For example, the CALL program does not require that most staff have a master’s-level education. The program’s 12 frontline “navigators” have bachelor’s degrees, and they are supported and supervised by five licensed clinicians. As Special Projects Manager Megan McGee explained, “I wanted to make sure we had a balance of the doers, the clinical, and . . . have them working together so we could really be effective.”⁶⁷

The Crisis Response Unit (CRU) in Olympia, Washington, pursued a similar approach to its new hires when expanding in 2021. According to former Outreach Services Coordinator Anne Larsen, rather than prioritizing candidates with professional degrees, the program asked candidates questions that were focused on “getting to the root of . . . who’s the population we serve, what’s the work that this person is going to be doing.”⁶⁸ Larsen noted that CRU experienced success building a more racially and ethnically diverse staff this way.

Read More

Integrate peers into crisis response

According to the Substance Abuse and Mental Health Services Administration, incorporating peers—people with lived experience of behavioral health conditions and crises—is a best practice for crisis services and systems.⁶⁹ Peers can use their skills and experience to establish rapport and strengthen engagement with people in crisis and support follow-up beyond the immediate crisis.⁷⁰ Although peers are increasingly being integrated across behavioral health systems, experts have noted the need to increase peer workforce salaries, improve supervision and career trajectories, and ensure that peers are integrated in ways that fully use their skill sets.⁷¹

San Francisco’s Street Crisis Response Team (SCRT) sends three-person teams to respond to people in crisis: a paramedic, a behavioral health clinician, and a behavioral health peer specialist.⁷² The peer specialist is employed by Richmond Area Multi-Services (RAMS), Inc., a contracted service provider that is a local leader in peer-based services.⁷³ SCRT leadership and staff report that the inclusion of peers contributes to the team’s ability to respond with a wide range of skills, experience, and approaches to people in crisis.⁷⁴ Simon Pang, section chief of community paramedicine for the San Francisco Fire Department, has stated that including a peer specialist in SCRT is “the gold standard for trauma-informed care.”⁷⁵ And according to Michael Marchiselli: “As a [SCRT] peer specialist, I can relate to people that are in a crisis and also I can understand people’s distrust with institutions and in turn, offer a different approach.”⁷⁶

Role definition is an ongoing challenge for the peer workforce. Toronto’s Reach Out Response Network suggests that “effective integration of peer workers . . . requires a balance between role flexibility and role clarity,” and programs must ensure that peers are not relegated to limited or inappropriate roles.⁷⁷ For example, assigning peers the responsibility of sitting with a person while they wait for clinical intervention is an example of underutilizing peers’ skills if it denies them other, more dynamic opportunities for interpersonal connection.⁷⁸

Read More

Professional development

Crisis response programs may require collaboration across different organizations and team members with different skills, experiences, and professional backgrounds. Joint training can be an important way for teams to strengthen their shared knowledge and skills. Training can also strengthen competencies for working with BIPOC and other equity-deserving communities, to support more effective service delivery for people in crisis.⁷⁹

Key recommendations

• Conduct joint trainings for multidisciplinary teams
• Improve cultural competence and responsive practice

Conduct joint trainings for multidisciplinary teams

Crisis response teams often include people from multiple disciplines because of the range of interventions that may be needed—including de-escalation, peer support, non-emergency medical care, and clinical assessment. This can be challenging when team members bring different tactics to a scene.

Program leaders recommend designing training programs with this challenge in mind. For example, San Francisco’s Street Crisis Response Team (SCRT), with its three-person team of a paramedic, clinician, and peer specialist, has emphasized the importance of joint training to support cohesion and collaboration when they are in the field.⁸⁰ SCRT leadership have noted that some team members have been used to being the primary decision-makers on scene and have had to enhance their skills in “sharing the remote” in SCRT’s more collaborative, interdisciplinary approach.⁸¹ Meanwhile, New York City’s B-HEARD program dispatches teams of emergency medical technicians/paramedics and social workers to 911 mental health calls. B-HEARD’s five-week training during the pilot phase included joint, experiential, scenario-based learning and sharing of skills across the team’s different disciplines.⁸²

Read More

Improve cultural competence and responsive practice

Everyone has implicit biases.⁸³ For crisis responders, these biases have the potential to adversely alter the substance and quality of the services they deliver.⁸⁴ Research suggests that the impact of implicit bias trainings as conventionally implemented is limited.⁸⁵ However, civilian-led teams that aim to reduce police involvement in crisis situations must account for their biases and find ways to provide culturally responsive interventions.

Local experts report that providing training on implicit bias, cultural competence, and related topics is a meaningful step toward providing equitable responses. B-HEARD team members, during the pilot phase, participated in a two-day training on racial equity and implicit bias—though a program leader cautioned that this kind of professional development should not be a one-off event.⁸⁶ St. Petersburg made the provision of implicit bias training a prerequisite for behavioral health organizations interested in staffing the CALL program, and Portland Street Response has planned additional trainings for team members on working with BIPOC communities, immigrant communities, as well as LGBTQ+ people, veterans, and more.⁸⁷ As more and more places navigate the early stages of program planning and implementation, they have a rare opportunity to establish a professional development paradigm that promotes equity by design.

Read More

The majority of people of color in the behavioral health workforce fill non-licensed, lower-level positions that lack opportunities for career advancement.⁸⁸ Moreover, low wages and a high demand for services contribute to burnout and turnover, which hinders patient access to high-quality care.⁸⁹ These workforce challenges can undermine the sustainability and growth of civilian response programs. Even in Eugene, Oregon, where CAHOOTS has operated out of the White Bird Clinic for more than 30 years, staff have said the program must secure greater funds from the city to provide a “reasonable wage” that reduces turnover before expanding further.⁹⁰

Jurisdictions must properly compensate frontline responders and adequately fund entities that are trusted by community members to lead these responses. This might mean housing programs in existing or newly created government agencies or contracting with community-based organizations to operate and staff these initiatives. In either case, local governments should be involved in program development efforts, focusing on strong stakeholder coordination and promoting equitable service delivery.

Key recommendations

• Provide competitive pay
• Structure program governance to promote adaptability, autonomy, and trust

Provide competitive pay

Civilian crisis responders typically do not receive compensation that is comparable with law enforcement. For example, CAHOOTS responders answered almost 17 percent of calls to Eugene’s emergency communications center in 2019, saving $2.2 million per year in officer wages.⁹¹ However, while “[CAHOOTS] team members start at $18/hour with no established path to an increase” according to a CAHOOTS press release, Eugene police officers earn no less than $30 an hour with greater opportunities for career advancement.⁹² Although there is community demand for continued expansion, CAHOOTS leaders have said the program must first renegotiate its contract with the City of Eugene to cover higher base wages that promote staff retention.⁹³ Currently, “staff generally build skills within the program and then move on to other professions that pay a wage commensurate to their skillset.”⁹⁴

One way to secure competitive compensation for crisis response staff is to make them employees of a government agency; as explored below, however, such decisions raise equity concerns of their own.

Anne Larsen, who previously oversaw the Crisis Response Unit (CRU) and Familiar Faces program in Olympia, Washington, has advocated for increased wages for civilian crisis responders.⁹⁵ The Olympia Police Department (OPD) initially contracted with behavioral health organizations to staff both programs, but Larsen grew concerned that these specialists lacked pathways to wage increases.⁹⁶ According to Larsen, when jurisdictions seek contractors to staff a community response program, “they always look at the budget” and “an agency is going to want to win by . . . lowballing.”⁹⁷ With this concern in mind, Olympia made CRU members city employees and approved new funding for the previously grant-supported Familiar Faces to join city operations, enabling the city to increase staff wages.⁹⁸ Larsen said the transition also provided greater job security for staff by insulating them from the city contracting process, through which positions may be more easily cut.⁹⁹

Jurisdictions may house their civilian response program in a government agency from the outset to address pay equity and job security concerns proactively. For example, Portland, Oregon’s Portland Street Response (PSR) was embedded within Portland Fire & Rescue ahead of the program’s pilot launch. Commissioner Jo Ann Hardesty, who oversees the city agency, explained in the Portland Tribune that PSR was structured this way “to institutionalize Portland Street Response so it can’t disappear on a political whim; to create living-wage positions with solid benefits; and to ensure that the jobs would be stable so turnover would be minimal . . . leading to better outcomes for all involved.”¹⁰⁰ When several city leaders raised the possibility of outsourcing the program to a nonprofit organization with lower staffing expenses, PSR staff responded with an open letter that described the meaning and value of an adequate wage.¹⁰¹ After a six-month evaluation highlighted PSR’s success, the City Council passed additional funds for the program’s citywide expansion and, ultimately, kept it embedded within Portland Fire & Rescue.¹⁰²

Read More

Structure program governance to promote adaptability, autonomy, and trust

The choice to embed crisis response programs in a government agency or non-governmental contractor has implications for antiracism and equity, such as whether or not a program has access to resources and infrastructure and the degree to which a program is trusted and respected by community members. In every jurisdiction, local government has an essential role to play in working toward equity, and the preferred model for program governance and service delivery may vary based on the local context and capacity.

Situating a program in a government agency can bring various benefits beyond improvements to pay and retention. Local program leaders report that it can facilitate access to greater resources, supplies, and advancement opportunities, and reduce overhead expenses.¹⁰³ Moreover, the ability of a government-operated program to use lights and sirens in rare cases may empower civilian responders to take on some particularly urgent calls that would otherwise receive status quo emergency responses.¹⁰⁴ The potential benefits of situating crisis response programs within existing government agencies likely depend on the current capacity and infrastructure of those agencies.¹⁰⁵

Yet the specific placement within government of a civilian response program can come with risks. Researchers Taleed El-Sabawi and Jennifer Carroll caution that programs housed under the “public safety arm” of local government may be “co-opted” and become “yet another law enforcement-led response.”¹⁰⁶ Even non-law enforcement entities—such as county health and social service agencies—have historically treated the populations they serve “paternalistically” and left them “feeling marginalized,” partly due to their close collaboration with the criminal legal system.¹⁰⁷

Local program stakeholders within government agencies acknowledged this tension. For example, Megan McGee, special projects manager with the St. Petersburg Police Department, said she was “not particularly in favor of developing an internal unit” within her agency because she “did not want something that was viewed as an extension of law enforcement.”¹⁰⁸ Rather than operating a new initiative out of the police department, St. Petersburg contracted with a behavioral health organization to staff its Community Assistance and Life Liaison (CALL) program.¹⁰⁹

Some advocates have likewise proposed funding community-based organizations to build trust in programs. For example, the New York City coalition Correct Crisis Intervention Today (CCIT-NYC) has said the city should contract with “community groups of color” for civilian crisis response, in contrast with B-HEARD’s current structure.¹¹⁰ After reviewing recommendations from the “Crisis Response Stakeholder Group” it convened, Allegheny County, Pennsylvania, announced that its solicitations for expanding and diversifying crisis services would “be explicit in seeking to attract organizations led by, operated by and serving people from groups experiencing the worst outcomes from our crisis systems, especially [B]lack and LGBTQ community members.”¹¹¹ Additionally, Toronto is launching four distinct pilot programs in 2022 that the city will contract with different community organizations to operate.¹¹² Asante Haughton, a Toronto-based mental health advocate and co-founder of the Reach Out Response Network (RORN), explains: “It made sense to connect with agencies already serving [Toronto’s diverse] communities because they had established rapport, were more culturally competent and appropriate.”¹¹³

In an effort to overcome distrust in existing responses, other local governments have established new agencies to spearhead civilian-led initiatives. For example, the city of Albuquerque, New Mexico, created Albuquerque Community Safety (ACS), a standalone department that began providing non-police responses to behavioral health crises in September 2021.¹¹⁴ Although ACS coordinates with police, as a result of community feedback, the agency’s responders collect personal information from clients using separate forms that police cannot access.¹¹⁵ Additional cities, from Sacramento, California, to Northampton and Cambridge, Massachusetts, have advanced similar plans to operate programs out of newly created government departments.¹¹⁶

As jurisdictions assess where to house a civilian response program, they should consider the equity and sustainability implications of operating initiatives out of newly created government departments or existing government agencies, and the role of contracted community-based organizations. Local stakeholders should consider the potential impact of local political cycles on a program’s sustainability, as well as the capacity of existing community-based organizations to deliver services aligned with the program’s goals. Regardless of where new response initiatives are ultimately housed, local governments have an essential role to play in facilitating the effective coordination and equitable implementation of crisis response services.

Read More

When someone experiences a behavioral health crisis, people might be hesitant to call 911 when armed responders are sent by default. This is particularly true in communities of color and LGBTQ+ communities where people have been disproportionately arrested, incarcerated, and subjected to state violence.¹¹⁷

Such hesitancy extends beyond policing, with profound implications for crisis response. People of color are less likely than white people to trust medical institutions and physicians more generally.¹¹⁸ Among Black people, this distrust can be attributed, at least in part, to historical and contemporary discrimination by the U.S. medical establishment, disproportionate use of involuntary hospitalization, and ongoing disparities in health outcomes.¹¹⁹ Latinx people similarly confront legacies of harm committed by the medical establishment—such as eugenics-based sterilization in Puerto Rico in the aftermath of Law 116—and today face disparities in access to high-quality, culturally responsive care.¹²⁰ Many other communities also experience discrimination and must overcome unique obstacles to receive the support they need. For example, trans people face persistent barriers to gender-affirming care, and in some places, experiencing a mental health crisis that results in involuntary commitment may foreclose future opportunities to access this life-saving treatment entirely.¹²¹

Amid this widespread distrust, grassroots efforts have taken shape to support people with unmet behavioral health needs. Grassroots organizations like the Black Emotional and Mental Health Collective, Anti Police-Terror Project, Call BlackLine, Trans Lifeline, Project LETS, and others have helped people overcome barriers to care, particularly among BIPOC communities, by providing them with crisis services and peer support in the absence of trusted institutional responses. Jurisdictions should look to these efforts and strive to develop programs that honor the concerns and expertise of grassroots crisis responders.

Key recommendations

• Acknowledge and address distrust in system-based call centers
• Acknowledge and address distrust in system-based responses

Acknowledge and address distrust in system-based call centers

In a crisis situation, the decision to call someone for help can be complicated not only by distrust in 911 but also by distrust in crisis lines because of the possibility that police might still show up.¹²² For example, although the National Suicide Prevention Lifeline directs crisis center staff to use “the least invasive intervention” possible, it also requires the initiation of an “active rescue” for people who staff determine are “unwilling and/or unable to take action to prevent [their] suicide” and who remain at imminent risk.¹²³ Often, in the absence of civilian responders who are unarmed and specially trained in de-escalation, this means having police respond to people in crisis without their consent.¹²⁴

Local crisis systems should consider how grassroots hotlines have tailored their approaches to address the concern among callers that they will receive a police response. For example, Trans Lifeline, which provides trans peer support to callers in the United States and Canada, says one of its “unwavering principles” is that it will “not call emergency services to assist a caller in danger without their request.”¹²⁵ The organization cites, among other concerns, the risks associated with police involvement, the potential consequences for young trans callers who may not be out to their families, and the possibility that an involuntary commitment will preclude them from receiving gender-affirming medical treatment in the future.¹²⁶

Similarly, Call BlackLine, which focuses on providing peer support and counseling by phone for BIPOC communities across the country, does not call the police as a matter of policy.¹²⁷ Vanessa Green, the organization’s founder, said that in cases involving acute crises, Call BlackLine’s operators will try to connect callers with mobile crisis teams where they are available.¹²⁸

As jurisdictions work to transform their crisis systems, they should continue to minimize the use of nonconsensual active rescues. Moreover, 911 and 988 staff should collaboratively determine how to maximize the use of local civilian responders rather than police when operators do initiate these interventions.

Read More

Acknowledge and address distrust in system-based responses

Some advocates have expressed concerns that government-based or government-adjacent civilian response programs might engage with people in crisis in ways that perpetuate distrust. For example, programs like CAHOOTS in Eugene, Oregon, still work with police and sometimes call them for backup.¹²⁹ Some civilian responders, like police, also have the power to involuntarily hospitalize—”psychiatrically incarcerate”—people in crisis, and in some cases they may be required to do so because of reporting requirements associated with their profession.¹³⁰ These responses can violate trust and exacerbate trauma.¹³¹ Grassroots, peer-led initiatives strive to develop crisis response approaches that minimize these harmful outcomes.¹³² For example, Project LETS trains crisis responders on how to “maximize [client] consent” and builds peer-led responses without the ability to involuntarily hospitalize people in crisis.¹³³ However, system-based programs may also build trust by clearly communicating their policies and protocols concerning police involvement and involuntary hospitalization.

Local governments that are developing new crisis response systems should develop programs that complement the vision of existing grassroots responses. For example, in Sacramento and Oakland, California, the Anti Police-Terror Project (APTP) launched local, volunteer-run “Mental Health First” programs to provide a non-police response to community members in crisis.¹³⁴ In 2021, the Oakland City Council passed a resolution—with the support of APTP advocates and their allies—that embedded a new crisis response program in the Fire Department and asserted that it would “center the input” from Oakland’s “most impacted communities.”¹³⁵

In Sacramento, however, City Council plans to open a Department of Community Response were met with concern from APTP co-founder Asantewaa Boykin regarding the continued involvement of police.¹³⁶ Advocates have also criticized the planning process for lacking sufficient community input.¹³⁷

Read More

Data should inform all stages of program implementation for crisis response programs, from the earliest stages of planning to ongoing monitoring and evaluation once a program launches. Collecting and using data is critical to understand what’s working well and how programs can improve and adapt throughout the process of implementation. Data should be collected, analyzed, and shared regularly with program stakeholders, including community advocates and groups tasked with oversight.

Effective data collection will help identify where there are gaps in access and delivery to ensure more equitable implementation and outcomes.

Key recommendations

• Track key performance metrics to evaluate for equity
• Collect feedback from a wide range of stakeholders
• Regularly share data and evaluation updates with program and community stakeholders

Track key performance metrics to evaluate for equity

Crisis response programs should collect data on key performance metrics to evaluate if the program is achieving its intended goals and to identify areas for improvement.

Some key metrics may relate to the calls that are being responded to, for example:

• volume of calls;
• origin of calls; and
• call types.

Other key metrics may relate to the on-scene crisis response and the interactions and outcomes of the response, for example:

• response time and time on-scene;
• types of services and supports offered;
• post-crisis follow-up;
• transporting and/or completing referrals to other services;
• involuntary mental health holds or transport; and
• calls that result in police involvement.¹³⁸

Metrics on the presence of police at crisis incidents—whether dispatched by call operators or requested by the response team—and the use of involuntary hospitalization are especially crucial for transparency with community members who are concerned about these outcomes.

For all metrics and outcomes tracked, programs should collect information about the clients they serve, to identify any gaps in access and outcomes. Key information includes:

• race and ethnicity;
• gender;
• mental health needs;
• substance use needs;
• other health needs; and
• other basic needs, such as housing.

Some crisis response programs have adopted a focus on antiracism and equity as part of their data collection and evaluation strategies.¹³⁹ For example, in San Francisco, the Street Crisis Response Team (SCRT) has stated that “each measured outcome, such as linkage to care, [police] involvement, and 5150 involuntary holds, will be measured for its ability to reduce disparities by race, ethnicity, gender identity and sexual orientation to the extent the data allow.”¹⁴⁰

In practice, programs have encountered challenges in collecting this information in consistent and client-centered ways. For Denver’s Support Team Assisted Response (STAR) program, advocates have been frustrated that race/ethnicity was recorded as unknown for more than 30 percent of clients served in its first six months.¹⁴¹ Greg Townley, the lead evaluator for Portland Street Response (PSR), explained that it can be difficult for program staff to collect this information in the field and that staff have been uneasy about making assumptions as to a client’s mental health or substance use needs or demographic characteristics in instances in which clients are not able to report it themselves.¹⁴²

Asante Haughton of Toronto’s Reach Out Response Network (RORN) noted that being asked to share one’s demographics and disability status can be very uncomfortable for some community members, and crisis responders should always ask for this information in a trauma-informed way.¹⁴³ Rachel Bromberg of RORN shared a helpful suggestion: “perceived race might be noted, and might be easier to note, because that's really what we care about.”¹⁴⁴ PSR’s six-month evaluation similarly recommended “noting whether or not the client is a person of color based on visual identification (which is likely already occurring internally or subconsciously).” The evaluators acknowledged “the limitation of this approach but believe it is a critical step toward enhancing our understanding of who the program is (or is not) serving.”¹⁴⁵

Another potential solution: programs that are connected to health and human services systems may be able to fill in missing demographic information from other databases for clients who have accessed services in the past and consented to data sharing.¹⁴⁶

In terms of tracking who is calling for help, 911 call centers do not collect demographic information about callers. However, if the location of calls can be tracked and analyzed, this may provide information about which neighborhoods are or are not receiving timely, appropriate responses.¹⁴⁷ As discussed earlier, inequity may be introduced by screening questions, dispatch protocols, and the implicit biases of operators.

Read More

Collect feedback from a wide range of stakeholders

In every community, there is a range of different stakeholder groups who will have important feedback on the implementation of a crisis response program. Arguably the most important group is community members who are directly served by the crisis response program. Other important groups to gather feedback from include community members who are calling for help for someone else (such as family members and friends, business owners and residents, and other service providers), operational partners (such as 911 and other first responders), and program staff.

In Portland, Oregon, the evaluators of the PSR program use interviews and surveys to gather feedback from clients and other community stakeholders. Acknowledging that it would not be appropriate to seek feedback from clients during or right after the moment of crisis, the team developed the following approaches.

• Interviews: PSR staff asks clients if they are willing to be interviewed and refers them to the evaluation team. The evaluation team then interviews clients at the time and place of their preference, “after they [have] had some time to process what happened.”¹⁴⁸ The interviews are used to gather clients’ feedback regarding their experiences with the PSR response and any follow-up services.
• Surveys: Street Roots, the local community organization that campaigned for the creation of PSR, helped develop and conduct a survey of unhoused community members. The survey included people who had been directly served by PSR and those who had not, and asked about their experiences with 911, PSR, and other first responders. These surveys generated valuable information about whether community members feel safe calling 911 and whether they are aware of PSR as a resource. The surveys collected demographic information and revealed that white community members were more aware of PSR than people of color, which has helped PSR understand the need for further outreach.¹⁴⁹

Post-call surveys are one tool that crisis response programs can use to gather feedback from community members. Post-call surveys can be very brief, asking callers about their satisfaction with the experience of calling for help and the services and support provided. They can also collect demographic and geographic information that can be reviewed to identify disparities in caller experiences.¹⁵⁰

Feedback from program staff is also essential for ongoing implementation and adaptation of programs. This could be a part of a formal program evaluation or part of regular team practice, facilitated by leadership and staff. Interviews, focus groups, and ride-alongs with staff were a key component of PSR’s evaluation. They informed some important considerations and recommendations for program expansion and sustainability, such as the types of calls and level of risk that PSR staff feel comfortable taking on and the need for support and supervision to avoid burnout and compassion fatigue.¹⁵¹ In Olympia, Washington, feedback from Crisis Response Unit (CRU) and Familiar Faces program team members informed the evolution of the staffing structure, leading to the addition of a nurse and a designated crisis responder to better serve client needs.¹⁵²

Read More

Regularly share data and evaluation updates with program and community stakeholders

Programs should provide regular updates to key stakeholders who are in positions to learn from and implement changes based on program data. These stakeholders may include program staff and leadership, as well as government officials who may have decision-making power over program expansion and funding.

Crucially, data and evaluation updates should also be shared with the public, community advocates, and any advisory and oversight groups—something that advocates in many communities have specifically called for.¹⁵³

Many programs have committed to publishing regular reports with data on their key performance metrics; for example, Portland Street Response maintains a dashboard that is updated on a weekly basis; San Francisco’s SCRT provides monthly summaries of its key performance indicators; and New York City’s B-HEARD has provided summaries at one, three, and six months to date.¹⁵⁴

Updates to stakeholders should include qualitative data, in addition to the quantitative metrics, to provide the full context of the program’s impact.¹⁵⁵ This can help prevent people forming overly simplistic conclusions based on a few data points.

A robust, comprehensive approach to data collection and evaluation requires resources. Portland Street Response has benefited from contracting with Portland State University researchers and Street Roots to conduct its program evaluation, as well as budgeting for gift cards to compensate community members’ time for completing surveys and interviews.¹⁵⁶ San Francisco’s SCRT secured additional grant funding to engage external research partners and complete a rigorous evaluation, including longer-term outcomes, post-crisis.¹⁵⁷ Depending on where a program is housed and how it is funded, access to resources for data collection and evaluation may be more limited.¹⁵⁸ For those designing and funding crisis response programs, this is an important piece to plan for early on.

Read More

Crisis response programs should implement processes for community oversight to facilitate accountability and ensure that programs continue to meet the needs of the community members they aim to serve. Approaches to community oversight can build on the principles and practices for community collaboration.

Key recommendations

• Establish mechanisms for ongoing feedback and accountability
• Attend to ongoing community advocacy

Establish mechanisms for ongoing feedback and accountability

To be effective, oversight mechanisms for crisis response programs should have some decision-making authority and not simply be advisory.¹⁵⁹ Legal scholar and researcher Taleed El-Sabawi explained that crisis response programs should learn from the experience of police accountability boards: “usually, these [police accountability] boards don't work well because they don't have enough teeth.”¹⁶⁰ Along with her colleague Jennifer J. Carroll, El-Sabawi has recommended that advisory boards for crisis response programs should have the power to approve the program’s implementation (such as its staffing model, dispatch protocols, and data collection and reporting plans) and the distribution of funds for the program.¹⁶¹

Community oversight boards should be active and ongoing participants in program implementation, and they should have the funding, resources, and support necessary to be effective in the community engagement, oversight, and advocacy they are tasked with.¹⁶²

Denver’s Support Team Assisted Response (STAR) program was launched as a one-year pilot in June 2020.¹⁶³ As part of the city-wide expansion plans, the city announced it would form a volunteer-based Community Advisory Committee to “bring a community lens to the STAR program.”¹⁶⁴ However, Vinnie Cervantes, organizing director of the Denver Alliance for Street Health Response (DASHR), believed the city’s approach fell short. DASHR and other advocates, who have stressed that “community ownership” rather than community oversight is the ultimate goal, envisioned an advisory committee that would have an ongoing role in monitoring the implementation of STAR, reviewing program data, and informing plans for expansion.¹⁶⁵ Instead, Cervantes explained, the city made decisions about STAR’s expansion before establishing the advisory committee and did not provide them with timely updates or opportunities for input and decision-making.¹⁶⁶ Excluding oversight boards from expansion planning risks sowing distrust with community partners.

Programs should also be intentional in the composition of the oversight boards they establish. El-Sabawi and Carroll recommend that advisory boards for crisis response programs should be comprised of “at least 51% behavioral healthcare consumers, persons who have experienced or are experiencing houselessness, members of local immigrant communities, sexual minorities, persons with disabilities, and racial or ethnic minorities.”¹⁶⁷ “We really encourage that the board reflect the composition of the community,” El-Sabawi explained.¹⁶⁸ In New York City, the Correct Crisis Intervention Today (CCIT) coalition’s proposal for a peer-driven mental health crisis response program was aligned with this recommendation. The proposal stipulated that the pilot should be monitored by an oversight board with peers from low-income Black, Latinx, and other communities of color, constituting more than half of the board.¹⁶⁹

Read More

Attend to ongoing community advocacy

Crisis response programs should be responsive to community advocacy efforts to improve the accessibility and quality of services offered. This may be particularly critical in communities where formalized opportunities are limited or under resourced.

For example, in Philadelphia, Pennsylvania, advocates from the Treatment Not Trauma Coalition explained how their relationships with supportive city councilmembers have facilitated their participation in advisory groups, committees, and other spaces where city leaders are making decisions about crisis response services.¹⁷⁰ Coalition members shared that, at times, city leadership focuses more on communicating updates than on creating opportunities for input and decision-making; however, coalition members are committed to having a “seat at the table” and continuing to advocate for their vision of crisis response for Philadelphia, asking hard questions and keeping city stakeholders accountable.¹⁷¹

Community advocacy can also help improve the effectiveness of more formalized community collaboration and oversight. In California, county mental health providers have been legally required to facilitate and fund stakeholder-driven planning processes since 2004.¹⁷² However, community members report that Los Angeles County’s stakeholder committees have not always been effective, open spaces and that only recently has the county started to take their feedback into account in meaningful ways. Daniela Hernández Chong Cuy, a Los Angeles-based mental health advocate, explained that this new receptiveness was partly due to “pressure from community-based organizations,” outside of the formal county committees.¹⁷³

Read More

Additional Resources

• Beck, Jackson, Melissa Reuland, and Leah Pope. Behavioral Health Crisis Alternatives: Shifting from Police to Community Responses (New York: Vera Institute of Justice, 2020).
• Council of State Governments Justice Center. “Expanding First Response: A Toolkit for Community Responder Programs.”
• Dholakia, Nazish. The People Responding to 911 Calls Instead of Police (New York: Vera Institute of Justice, 2022).
• El-Sabawi, Taleed, and Jennifer J. Carroll. “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022).
• The Front End Project. From Harm to Health: Centering Racial Equity and Lived Experience in Mental Health Crisis Response (New York: Fountain House, 2021). The Front End Project is a collaboration between Fountain House, the Center for Court Innovation (CCI), The W. Haywood Burns Institute, the Technical Assistance Collaborative (TAC), and the Mental Health Strategic Impact Initiative (S2i).
• Neylon, Kristin. Strategies and Considerations for Providing a More Equitable Crisis Continuum for People of Color in the United States (Alexandria, VA: National Association of State Mental Health Program Directors Research Institute, Inc., 2021).
• Policy Research Associates. “Leveraging the Sequential Intercept Model to Address Diversity, Equity, and Inclusion.” Policy Research Associates, January 12, 2021.
• Usher, Laura, Amy Watson, Ron Bruno, Suzanne Andriukaitis, Don Kamin, Carol Speed, and Sabrina Taylor. Crisis Intervention Team (CIT) Programs: A Best Practice Guide for Transforming Community Responses to Mental Health Crises (Memphis, TN: CIT International, 2019).
• Vera Institute of Justice, Investing in Evidence-Based Alternatives to Policing: Civilian Crisis Response (New York: Vera Institute of Justice, 2021).

Acknowledgments

The authors would like to thank the subject matter experts and program stakeholders whose experiences, insights, and recommendations informed the development of this toolkit. The authors would also like to thank all those who assisted in identifying and connecting them with interviewees: Mary Crowley, Derek Loh, Alex Roth, Tara Dhanraj, Melvin Washington II, Elizabeth Swavola, Amy Cross, Kaitlin Kall, and Sandra Harrell.

The authors would like to thank their colleagues whose crucial contributions helped shape this toolkit: Melissa Reuland, Leah G. Pope, Daniela Gilbert, Caroline Walcott, Sandra van den Heuvel, Nina Siulc, and Jim Parsons. They are grateful to Ed Chung and Cindy Reed for their review and comments. A special thank you to Léon Digard, Maris Mapolski, Abbi Leman, and Jac Arnade-Colwill for their editorial support, and to Jill Hubley, Sara Duell, and Michael Mehler for their contributions to design and creative direction.

Photography by Tina Russell, Justin Katigbak, and Amistad Law Project.

This toolkit has been made possible in part by funding from the NFL Foundation and the NFL’s Inspire Change grant program and the Microsoft Justice Reform Initiative.

For more information, please contact Daniela Gilbert, director, Redefining Public Safety, at dgilbert@vera.org

Endnotes

¹ Vera Institute of Justice, “Arrest Trends”; Vera Institute of Justice, “Incarceration Trends”; and “Fatal Force: Police Shootings Database,” database (Washington, DC: Washington Post, accessed January 10, 2022). See also 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; and John Jay College of Criminal Justice, and National Organization of Black Law Enforcement Executives, Future of Public Safety (New York: John Jay College of Criminal Justice, 2020), 5-8.

² Justin Pickett, Amanda Graham, and Francis T. Cullen, “The American Racial Divide in Fear of the Police,” SocArXiv, April 13, 2021.

³ Brian Sharp, “Daniel Prude: One Year after His Death Became Public Fallout Continues,” Democrat and Chronicle, September 2, 2021; Dean Meminger, “Exclusive: Sister of Mentally Ill Senior Citizen Killed By NYPD Responds to Mayor's New Mental Health Initiative,” Spectrum News NY1, November 11, 2020; Amistad Law Project, “The Fight for Non-Police Responses to Mental Health Calls Continues,” Amistad Law Project, October 13, 2021; and Eric Westervelt, “Mental Health And Police Violence: How Crisis Intervention Teams Are Failing,” WBUR, September 18, 2020.

⁴ Jackson Beck, Melissa Reuland, and Leah Pope, “Behavioral Health Crisis Alternatives: Shifting from Police to Community Responses,” Vera Institute of Justice, November 2020; Vera Institute of Justice, Investing in Evidence-Based Alternatives to Policing: Civilian Crisis Response (New York: Vera Institute of Justice, 2021); and Council of State Governments Justice Center, “Expanding First Response: A Toolkit for Community Responder Programs.”

⁵ Kaitlin Gazi, Paula Verrett, and Keris Myrick, “Lived Experience Engagement and Race Equity: In This Together” (paper presented at the National Alliance on Mental Illness Integrating Peers in Crisis Response Services Webinar, August 10, 2021).

⁶ Rebecca Woolington and Melissa Lewis, “Portland Homeless Accounted For Majority Of Police Arrests In 2017, Analysis Finds,” The Oregonian, updated January 30, 2019.

⁷ Street Roots, “About,” accessed February 3, 2022; and Kaia Sand, “Believe Our Stories and Listen: Perspectives on First Response on the Streets,” Street Roots, September 19, 2019.

⁸ Kaia Sand, “Believe Our Stories and Listen: Perspectives on First Response on the Streets,” Street Roots, September 19, 2019.

⁹ Kaia Sand, “Believe Our Stories and Listen: Perspectives on First Response on the Streets,” Street Roots, September 19, 2019; and Greg Townley, Kaia Sand, and Thea Kindschuh, Believe Our Stories and Listen: Portland Street Response Survey Report (Portland, OR: Portland Street Response Community Outreach Workgroup, 2019).

¹⁰ Kaia Sand, “Believe Our Stories and Listen: Perspectives on First Response on the Streets,” Street Roots, September 19, 2019. For an overview of the community engagement work group’s goals and activities, see The Justice Collaborative Policing Task Force, Developing a Community-Based Emergency First Responders (EFR) Program (San Francisco: The Justice Collaborative Institute, 2020), 40-43.

¹¹ Reach Out Response Network, Final Report on Alternative Crisis Response Models for Toronto (Toronto, ON: Reach Out Response Network, 2020), 5.

¹² Reach Out Response Network, Final Report on Alternative Crisis Response Models for Toronto (Toronto, ON: Reach Out Response Network, 2020).

¹³ Reach Out Response Network, Final Report on Alternative Crisis Response Models for Toronto (Toronto, ON: Reach Out Response Network, 2020), 5.

¹⁴ The core planning team for San Francisco’s Street Crisis Response Team included a peer specialist from RAMS Inc., one of the program’s service providers. San Francisco Department of Public Health, Street Crisis Response Team Issue Brief (San Francisco: San Francisco Department of Public Health, 2021), 1.

¹⁵ Interviews 25, 27, and 28. For example, since 2020, six local clubhouses that are affiliated with Fountain House’s national network have been leading local campaigns to “advocate locally or statewide for public health responses to mental health crisis.” Fountain House, “The Care Responders Campaign—Ensuring that Mental Health Emergencies Receive the Right Public Health Response.”

¹⁶ Interview 32.

¹⁷ According to representatives from OCMH, New York City’s work to improve crisis response and plan the B-HEARD pilot was developed with the NYC Crisis Prevention and Response Task Force, which includes advocates, city agency leadership, and community members. For more information, see Mayor’s Office of Community Mental Health, “New York City Announces New Mental Health Teams to Respond to Mental Health Crises,” November 10, 2020.

¹⁸ Interview 05.

¹⁹ Interview 01.

²⁰ P.R. Lockhart, “Living While Black and the Criminalization of Blackness,” Vox, August 1, 2018; and Jim Parsons & Frankie Wunschel, “Changing Police Practices Means Changing 911,” Vera Institute of Justice, September 29, 2020.

²¹ Katrina Feldkamp and S. Rebecca Neusteter, “The Little Known, Racist History of the 911 Emergency Call System,” In These Times, January 26, 2021.

²² S. Rebecca Neusteter, Megan O’Toole, Mawia Khogali, et al., Understanding Police Enforcement: A Multicity 911 Analysis (New York: Vera Institute of Justice, 2020); and Amos Irwin & Betsy Pearl, “The Community Responder Model,” Center for American Progress, October 28, 2020.

²³ Interview 14

²⁴ NAMI, “988: Reimaging Crisis Response.”

²⁵ Jackson Beck, Melissa Reuland, and Leah Pope, “Case Study: CAHOOTS,” Vera Institute of Justice, November 2020; and White Bird Clinic, “CAHOOTS.” After receiving input from community members, Eugene is exploring a separate phone line for CAHOOTS that would be disconnected from the police department.

²⁶ Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 10. During its pilot period, PSR has encouraged community members to specifically request PSR when they call 911. Portland Street Response, “Portland Street Response Frequently Asked Questions,” Portland.gov.

²⁷ City of Rochester, “Crisis Intervention Services,” CityofRochester.gov; and Daniele Lyman-Torres and Alia Henton-Williams, Person in Crisis Team Pilot Plan (Rochester, NY: Rochester Department of Recreation and Human Services, 2021).

²⁸ In the United States, 211 has been designated by the FCC as the three-digit number for information and referrals to social services and other assistance. In some communities, including Rochester and the Finger Lakes region, 211 is operated by a service provider that also provides 24/7 crisis line services. 211, “About 211”; 211 Life Line, “About Us”; and Daniele Lyman-Torres and Alia Henton-Williams, Person in Crisis Team Pilot Plan (Rochester, NY: Rochester Department of Recreation and Human Services, 2021).

²⁹ Daniele Lyman-Torres and Alia Henton-Williams, Person in Crisis Team Pilot Plan (Rochester, NY: Rochester Department of Recreation and Human Services, 2021), 3; and City of Rochester, “Crisis Intervention Services,” CityofRochester.gov.

³⁰ Interview 26.

³¹ Interview 21.

³² Interview 03.

³³ Reach Out Response Network, Final Report on Alternative Crisis Response Models for Toronto (Toronto, ON: Reach Out Response Network, 2020), 54-60.

³⁴ Federal Communications Commission, “Video Relay Service (VRS).”

³⁵ Interview 9; Federal Communications Commission, “Text to 911: What You Need to Know”; and “Text 911 Master PSAP Registry.”

³⁶ Veronica Stracqualursi, “FCC Approves Texting '988' To Reach National Suicide Prevention Lifeline By Next Year,” CNN, November 18, 2021; and Stephanie Hepburn, “988 and Deaf Services,” #CrisisTalk, February 22, 2022.

³⁷ Vera Institute of Justice, “911 Analysis: How Civilian Crisis Responders Can Divert Behavioral Health Calls from Police,” April 11, 2022.

³⁸ David Graham, “The Stumbling Block to One of the Most Promising Police Reforms,” The Atlantic, February 22, 2022.

³⁹ Interview 18; “Community Assistance and Life Liaison Pilot Evaluation Report,” St. Petersburg Police Department, 2021, on file with authors.

⁴⁰ Interview 18.

⁴¹ Pew Charitable Trusts, New Research Suggests 911 Call Centers Lack Resources to Handle Behavioral Health Crises (Washington, DC: Pew Charitable Trusts, 2021), 2, 6-7.

⁴² Pew Charitable Trusts, New Research Suggests 911 Call Centers Lack Resources to Handle Behavioral Health Crises (Washington, DC: Pew Charitable Trusts, 2021), 7.

⁴³ Jackson Beck, Melissa Reuland, and Leah Pope, Behavioral Health Crisis Alternatives, Case Study: Robust Crisis Care and Diverting 911 Calls to Crisis Lines: Phoenix, AZ (New York: Vera Institute of Justice, 2020); and Stephanie Hepburn, “Embedding Crisis Response in Harris County’s 911 Dispatch Center,” #CrisisTalk, December 14, 2021.

⁴⁴ Interview 26.

⁴⁵ Jennifer L. Eberhardt, Phillip Atiba Goff, Valerie J. Purdie et al., “Seeing Black: Race, Crime, and Visual Processing,” Journal of Personality and Social Psychology 87, no. 6 (2004), 876-93. Research has explored the role that implicit and other cognitive biases play in perpetuating racial disparities across the criminal legal system—for example, in police shootings see Joshua Correll, Sean M. Hudson, Steffanie Guillermo, et al., “The Police Officer‘s Dilemma: A Decade of Research on Racial Bias in the Decision to Shoot,” Social and Personality Psychology Compass 8, no. 5 (2014), 201-213; in criminal case processing see Vanessa Meterko and Glinda Cooper, “Cognitive Biases in Criminal Case Evaluation: A Review of the Research,” Journal of Police and Criminal Psychology (2021); and in the triage practices of public defenders see L. Song Richardson and Phillip Atiba Goff, “Implicit Racial Bias in Public Defender Triage,” The Yale Law Journal 122, no. 8 (2013), 2626-2649.

⁴⁶ Protocols to support operators may range from written policies and guides to scripts, screening questions, and decision trees. For more information and examples, see Jackson Beck, Melissa Reuland, and Leah Pope, “Case Study: Robust Crisis Care and Diverting 911 Calls to Crisis Lines,” Vera Institute of Justice, November 2020; Portland.gov., “Portland Street Response Frequently Asked Questions,” 2022; Transform 911, Transforming 911: Assessing the Landscape and Identifying New Areas of Action and Inquiry - Chapter Four: Emergency Communications Center Operations (Chicago: The University of Chicago Health Lab, 2022).

⁴⁷ Jessica W. Gillooly, “‘Lights and Sirens’: Variation in 911 Operator Risk Appraisal and its Effects on Police Officer Perceptions at the Scene,” Journal of Policy Analysis and Management (forthcoming).

⁴⁸ Jessica Gillooly, “Op-Ed: The First Lesson Of Fielding 911 Calls: Don’t Be Alarmist,” Los Angeles Times, January 7th, 2022; Jessica W. Gillooly, "How 911 Callers and Call‐takers Impact Police Encounters with the Public: The Case of the Henry Louis Gates Jr. Arrest," Criminology & Public Policy 19, no. 3 (2020): 787-804; Roge Karma, “Want to Fix Policing? Start with a Better 911 System,” Vox, August 10, 2020.

⁴⁹ Katherine Beckett, Forrest Stuart and Monica Bell, “From Crisis to Care,” Inquest, September 2, 2021.

⁵⁰ Interview 18.

⁵¹ “Community Assistance and Life Liaison Pilot Evaluation Report,” St Petersburg Police, 2021. On file with authors.

⁵² During its first three months, only 23 percent of the emergency mental health calls made in the pilot location were routed to B-HEARD. This was attributed to a lack of resources and personnel for B-HEARD, as well as the discretionary judgement of dispatchers around assessing risk of imminent harm. Caroline Lewis, “NYC Tried To Remove NYPD From 911 Mental Health Emergencies—But It’s Had Little Success,” Gothamist, October 22, 2021.

⁵³ Interview 32.

⁵⁴ Ibid.

⁵⁵ San Francisco Department of Public Health, Street Crisis Response Team Issue Brief (San Francisco: San Francisco Department of Public Health, 2021), 2; and San Francisco Department of Public Health, Street Crisis Response Team (SCRT) Pilot - August 2021 Update (San Francisco: San Francisco Department of Public Health, 2021).

⁵⁶ Robert Smuts and Simon Pang, “Transitioning 911 Response: San Francisco’s Street Crisis Response Team (SCRT) Pilot Program” (presentation at the Transforming Dispatch and Crisis Response Services: Meeting Challenges with Innovation webinar, hosted by The Academic Training to Inform Police Responses, March 2, 2021).

⁵⁷ Teams of civilian crisis responders are often referred to as “mobile crisis teams” and are an important feature of robust crisis systems. However, they have not historically been implemented with the ability to answer 911 calls as an alternative to police. SAMHSA’s crisis care guidelines recommend that mobile crisis teams have at least two people, including at least one licensed and/or credentialed clinician who can assess the needs of people in crisis. SAMHSA, National Guidelines for Behavioral Health Crisis Care – Best Practice Toolkit (Washington, DC: SAMHSA, 2020). Vera defines “mobile crisis teams” as 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. See Jackson Beck, Melissa Reuland, Leah Pope, “Behavioral Health Crisis Alternatives,” Vera Institute of Justice, November 2020. Acknowledging workforce and healthcare system limitations, some national experts have called for a new kind of crisis response professional to staff these teams. Jennifer J. Carroll, Taleed El-Sabawi, Dan Fichter, et al., “The Workforce For Non-Police Behavioral Health Crisis Response Doesn’t Exist - We Need To Create It,” Health Affairs, September 8, 2021.

⁵⁸ Interview 02.

⁵⁹ Susan Walker, Euan Mackay, Phoebe Barnett, et al., “Clinical and Social Factors Associated with Increased Risk for Involuntary Psychiatric Hospitalisation: A Systematic Review, Meta-Analysis, And Narrative Synthesis,” Lancet Psychiatry 6, no. 12 (2019), 1039-1053; Jeffrey Swanson, Marvin Swartz, Richard A. Van Dorn, et al., “Racial Disparities in Involuntary Outpatient Commitment: Are They Real?,” Health Affairs 28, no. 3 (2009), 816-826; Jossie A Carreras Tartak, Nicholas Brisbon, Sarah Wilkie, et al., “Racial And Ethnic Disparities In Emergency Department Restraint Use: A Multicenter Retrospective Analysis,” Academic Emergency Medicine 28, no. 9 (2021), 957-965; and Katie Brooks Biello, James Rawlings, Amy Carroll-Scott, et al., “Racial Disparities in Age at Preventable Hospitalization Among U.S. Adults,” American Journal of Preventative Medicine 38, no. 1 (2010), 54-60.

⁶⁰ Interview 34.

⁶¹ Jennifer J. Carroll, Taleed El-Sabawi, Dan Fichter, et al., “The Workforce For Non-Police Behavioral Health Crisis Response Doesn’t Exist - We Need To Create It,” Health Affairs, September 8, 2021.

⁶² NYCLU, “NYCLU Calls For Immediate Action Regarding The Policing Of Protestors, Responses To Residents In Mental Health Crisis, And Transparency On Police-Involved Deaths,” letter to Rochester, NY, Mayor Lovely Warren, October 7, 2020.

⁶³ Interview 26; and United States Census Bureau, “QuickFacts: Rochester, New York.”

⁶⁴ Interview 26.

⁶⁵ Ibid.

⁶⁶ Interview 18.

⁶⁷ Ibid.

⁶⁸ Interview 30.

⁶⁹ SAMHSA, National Guidelines for Behavioral Health Crisis Care – Best Practice Toolkit (Washington, DC: SAMHSA, 2020), 18-21.

⁷⁰ For an overview of key functions of peer support in the behavioral health system, including crisis support, wellness planning, and linkage to resources, see Philadelphia Dept. of Behavioral Health and Intellectual Disabilities Services and Achara Consulting Inc. “Peer Support Toolkit,” (Philadelphia, PA: DBHIDS, 2017).

⁷¹ Interview 19; Stephanie Hepburn, “The Chronic Misunderstanding of the Peer Role in Behavioral Health,” #CrisisTalk, August 10, 2021; Jennifer J. Carroll, Taleed El-Sabawi, Dan Fichter, et al., “The Workforce For Non-Police Behavioral Health Crisis Response Doesn’t Exist - We Need To Create It,” Health Affairs, September 8, 2021; Council of State Governments Justice Center, Advancing the Work of Peer Support Specialists in Behavioral Health-Criminal Justice Programming (New York: CSG Justice Center, 2021).

⁷² City & County of San Francisco, “What is the Street Crisis Response Team?”

⁷³ RAMS, “Division of Peer-Based Services.”

⁷⁴ Interview 29.

⁷⁵ Ali Velshi, “Chief Simon Pang on how San Francisco is Transforming Policing,” MSNBC, broadcast April 18, 2021.

⁷⁶ City & County of San Francisco, “What is the Street Crisis Response Team?” San Francisco, “Street Crisis Response Team 9-2-21,” uploaded September 3, 2021, YouTube video, 4:04.

⁷⁷ Reach Out Response Network, Report on International Crisis Response Team Trainings (Toronto, ON: Reach Out Response Network, 2021), 14.

⁷⁸ Stephanie Hepburn, “The Chronic Misunderstanding of the Peer Role in Behavioral Health,” #CrisisTalk, August 10, 2021.

⁷⁹ Reach Out Response Network, Report on International Crisis Response Team Trainings (Toronto, ON: Reach Out Response Network, 2021), 14.

⁸⁰ Reach Out Response Network, Report on International Crisis Response Team Trainings (Toronto, ON: Reach Out Response Network, 2021), 14; and Interview 29.

⁸¹ Interview 29.

⁸² Interview 32.

⁸³ Jenée Desmond-Harris, “Implicit Bias Means We’re All Probably At Least A Little Bit Racist,” Vox, August 15, 2016.

⁸⁴ Yesenia Merino, Leslie Adams, and William J. Hall, “Implicit Bias and Mental Health Professionals: Priorities and Directions for Research,” Psychiatric Services 69, no. 6 (2018).

⁸⁵ Patrick S. Forscher, Calvin K. Lai, Jordan R. Ast, et al., “A Meta-Analysis Of Procedures To Change Implicit Measures,” Journal of Personality and Social Psychology 117, no. 3 (2019), 522-59; Calvin K. Lai, Allison L. Skinner, Erin Cooley, et al., “Reducing Implicit Racial Preferences: II. Intervention Effectiveness Across Time,” Journal of Experimental Psychology, 145, no. 8 (2016), 1001-1016; and Tonya Mosley, “Why Implicit Bias Training for Police Doesn’t Work – And What Can Be Done to Combat Racism,” interview with Jack Glaser, WBUR, aired April 22, 2021.

⁸⁶ Interview 32.

⁸⁷ Interview 18; Reach Out Response Network, Report on International Crisis Response Team Trainings (Toronto, ON: Reach Out Response Network, 2021), 9, 16.

⁸⁸ Mia Antezzo, Jodi Manz, Eliza Mette, et al., “State Strategies to Increase Diversity in the Behavioral Health Workforce,” National Academy for State Health Policy, December 13, 2021.

⁸⁹ Behavioral Health + Economics Network, Addressing the Behavioral Health Workforce Shortage (Washington, DC: Behavioral Health + Economics Network, 2018); and Wolfram A. Brandt, Christoph J. Bielitz, and Alexander Georgi, “The Impact of Staff Turnover and Staff Density on Treatment Quality in a Psychiatric Clinic,” Frontiers in Psychology 7 (2016).

⁹⁰ Ebony Morgan and Rory Elliott, “CAHOOTS Asks for at Least 5% of Community Safety Initiative Budget Funds,” press release (Eugene, OR: White Bird Clinic, May 20, 2021).

⁹¹ Eugene Police Department Crime Analysis Unit, CAHOOTS Program Analysis (Eugene, OR: Eugene Police Crime Analysis Unit, 2020); and Ebony Morgan and Rory Elliott, “CAHOOTS Asks for at Least 5% of Community Safety Initiative Budget Funds,” press release (Eugene, OR: White Bird Clinic, May 20, 2021).

⁹² Ebony Morgan and Rory Elliott, “CAHOOTS Asks for at Least 5% of Community Safety Initiative Budget Funds,” press release (Eugene, OR: White Bird Clinic, May 20, 2021); and Contract between the City of Eugene and the Eugene Police Employees Association, effective July 1, 2019, Appendix A.

⁹³ Ebony Morgan and Rory Elliott, “CAHOOTS Asks for at Least 5% of Community Safety Initiative Budget Funds,” press release (Eugene, OR: White Bird Clinic, May 20, 2021).

⁹⁴ Ibid.

⁹⁵ Jackson Beck, Melissa Reuland, and Leah Pope, “Case Study: CRU and Familiar Faces,” Vera Institute of Justice, November 2020.

⁹⁶ Interview 30.

⁹⁷ Ibid.

⁹⁸ Anne Larsen, “What’s up with CRU, Olympia’s Crisis Response Unit,” IFIBER One News, July 13, 2021; JOLT Staff, “Familiar Faces Program Becomes a Permanent Part of Downtown Services,” JOLT, July 6, 2021; and Interview 30.

⁹⁹ Interview 30.

¹⁰⁰ Jo Ann Hardesty, “My View: Increase Portland Street Response Funding,” Portland Tribune, May 12, 2021.

¹⁰¹ Rebecca Ellis, “$5.7 billion City Budget Does Not Fully Fund Portland Street Response,” Oregon Public Broadcasting, May 14, 2021.

¹⁰² Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 10; Jo Ann Hardesty, “Commissioner Hardesty Requests Funding In Fall Budget Monitoring Process To Allow Citywide Expansion Of Portland Street Response,” press release (Portland, OR: Office of Commissioner Jo Ann Hardesty, October 6, 2021); and Rebecca Ellis, “Portland City Council OKs Money For Police Body Cameras, More Homeless Services,” Oregon Public Broadcasting, November 17, 2021.

¹⁰³ Interview 30; and Jo Ann Hardesty, “My View: Increase Portland Street Response Funding,” Portland Tribune, May 12, 2021.

¹⁰⁴ Jo Ann Hardesty, “My View: Increase Portland Street Response Funding,” Portland Tribune, May 12, 2021; and Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 10.

¹⁰⁵ For example, before launching the Mobile Assistance Community Responders of Oakland (MACRO) pilot program in Oakland, California, under the oversight of the Oakland Fire Department, stakeholders noted the benefits of embedding included access to the existing 911 dispatch system. The city also considered contracting with existing service providers in order to staff the program and speed its launch. Natalie Orenstein, “Call 911 for a Counselor? Oakland Will Pilot One Alternative To Police,” Oaklandside, June 29, 2020; and Natalie Orenstein, “It’s Decided: The Oakland Fire Department Will Run MACRO, a New Non-Police Emergency Response Program,” Oaklandside, March 4, 2021.

¹⁰⁶ Taleed El-Sabawi and Jennifer J. Carroll, “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022), 59 (working paper).

¹⁰⁷ Taleed El-Sabawi and Jennifer J. Carroll, “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022), 56 (working paper).

¹⁰⁸ Interview 18.

¹⁰⁹ Ibid.

¹¹⁰ CCIT-NYC, “Our Proposal.”

¹¹¹ Interview 35; and Allegheny County Department of Human Services, Improving Crisis Prevention and Response (Pittsburgh, PA: Allegheny County Department of Human Services, 2022).

¹¹² Anil Arora, Toronto: A Data Story on Ethnocultural Diversity and Inclusion in Canada (Ottawa, ON: Statistics Canada, 2019); City of Toronto, “City Of Toronto Announces Four Community Partners As Part Of The Launch Of The Community Crisis Support Service Pilot,” press release (Toronto, ON: City of Toronto, January 19, 2022).

¹¹³ Interview 15.

¹¹⁴ Council of State Governments Justice Center, “Expanding First Response: Albuquerque Community Safety Department—Albuquerque, NM.”

¹¹⁵ Ibid.

¹¹⁶ City of Sacramento Office of Community Response, “Department of Community Response”;

Dusty Christensen, “Northampton Hires Director to Set up Community Care Department,” Daily Hampshire Gazette, November 10, 2021; and Olivia Deng, “Heart Proposal Is Heard as a Policing Alternative, but City Moves Ahead on Community Safety Office,” Cambridge Day, December 25, 2021.

¹¹⁷ P.R. Lockhart, “Living While Black and the Criminalization of Blackness,” Vox, August 1, 2018; Jim Parsons & Frankie Wunschel, “Changing Police Practices Means Changing 911,” Vera Institute of Justice, September 29, 2020; Vera Institute of Justice, “Arrest Trends”; Vera Institute of Justice, “Incarceration Trends”; “Fatal Force: Police Shootings Database,” database (Washington, DC: Washington Post, accessed January 10, 2022); and Mel Langness and Gabi Velasco, “'No Cops at Pride’: How the Criminal Justice System Harms LGBTQ People,” Urban Institute, June 30, 2020.

¹¹⁸ Sirry Alang, Donna D. McAlpine, and Rachel Hardeman, “Police Brutality and Mistrust in Medical Institutions,” Journal of Racial and Ethnic Health Disparities 7, no. 4 (2020), 760-768; Katrina Armstrong, Karima L. Ravenell, Suzanne McMurphy, et al., “Racial/Ethnic Differences in Physician Distrust in the United States,” American Journal of Public Health 97, no. 7 (2007), 1283-1289.

¹¹⁹ J. Corey Williams, “Black Americans Don’t Trust Our Healthcare System—Here’s Why,” The Hill, August 24, 2017; and Susan Walker, Euan Mackay, Phoebe Barnett, et al., “Clinical and Social Factors Associated with Increased Risk for Involuntary Psychiatric Hospitalisation: A Systematic Review, Meta-Analysis, And Narrative Synthesis,” Lancet Psychiatry 6, no. 12 (2019), 1039-1053.

¹²⁰ Kathryn Krase, “Sterilization Abuse: The Policies Behind the Practice,” National Women’s Health Network, January 5, 1996; and National Alliance on Mental Illness, “Hispanic/Latinx,” accessed March 16, 2022.

¹²¹ Brian Mastroianni, “Experts Say Gender-Affirming Medical Care Can Be Lifesaving for Youth,” Healthline, March 1, 2022; and Trans Lifeline, “Why No Non-Consensual Active Rescue?” June 2, 2018.

¹²² Interview 11.

¹²³ John Draper, Gillian Murphy, Eduardo Vega, et al., “Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: The Importance of Active Engagement, Active Rescue, and Collaboration Between Crisis and Emergency Services,” Suicide and Life-Threatening Behavior 45, no. 3 (2015), 261-270, 264.

¹²⁴ John Draper, Gillian Murphy, Eduardo Vega, et al., “Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: The Importance of Active Engagement, Active Rescue, and Collaboration Between Crisis and Emergency Services,” Suicide and Life-Threatening Behavior 45, no. 3 (2015), 261-270, 267; and National Council for Mental Wellbeing, Crisis Services Survey Report (Washington, DC: National Council for Mental Wellbeing, 2019), 9.

¹²⁵ Trans Lifeline, “Why No Non-Consensual Active Rescue?” June 2, 2018; and Trans Lifeline, “Cops Out of Crisis Calls: Meet Our New Advocacy Department.”

¹²⁶ Ibid.

¹²⁷ Call BlackLine, “About/FAQ”; and Tiana Headley, “Call BlackLine: Community Care and Liberation on Speed Dial,” The River, February 1, 2021.

¹²⁸ Interview 16.

¹²⁹ Interview 20, Participant A; and Eugene Police Department Crime Analysis Unit, CAHOOTS Program Analysis (Eugene, OR: Eugene Police Crime Analysis Unit, 2020).

¹³⁰ Interview 20, Participant B. For an overview of state laws governing involuntary mental health treatment and mental health professionals’ duty to warn, see Leslie C. Hedman, John Petrila, William H. Fisher, et al., “State Laws on Emergency Holds for Mental Health Stabilization,” Psychiatric Services 67, no. 5 (2016), 529-535; Treatment Advocacy Center, “State Treatment Laws”; and National Conference of State Legislatures, “Mental Health Professionals’ Duty to Warn.”

¹³¹ Interview 20. See also Diana Paksarian, Ramin Mojtabai, Bernadette Cullen, et al., “Perceptions of Hospitalization-Related Trauma and Treatment Participation Among Individuals with Psychotic Disorders,” Psychiatric Services 65, no. 2 (2014), 266-269.

¹³² Mimi E. Kim, Megyung Chung, Shira Hassan, et al., Defund the Police - Invest in Community Care: A Guide to Alternative Mental Health Responses (New York: Interrupting Criminalization, 2021).

¹³³ Interview 20, Participants A and B.

¹³⁴ Anti Police-Terror Project, “M.H. First.”

¹³⁵ City of Oakland, Cal., Resolution No. 88553 (March 16, 2021); and Mimi E. Kim, Megyung Chung, Shira Hassan, et al., Defund the Police - Invest in Community Care: A Guide to Alternative Mental Health Responses (New York: Interrupting Criminalization, 2021), 30-31.

¹³⁶ Mimi E. Kim, Megyung Chung, Shira Hassan, et al., “Defund the Police - Invest in Community Care: A Guide to Alternative Mental Health Responses (New York: Interrupting Criminalization, 2021), 29.

¹³⁷ Rosalio Ahumada, “'We Don’t Need Police, Period.’ Who Should Handle Mental Health 911 Calls In Sacramento?,” Sacramento Bee, March 25, 2021; and Mimi E. Kim, Megyung Chung, Shira Hassan, et al., Defund the Police - Invest in Community Care: A Guide to Alternative Mental Health Responses (New York: Interrupting Criminalization, 2021), 29.

¹³⁸ For additional resources on key metrics for crisis response programs, see Clifford Courvoisier, “Explainer: Using Data to Improve the Effectiveness of Community Responder Programs,” CSG Justice Center, October 11, 2021.

¹³⁹ For more on racial equity and health equity impact assessment strategies, see Race Forward, Racial Equity Impact Assessment (Washington, DC: Race Forward, 2009); Wellesley Institute, “Health Equity Impact Assessment”; Sosunmolu Shoyinka, Rachel Talley, and Kenneth Minkoff, Self-Assessment for Modification of Anti-Racism Tool (SMART) (Dallas, TX: American Association for Community Psychiatry, 2021); and Color of Pain, “Racial and Ethnic Impact Statements.”

¹⁴⁰ San Francisco Department of Public Health, Street Crisis Response Team Issue Brief (San Francisco: San Francisco Department of Public Health, 2021), 6.

¹⁴¹ David Sachs, “People Who Have Been Demanding Police Alternatives For Years Want The City To Yield Some Control Of Its Young Program,” Denverite, April 1, 2021; and David Sachs, “In the First Six Months of Health Care Professionals Replacing Police Officers, No One They Encountered Was Arrested,” Denverite, February 2, 2021.

¹⁴² Interview 22; and Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 48.

¹⁴³ Interview 15.

¹⁴⁴ Ibid.

¹⁴⁵ Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 86.

¹⁴⁶ San Francisco Department of Public Health, Street Crisis Response Team Issue Brief (San Francisco: San Francisco Department of Public Health, 2021); Interview 32.

¹⁴⁷ Jim Parsons & Frankie Wunschel, “Changing Police Practices Means Changing 911,” Vera Institute of Justice, September 29, 2020.

¹⁴⁸ Interview 22.

¹⁴⁹ Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 35-36, 82.

¹⁵⁰ For more on how post-call surveys have been used to evaluate and provide feedback to the National Suicide Prevention Lifeline, see Stephanie Hepburn, “Dr. Madelyn Gould on How Automation Creates a Crisis-Intervention Feedback Loop,” #CrisisTalk, January 18, 2022.

¹⁵¹ Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 8.

¹⁵² Interview 30.

¹⁵³ One piece of model legislation requires crisis response programs to share a standardized set of data on calls received, services provided, and demographic information on program participants with an established advisory board and the public on a quarterly basis. Taleed El-Sabawi and Jennifer J. Carroll, “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022), Appendix A. See also CCIT-NYC, “Our Proposal.”

¹⁵⁴ Portland Street Response, “Portland Street Response Data Dashboard,” database (Portland, OR: Portland Street Response); SCRT, “What is the Street Crisis Response Team?”; and New York Mayor’s Office of Community Mental Health, “B-HEARD.”

¹⁵⁵ Interview 22.

¹⁵⁶ Greg Townley and Emily Leickly, Portland Street Response: Six-Month Evaluation (Portland, OR: Portland State University Homelessness Research & Action Collaborative, 2021), 31.

¹⁵⁷ San Francisco Department of Public Health, Street Crisis Response Team Issue Brief (San Francisco: San Francisco Department of Public Health, 2021), 4.

¹⁵⁸ Interview 26.

¹⁵⁹ Interview 05.

¹⁶⁰ Interview 10. See also Joseph De Angelis, Richard Rosenthal, and Brian Buchner, Civilian Oversight of Law Enforcement: A Review of the Strengths and Weaknesses of Various Models (Washington, DC: OJP Diagnostic Center, 2016); Will Cleveland, “Rochester Police Accountability board stripped of disciplinary powers, court rules,” Rochester Democrat & Chronicle, May 7, 2020; and Vinnie Cervantes, “Here Are 4 Areas the next Denver Police Monitor Should Focus On,” Colorado Newsline, March 9, 2022.

¹⁶¹ Taleed El-Sabawi and Jennifer J. Carroll, “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022), 66-67 (working paper).

¹⁶² Interview 21.

¹⁶³ David Sachs, “Denver’s STAR Program, Sending Mental Health Pros on Certain Calls Instead of Police Officers, is about to Get Bigger,” Denverite, August 30, 2021.

¹⁶⁴ City of Denver, “DDPHE to Expand STAR Program After Successful Pilot,” press release (Denver: Co: City of Denver, August 30, 2021).

¹⁶⁵ Interview 34; For more on the community demands of STAR, see STAR Expansion Committee, Charter and Proposals for Expansion (Denver, CO: STAR Expansion Committee, 2021).

¹⁶⁶ Interview 34; and David Sachs, “People Who Have Been Demanding Police Alternatives For Years Want The City To Yield Some Control Of Its Young Program,” Denverite, April 1, 2021.

¹⁶⁷ Taleed El-Sabawi and Jennifer J. Carroll, “A Model for Defunding: An Evidence-Based Statute for Behavioral Health Crisis Response,” Temple Law Review 94 (2022), 47-48 (working paper).

¹⁶⁸ Interview 10.

¹⁶⁹ CCIT-NYC, “Our Proposal.”

¹⁷⁰ Interview 31.

¹⁷¹ Ibid.

¹⁷² CA Prop. 63, “Mental Health Services Act” (2004).

¹⁷³ Interview 21. For more information about Los Angeles County Department of Mental Health’s stakeholder engagement process for groups that have been historically underserved, see Los Angeles County Department of Mental Health, “Underserved Cultural Communities (UsCC),” updated September 22, 2021.