Thirty-one years ago, the Eugene, Ore., mobile crisis-intervention program Cahoots (Crisis Assistance Helping Out On The Streets) was born. The 24/7 service, provided by the nonprofit White Bird Clinic and integrated into the city’s public-safety infrastructure, dispatches a medic and crisis worker to respond to non-criminal crises involving people experiencing mental illness problems, substance abuse and homelessness.
“In those situations where there’s not a criminal issue, there’s not an emergent threat to the safety of an individual or a neighborhood, why do we need the police to be the ones responding?” Tim Black, Cahoots’s operations coordinator, told MarketWatch. “Why can’t it be folks from that community who are coming with unconditional positive regard and empathy, instead of force?”
Cahoots, a free, voluntary and confidential program that has also served nearby Springfield, Ore., for the past five years, has received a surge of attention during America’s new reckoning on racial and criminal justice as Minneapolis moves to dismantle its police department and activists call to “defund the police,” or redirect some resources from law enforcement toward other social services in a community.
“For the past three decades, we’ve been really demonstrating how public-safety dollars can go to something other than law enforcement,” Black said. “So when we hear these conversations around ‘defund the police’ that are happening now, what we’re hearing is an opportunity to really engage in meaningful dialogue about what public safety actually means.”
Advocates at Cahoots and elsewhere have long argued that trained mental-health and medical professionals, not armed police, should be the ones deployed to respond to people experiencing behavioral-health distress — a view that some people with law-enforcement backgrounds appear to share.
After all, these interactions sometimes prove deadly: Adults with severe mental illness account for one in four people killed in police encounters, according to a 2015 report from the Treatment Advocacy Center, a national nonprofit based in Arlington, Va., and individuals with untreated mental illness face a 16-times-greater risk of being killed in a law-enforcement encounter compared to other civilians.
“ An ambulance and medical professionals represent a standard response for someone having a heart attack or stroke — but ‘for some reason, we have decided that mental illness needs to be treated differently.’ ”
And despite misconceptions about individuals with serious mental illness, they account for just 3% to 5% of violent acts, according to the Health and Human Services Department. But they are more than 10 times more likely than the general population to be victims of violent crime.
An ambulance and medical professionals represent a standard response for someone having a heart attack or stroke — but “for some reason, we have decided that mental illness needs to be treated differently,” John Snook, the executive director of the Treatment Advocacy Center, told MarketWatch.
‘Mental-health crises are not appropriate criminal-justice matters’
A history of past negative encounters with police can inform how some individuals in crisis respond to interactions with law enforcement, Black said.
“You’re already feeling scared, you’re already feeling escalated, your heart rate’s up, you’re stressed. And this officer arrives on scene — maybe you’ve never met that officer before, but you know how your cousin was treated when they were arrested three months ago. Maybe you’ve had more severe mental-health symptoms in the past and had some tough interactions with other police in another city,” he said by way of example.
“If you’re already feeling really elevated [and] fearful, and then there is a further trigger to continue to escalate that fear and anxiety, it’s a lot harder to really compose yourself in a way that police generally want us to compose ourselves when interacting with us,” he added.
Cahoots staff, in contrast, show up to a scene in a white van wearing informal attire, Black said: “We can send a clear message that we’re not the police, that we’re not the fire department.”
A number of factors have led to a need for community-based crisis responses for people experiencing serious mental illness, including a decrease in inpatient psychiatric beds over the past several decades, a lack of adequate funding for community-based mental-health services, and “the widely accepted principle — and law — that care should be provided in the least-restrictive environment, ideally in the community,” according to a 2019 literature review of police-based and other crisis-response models published by the Vera Institute of Justice.
While mental-health advocates can’t decide how cities set their budgets going forward, “there’s been broad agreement that mental-health crises are not appropriate criminal-justice matters,” Snook said.
Snook says individuals with mental illness should get the treatment they need before they become very sick, and communities should add sufficient capacity for inpatient psychiatric beds. In the event of a mental-health emergency, dispatchers should contact mental-health professionals, he added; law enforcement might play a supporting role if there’s a criminal or safety concern.
Ideally, Snook added, “this isn’t the first time anyone’s heard that you’re in need of care — and someone coordinates with you to ensure that you get the response that you need.”
“In America, we have not prioritized things like health care. We have not prioritized mental-health treatment. We have not prioritized early intervention or safe communities in ways that feel right for those communities,” Theresa Nguyen, the chief program officer for the nonprofit Mental Health America, told MarketWatch. “So I think we’re all called to ask ourselves why that’s the case and how we should do better.”
“ One survey respondent said, ‘We should not be in the mental health transport business. … We are a police department, not doctors.’ Another asked, ‘Since when did we consider the idea, even with the best intentions, that placing someone in need of psychiatric care in the back of a squad car is a good thing?’ ”
‘If you don’t have resources, you’re just sending whoever is there’
About one-fifth of total law-enforcement staff time and 10% of law-enforcement agencies’ total budgets in 2017 went toward responding to and transporting people with mental illness, a separate 2019 survey of sheriffs’ offices and police departments by the Treatment Advocacy Center found. The study estimated that law enforcement nationwide had spent an estimated $918 million transporting individuals with severe mental illness that year.
One survey respondent said, “We should not be in the mental health transport business. … We are a police department, not doctors.” Another asked, “Since when did we consider the idea, even with the best intentions, that placing someone in need of psychiatric care in the back of a squad car is a good thing?”
Law-enforcement officials have become “the de facto facilitators of treatment for individuals with serious mental illness and those in the midst of a psychiatric crisis,” the report added, despite many not having planned or trained to be in that role.
“What we often see is because cities or counties don’t have mobile response teams, they have to rely on law-enforcement officers to respond to these calls — not because police officers want to, but because [communities] haven’t invested in having other people there,” Nguyen said.
“The hardest thing for a city or county is that if you don’t have resources, you’re just sending whoever is there — and when you send whoever is there, that’s not the same thing as sending who is best,” she added.
‘They realize that we’re not part of that same system’
Around one in five calls that come in to the Eugene police department results in a Cahoots response, Black said. During a typical Cahoots call, a person experiencing a crisis or a third party will put in a call to dispatch (through the police non-emergency line and/or 911), and a Cahoots team is sent to the scene, Black said. The workers approach the interaction “from a lens of least intervention necessary” — aiming to listen to and empathize with the individual, he said, and identify what they need to feel safe, supported and stable.
Workers arrive unarmed and don’t carry tasers or pepper spray, he said: “Our line to safety is the radio that we wear on our shoulder.”
The team is equipped to provide first aid and non-emergency medical care; when necessary and appropriate, Cahoots will also provide transportation to services, Black added. “For those communities that have either directly or indirectly experienced violence and oppression by traditional public-safety institutions, when they see us coming, they realize that we’re not part of that same system,” he said.
The program’s total operating budget for this past fiscal year totaled $1.9 million, he added — “and that’s to serve a metro area of 250,000 people with a total of 24,000 calls last calendar year.” The Cahoots program costs on average $71 an hour, which covers equipment, operational expenses and salaries for a medic and a crisis worker, he said.
“You can do the math on how much it costs to have two officers show up, with everything else that comes along with that,” Black said, suggesting Cahoots is the cheaper option. Of those 24,000 calls, just 150 interactions (less than 1%) escalated to the point of Cahoots responders calling for police backup. The program is funded entirely by the city in Eugene, and by a combination of city funds and a state grant in Springfield, he said.
The Cahoots model has inspired similar efforts around the country, including a pilot program in Denver, Colo., and a program in Olympia, Wash. Cahoots is in conversation with Houston, Texas city council members, Black added, and is supporting development of the Portland Street Response in Portland, Ore.
Cahoots is just one model for how communities have changed how they respond to people experiencing mental-health crises. Other approaches include pairing police officers with mental-health professionals, and the widely used Crisis Intervention Team (CIT) model, whose 40-hour curriculum trains law-enforcement officers in responding to behavioral-health crises.
“ ‘What we’re doing now isn’t working, and in fact it’s resulted in more deaths — so it’s time for us to try something new.’ ”
‘The time is now’
Matt Kudish, the executive director of National Alliance on Mental Illness of New York City (NAMI-NYC), supports a non-police response for people in emotional distress. While NAMI isn’t against CIT training in general, Kudish argues that it hasn’t worked in New York City specifically, pointing to reports that more than a dozen individuals in mental-health crisis have been shot and killed by city police over the past three years.
“Reducing the NYPD’s budget is the right move for our city, and the time is now,” Kudish said. “Our stance for quite some time now has been to fund a non-police response, and I think that reducing the NYPD’s budget and reallocating these dollars into community-based services that address mental health and mental illness, that address health care in general, that address issues of homelessness, is an appropriate reallocation of funds.” (The NYPD did not return a MarketWatch request for comment.)
Kudish endorsed the Cahoots model or some variation of it, acknowledging that every city and its needs are different. Leaders would have to determine whether the Cahoots model in its current form would have a meaningful impact on a city like New York, which is very different from Eugene or Springfield, he said.
“What we’re doing now isn’t working, and in fact it’s resulted in more deaths — so it’s time for us to try something new,” he said. “If we can leverage these dollars from the NYPD’s budget to fund a pilot that’s proven in other areas — that could actually have a profound effect on the lives of those among us who are living with mental illness — it just feels like a no-brainer.”
The recent spotlight shone on Cahoots feels “surreal,” Black said. But it signals to him that the country is ready for a new conversation about public safety.
“Mental-health advocates like myself, we want to see a response that is appropriate for the situation at hand,” he said. “Part of the answer is a very close reevaluation of how public-safety dollars are being spent, whether law-enforcement agencies need the size of budgets that they have, and whether some of those dollars could be making a bigger impact by going towards services to respond to mental health, housing [and] addiction.”