A Fourth Dimension to 911: Centering Equity in Mental Health Crisis Response

By Betsy Gardner • MARCH 26, 2021

In February 2021, New York Attorney General Letitia James announced that no officers would be charged in the death of Daniel Prude, a Black man handcuffed, hooded, and pinned to the ground while experiencing a severe mental health crisis in March 2020. This news has, as it should, provoked an outpouring of questions and frustrations. The United States Justice Department has announced a civil rights review into the circumstances.

Yet this situation was, unfortunately, all too predictable; Black people are three times more likely to be killed during a police encounter than white people, according to a study from the Harvard T.H. Chan School of Public Health, and research by advocacy groups and mental health professionals has found that “the risk of being killed during a police incident is 16 times greater for individuals with untreated mental illness than for other civilians approached or stopped by officers.”

While we have written before about how data can help hold police accountable for biases and reveal racially-motivated patterns of violence, more cities are starting to adopt a new type of public safety program that seeks to eliminate criminal and law enforcement responses in situations involving anyone experiencing mental illness.

One of the earliest programs in the U.S. to replace a law enforcement response with a trained mental health response is Crisis Assistance Helping Out On The Streets (CAHOOTS) in Eugene, Oregon. Launched in 1989, CAHOOTS is a “community-based public safety system to provide mental health first response for crises involving mental illness, homelessness, and addiction,” and is a partnership between local government and the city’s White Bird Clinic. When it started, CAHOOTS was one of the very few programs that sought to address disproportionate and often-ineffective policing in situations that are better suited for trained mental health responses. Instead of law enforcement officers (LEOs) responding to mental-health related crisis situations like “welfare checks, substance abuse, suicide threats” and more, dispatch mobilizes two-person CAHOOTS teams, consisting of one medical professional and one trained crisis worker, both unarmed.

Although this model has been around for three decades, the recent renewed attention to racial justice, policing, and mental health means that the CAHOOTS model is currently being adapted, tested and piloted by several other cities.

Data Shows a Need

While CAHOOTS in Eugene proved the possibility for handling mental health crises in a different way, each individual city government uses local data to see and understand their own unique needs. For most cities implementing a new alternative type of mental health care and response, gathering cross-departmental pre-program data is a collaborative process.

In 2016, in response to data including that the Rocky Mountain area of the United States has significantly higher rates of suicide compared to the rest of the country, the city of Denver piloted a crisis intervention response to handle mental health emergency calls. According to Scott Snow, director of the Denver Police Department’s Crisis Services Bureau, another factor in having police respond to mental health calls — especially suicide calls — is the increased risk of a lethal event, colloquially known as “suicide by cop.” The initial data on the success of this pilot led to implementation of the Support Team Assisted Response (STAR) program, which is a “fourth dimension” to emergency response alongside traditional medical, fire, and police.

Denver STAR Infographic listing numbers to call, the launch data in June 2020, and explaining what kinds of calls the team responds too. It also reiterates that no police officers ride on the van.

The city of San Francisco’s Street Crisis Response Team (SCRT) relies heavily on inter-agency data and cooperation. Launched in November 2020 and still in the pilot phase, this new team is administered by the San Francisco Department of Public Health (DPH) in partnership with the city’s Fire Department; however, the Department of Emergency Management is responsible for managing and training the city’s 911 system and call centers. To prepare for this type of response, officials from all three departments, along with police, worked together to analyze 911 data and determine which calls would be best suited for a non-police response. For San Francisco, those were the Code 800B calls, i.e., a person who appears to be mentally unstable and without a weapon. One member of the SCRT is a community paramedic from the San Francisco Fire Department (SFFD), and the whole team responds in SFFD vehicles, another point of collaboration between departments.

Of course, another important source of data and input is the community. Public engagement not only helps determine the needs, but it also indicates whether or not a service like this will be used, how comfortable communities would be with mental health responders, and what kind of additional support should be provided after an acute crisis.

Civic Engagement and Political Support

For each of these programs, community engagement before, during, and after is key. As Snow explained, the community had a strong interest in the Denver STAR program, particularly advocates for and groups of people experiencing homelessness and/or addiction. After the 2016 pilot, the city held discussions with the community to review the pilot’s success and learn from the initial effort. The support was so overwhelming that in 2018 voters approved a sales tax increase for community-based mental health services and crisis response, a portion of which helps fund STAR. And most recently, despite shrinking pandemic budgets, the city approved a 1.4 million dollar budget for expanding STAR.

The process in San Francisco was a bit different but still showed similar community and government support. According to Lauren Brunner, the program coordinator for Mental Health Reform at SF Department of Public Health, the December 2019 passage of Mental Health SF legislation was a major catalyst; with strong support from Mayor London Breed and the Board of Supervisors, Mental Health SF is an “overhaul of San Francisco’s mental health system and guarantees mental health care to all San Franciscans who lack insurance or who are experiencing homelessness.” Coupled with strong calls from the community for police reform and alternatives to policing, the SCRT had strong popular and official support, and the team conducted several rounds of community engagement prior to launching.

And for both cities, the 911 system and police teams were champions of these alternative mental health response programs. Snow called the Denver 911 team “the first, if not top champion” of STAR, and the Denver Police Department appreciates that STAR takes on a portion of calls that they are more equipped to handle; so far, none of the 1000 STAR calls have needed to be elevated to the police. In SF, Brunner reports that a majority of SCRT calls in the pilot program’s first few months were deescalated and “resolved within the community,” again averting a potentially violent situation and diverting police efforts towards crime rather than homelessness or mental health issues.

In other cities, similar mental health programs are stemming from community requests; in New York City, the Mayor’s Office of ThriveNYC is a holistic mental health office that works across 13 agencies and with 200 community-based mental health agencies to provide support for New Yorkers. Although ThriveNYC wasn’t meant to be an alternative to policing, and in fact works with NYPD to offer crisis intervention training for officers and co-response teams that pair a clinician with police officers, the data shows that community members may be turning to ThriveNYC’s programs like the NYC Well mental health and substance misuse helpline, rather than calling 911 for police.

Screenshot of the Thrive NYC dashboard with overlays that show where New Yorkers don't have health insurance/suffer from depression

ThriveNYC Data Dashboard

According to NYC officials, the city government wanted this to be more than just a crisis hotline, which is why it is not connected with the city’s 911 system and provides a host of non-acute services like referrals and peer support. In fact, NYC Well was envisioned as a pre-crisis service that could help prevent mental health emergencies due to early intervention. However, the data does show that some NYC Well calls are in place of 911 calls, and all mental health related 311 calls get diverted to NYC Well. ThriveNYC officials, along with partners in other city departments, are also developing a pilot program to ensure a health-centered response to mental health 911 calls in three high-need precincts.

One reason that many of these programs have such strong community support is due to the many racial justice protests in the summer of 2020. Calls for defunding the police renewed interest in programs like CAHOOTS, which is a model of not just alternative response but also alternative financial investment.

Funding an Alternative 911 Response

None of the programs mentioned are using funds that have been directly diverted from local police forces. Instead, funding comes from a mix of taxes, fundraising, and administrative or legislative discretion. However, all three cities showcased here have found that the broad community and political support has translated to reliable funding.

In Denver, residents have consistently voted to fund STAR, as mentioned above. Yet city residents recently went above and beyond, raising $40,000 during a summer 2020 fundraising drive, which was four times what the Snow has expected. This money went toward care packages, rehydration packets, and other emergency goods that the STAR team provides on calls. In San Francisco, initial funding for SCRT comes from a voter-approved gross receipts tax for homelessness services and grant funding from the Robert Wood Johnson Foundation covers a rigorous research evaluation of the SCRT pilot project. And in New York, NYCWell funding has just been increased based on call volume data.

Using Data to Guide Improvements and Ensure Equity

While data collection during acute crisis or community interventions can be challenging, data on these programs is important for more than funding purposes. Data helps guide where and how services are provided and acts as a check on program equity goals, plus makes sure that these programs are a good use of public money. The initial evaluations of all these programs show significant value and worth.

Density map of STAR responses by geography

In San Francisco, one of the evaluation objectives is to understand the equity of the SCRT pilot implementation by looking at demographic data to make sure the teams are actually reaching the communities they want to be serving. This is especially important for SF, where mental health crisis response is positioned as an alternative to LEOs in over-policed communities. The evaluation is even paying attention to the appearance of the SCRT responders; pre-implementation focus groups led officials to a mixed approach, with an ambulance-like vehicle and some responders wearing street clothes and others wearing paramedic uniforms, although this approach will be reviewed again when the pilot is complete.

Three members of the SF Street Crisis Response Team in front of a city van, wearing masks and waving to the camera

This is much more than a fashion decision, and is actually a consideration for all non-police responder programs. In Denver, STAR responders wear t-shirts that say “Support not Stigma” and drive unmarked vehicles. In order to build and maintain community trust, having a visual differentiation from LEOs and police cars is important, and officials will carefully measure trust and use resident feedback to guide how these mental health responders interact with the communities they’re working in. As Snow explained, although increased trust in government is not a primary objective, “If we do this correctly, trust will be an outcome.”

In New York City, the initial data analysis of NYC Well calls was consistent with other data on help-seeking behavior: male-identifying individuals, and in particular black men, are most likely to have other people calling for mental health services on their behalf. In the case of NYC Well, this could also be an indicator of a fear of calling 911 (among these particular subgroups), and so individuals calling on behalf of them would prefer to call an alternative to police for help. Knowing this, NYC Well is able to make better decisions about where and how to promote the healthline and tailor services.

For every alternative mental health response, equity is a central tenet. According to Snow, the ultimate goal is an “informed, equitable behavioral health response” that respects community health and ensures dignity for everyone. Each city has a slightly different path, but ultimately shares this same goal. The cities in this piece are trying to move away from a legacy of violently policing mental health, and are models for the various ways that cities — with their communities — can undo systems that harm instead of protect.


About the Author

Betsy Gardner

Betsy Gardner is the editor of Data-Smart City Solutions and the producer of the Data-Smart City Pod. Prior to joining the Ash Center, Betsy worked in a variety of roles in higher education, focusing on deconstructing racial and gender inequality through research, writing, and facilitation. She also researched government spending and transparency at the Lincoln Institute of Land Policy. Betsy holds a master’s degree in Urban and Regional Policy from Northeastern University, a bachelor’s degree in Art History from Boston University, and a graduate certificate in Digital Storytelling from the Harvard Extension School.