It is time for a community approach to mental health

  • October 13, 2021

Health & Healing

Abolitionists and mental health advocates in the US are working to replace both police and psychiatry by reimagining how we respond to mental health crisis.

The CAHOOTS team in Eugene and Springfield, OR, USA. Credit: Todd Cooper/Eugene Weekly

The 2020 uprising in response to the murder of George Floyd by Minneapolis police officer Derek Chauvin has made the average US American aware of the movement to abolish police and prisons. In recent discussions of police violence, pundits and politicians have suggested that one solution is to defund the police and reinvest in the mental health system. Many people who have actually experienced that system, however, argue that the solution will not be nearly that simple. “We’re not able to face the fact that mental health care is very violent, and very harmful, and we have to start creating options,” says Will Hall, a counselor and mental health advocate based in Oakland, CA. “And one of the most extreme examples is the police response to mental health crisis.”

While there is a severe lack of reliable data collection on fatal police encounters in the US, the data available shows that one in four individuals killed by law enforcement have a severe mental illness, making reinvestment in the mental health system appear to many to be a logical first step in reducing police violence.

The alarming number of reports of police killing people during so-called wellness checks, in which officers are sent to check on someone experiencing a mental health crisis, often in response to a call by a concerned family member or friend, has directed national attention to programs that send mobile crisis units to respond to such calls. Some of these programs work with the police, either sending civilians to respond along with an officer or answering calls that come in through the local police line, while others are entirely community-based, providing a number to call instead of the police for help. Many employ folks with lived experience of mental illness or substance use, popularly known as peers.

While mobile crisis teams have been hailed in the media as a proven alternative to police in certain cases, many believe the programs that employ mental health professionals, who also have the authority to hospitalize people involuntarily, do not go far enough. Activists within the psychiatric survivors movement, also known as the “mad movement,” argue that psychiatry is just another carceral system that disproportionately harms Black and brown people, and that it should be abolished along with the police and prison systems, to be replaced with community-based initiatives.

After many decades of pushing back against the abuses of psychiatry — abuses of which most people have only been marginally aware — this social movement has become more visible recently as it has intersected with the movement to end police violence. The point where their interests most intersect is the need for alternative responses to mental health crisis, which some communities are already working to fill.

The CAHOOTS program in Eugene, OR, one of the most successful crisis response programs to replace police in answering mental health crisis calls, aims to maintain a delicate balance between the community and the police with whom they partner. Grassroots programs like Mental Health First in northern California, on the other hand, offer a different model by working independently of law enforcement and the mental health system. As elected officials seize on programs like these as a way to satisfy their constituents’ calls to defund the police, psychiatric survivors call for a holistic approach that would not only respect the self-determination of people experiencing crisis, but also address the root causes of our collective mental health crisis.

A Different Kind of Response

“I’m a mental health system abolitionist,” says Hall. In addition to his counseling work, he advocates for people who have experienced physical and sexual abuse in that system, and organizes campaigns as part of the psychiatric survivors movement, which has fought for the rights of psychiatric patients and for alternatives to psychiatry since the 1960’s. Now, he says, “I feel like we have an incredible opportunity, because of the leadership of the Black Lives Matter movement, to make change.”

Currently working toward his PhD in Psychiatric Epidemiology at Maastricht University in the Netherlands, Hall has focused his research on antipsychotic drug withdrawal. He has conducted a survey of about 4,000 people who have successfully come off antipsychotics, and is now performing statistical analysis of that data. Hall believes, however, that the experience that most qualifies him to support the people with whom he works is his experience as a psychiatric patient. At 26 years old, after several years of having what he describes as a manic reaction to the Prozac he had been taking, he went to seek help from a walk-in clinic in San Francisco, where he was told he was a danger to himself and involuntarily hospitalized in a public psychiatric ward. During his year-long stay there, he spent two-and-a-half months in a locked unit, was pressured to take psychiatric drugs without real consent, and was put in restraints and isolation cells.

When he came out of the hospital, he says, he believed everything that had happened to him was justified and in his best interest, until he began to do his own research. When he found the psychiatric survivors movement, he learned about the long history of people pushing back against human rights violations they have experienced in the mental health system. Today, as a counselor, he offers alternative approaches to processing trauma, such as Open Dialogue, and helps people reclaim their autonomy by determining for themselves what works for them. He is a strong proponent of peer support, which basically means people with lived experience of mental health issues, trauma and the psychiatric system mutually supporting one other by sharing their experiences.

“There’s a huge need, for people who are looking for something different than what the psychiatric system is offering them,” says Hall. “A lot of people encounter violence. They encounter terrible, toxic side effects and they’re told there are no alternatives to the medications. They encounter a lack of awareness of trauma, and a lot of people who aren’t interested in listening very deeply. And so often, people come to me because they have a different understanding of what their needs are, and they want a different kind of response.”

Through his organization Compassion Not Cops, Hall campaigns for an end to the practice of sending police to check on people experiencing a mental health crisis, such as those who have expressed suicidal feelings. “I frequently counsel people to be very careful about who they tell that they have suicidal feelings, because literally, there could be a knock on your door,” he says.

The George Floyd rebellion has shone a light on many cases that did not receive much media attention when they took place, of people who have been shot by police summoned to perform wellness checks, and the fact that most of the people killed in these cases are Black. Police often approach the situation as if the person they are checking on is dangerous, frightening the person and escalating the situation. In many cases, especially for people from communities that have historically been abused by police, just having cops show up at one’s home with guns and handcuffs can escalate the emotional distress one is already experiencing, and the officers often react with violence.

Hall says he works with a lot of families who are terrified of the police. “I literally have to coach families to protect their children from getting killed by the police.” He trains the families of the people he works with to de-escalate the police by meeting them outside before they come into the house and telling them their son or daughter is not violent and not armed. He also advises them to prepare their son or daughter for the police coming, to have a witness present so the police know there is someone there, and to pull out their cell phones and film the encounter “if things get scary.”

“One of the most devastating impacts of the way we respond to a mental health crisis,” he says, “is that people learn not to talk about their suicidal feelings so they don’t get locked up, and they go into hiding. It’s harder to reach people after that.”

A Step In the Right Direction

While many families are forced to call the police in these situations because there are no other resources in their area, several communities in the US have established alternatives to police response with demonstrated success. “Dealing with folks in a mental health crisis is a really specific skill,” says Ebony Morgan, Program Coordinator of CAHOOTS (Crisis Assistance Helping Out On The Streets), a public safety system that provides mobile crisis intervention for the cities of Eugene and Springfield, OR. The program, launched in 1989 by White Bird Clinic, has garnered a great deal of notice since George Floyd’s murder in May 2020 sparked worldwide protests against police violence and racism. Many communities have reached out to CAHOOTS about using their model to start similar programs in their areas.

For the past 32 years, dispatchers at Eugene’s 911 and police non-emergency lines have routed calls to CAHOOTS that are non-violent and non-criminal in nature, which can include community members struggling with mental health issues or needing substance use support. If someone reports that they or a family member is experiencing suicidal ideation, for example, a two-person team consisting of a crisis worker and a medic will meet the person where they are to talk them through their distress and help make a plan to keep them safe, based on what the client determines their needs are. This can sometimes include connecting them with behavioral health services, but this is always voluntary.

“If you tell us you’re feeling suicidal, that doesn’t mean we’re going to make you go to the hospital, because that might not be a therapeutic intervention for you,” says Morgan. Out of the 24,000 calls the program responded to in 2019, police backup was requested by crisis workers only 311 times. Morgan says requesting police backup usually means the client’s safety is in danger. The one time she has called for a Code 3 police response, which means police getting there with lights and sirens, the client was actively trying to harm themselves. She says the fact that their services are consent-based is why they get the trust they get from the community, so she would never call the police without letting someone know first and letting them know why she has to do that. “If that’s what it takes to keep you safe that day, this is obviously not how we want it to go down, but ultimately it’s our responsibility to make sure no one gets hurt.”

According to Morgan, “very, very, very rarely” are these requests due to someone lashing out at them. “Just because you’re having a mental health crisis does not mean you want to hurt somebody else. We try to keep that at the front of our minds all the time, and we’ve never had a serious injury or death on the CAHOOTS team due to a call we’ve gone out on.”

Most existing mobile crisis intervention programs in cities across the US employ mental health clinicians, who are authorized to place people on an involuntary psychiatric hold, with many also employing peer counselors. Mental health advocates like Hall have suggested that, while replacing police with mental health professionals may seem like a solution because it reduces the chances of violence, ultimately it is not likely to help the person in crisis. “The situation is so bad that sending anyone other than the police would be an improvement,” Hall says. He goes on to say, however, that clinicians often do not have anything in their toolkit other than hospitalizations and drugs. The most crucial things peers have to offer, Hall believes, are connection and being listened to, which makes them better equipped to help the person de-escalate and start to think about how to put their lives together. “If we can send people who can connect with the person, we could create a listening environment, and safety.”

“We prioritize hiring folks that to some degree get it,” says Morgan. While many members of the CAHOOTS staff have lived experience, she explains, it is necessary to have experience working with people in a mental health crisis in order to apply for the job. “We have people that are currently in recovery, people with their own mental health diagnoses, a lot of lived experience on the team that allows us to bring that compassion and inside knowledge of some of these things. We don’t often talk about our own experience because that’s not what people need, but they do need someone they feel like they can relate to.” One of the most important qualifications they look for is the ability to de-escalate a situation. They require candidates to have worked in a walk-in crisis center or other kind of facility “where they have become familiar with mental health and how to respond to it in a compassionate and therapeutic way.”

Working Within the System

Morgan joined CAHOOTS as a crisis worker in January 2020 while studying to be a nurse, and says part of the reason she chose to stay with this work after graduating nursing school is that her own father was killed during a police encounter. “I saw so much value in this work,” she says. Her hope is that CAHOOTS will get the support it needs locally to be a stable program and become a third pillar of safety in the community, along with the police and Fire & EMS departments. “Ideally to me, what we’re going to see is that mental health is seen as a priority, and is prioritized in the first-responder world just as much as anything else.”

CAHOOTS is in the process of re-evaluating their model and working to improve it based on the input of the communities most in need of their services. Morgan acknowledges that the program failed to reach out to the BIPOC community when they developed the model 32 years ago. Steps they have taken to rectify this include creating a role for bilingual service expansion, getting staff trained in Spanish, bringing in more bilingual folks and trying to figure out how to be more actively accessible in the field. They have developed the Stewardship Council, which holds quarterly meetings where a panel of community members and partners bring them direct feedback from the communities they represent.

One of the most common pieces of feedback they have received is that community members would like another way to access CAHOOTS than what is currently available. Many people from communities with historically tense relationships with police, such as people of color and unhoused people, do not feel safe having to call the police line in order to reach CAHOOTS, which is why the city is now considering a separate phone line for the program that would not be connected to the police department.

“CAHOOTS is not a perfect model,” says Morgan. “I believe we help our community quite a bit, but we haven’t done everything right. And there’s not a lot to compare ourselves to, to say what is the best practice. We are just doing the best we can and adjusting as we go. What I would love to see is that there are a bunch of programs in a bunch of areas responding to community needs, and we could all come together in some way and figure out what the best pathway forward is.”

So many communities have now reached out to CAHOOTS about starting similar programs that White Bird Clinic has started a consulting group for people with knowledge of CAHOOTS to work with these communities. Morgan says the list of people looking to start programs based on this model is ever-growing. “It’s really inspiring to see.”

One pilot program that has recently emerged based on the CAHOOTS model is Mobile Assistance Community Responders of Oakland (MACRO). The City Council of Oakland, CA passed legislation to launch the project in March, after nearly two years of advocacy by the Coalition for Police Accountability. The Coalition was formed by community groups to put a charter amendment on the ballot in 2016 to create the Oakland Police Commission, an independent oversight body for the Oakland Police Department, which has been under federal oversight for 18 years due to its history of brutality and civil rights violations.

The idea for MACRO came out of a hearing the Commission held in February 2019 on policing in the unhoused community, where about 75 unhoused people testified. Many asserted that any interaction with police was problematic for them and that they needed someone other than the police to call in a crisis. After the Coalition for Police Accountability learned about the CAHOOTS program, members of CAHOOTS came down from Eugene to give a presentation to the community and met with Oakland’s fire department, police dispatch, mayor and City Council members. The project has received strong support from the public. “There’s no segment of Oakland that doesn’t get kind of excited about MACRO,” says Coalition member Anne Janks.

Working with the Urban Strategies Council to develop the model for the program, the Coalition had many conversations with community members most impacted by police, including African immigrants, Latinx groups and the disabled community. Janks recalls that they went out into the community to get input from unhoused people, and attended support groups for families of children with mental health challenges to hear about their problems with police. After what she describes as a fight to make sure the City Council would fund the program for success, the Council approved a budget of $6.2 million for MACRO in June, rather than the $2.6 million budget originally proposed by Mayor Libby Schaaf.

“For us, it’s about disrupting unnecessary police interactions, which sometimes turn into other things,” says Janks. The Coalition’s primary interest in this, she explains, is to prevent violence by displacing police from low-level calls. “Even if they have the humanity, they just don’t have the time and the tools to successfully manage a lot of the emergency calls that they’re currently expected to.”

At a time when many in their community want to replace the system they work within, CAHOOTS is facing tough questions. On the movement for police abolition, Morgan says they have spent the last year navigating the balance between members of their community who are calling for this, and the police, who are their community partners and who pay them through their contract with them. She points out that police do not want to be a catchall for everything that goes wrong in the community. “What we believe is that we need to be able to meet the needs of our community with the resources appropriate for them,” she says. “We truly believe in harm reduction, and the least intervention necessary. So, send into your community the people that are trained for that specific thing and have the capacity to handle it.”

Relying On Each Other

In Sacramento, CA, the Anti-Police Terror Project offers a different model of community-based crisis response program — one that operates completely independently of the police — with Mental Health First. Asantewaa Boykin, a founder of APTP and Program Director of Mental Health First, describes the Anti-Police Terror Project as “a multi-ethnic, multi-generational, Black-led coalition of organizations and individuals committed to eradicating police terror in all its forms.”

Because the organizers who make up APTP have a culture of relying on each other rather than calling the police, they launched Mental Health First in January 2020 to provide an alternative to police response for mental health crisis. “When our loved ones were in crisis, we knew that the police would essentially make it worse,” she says. “We rely on ourselves, so it was this thing we created out of necessity.” As an emergency room nurse, Boykin knows that a lot of folks are reluctant to go to an ER with a cop out front, even for physical health issues. While working with families and community members impacted by police violence, organizers began to notice the number of people that were killed by police while needing care of some sort, whether it was addiction services or mental health crisis response. Once they saw that this need for alternatives existed, they began to talk about how to either advocate for something to fill this gap, or fill it themselves.

From 7pm to 7am on weekends, the program’s volunteers, of which there are a few dozen, answer phone calls on their own direct line and go into the community to respond to people experiencing crisis, which may involve mental health issues, substance use or family violence. Calls might come from a family member of someone who has expressed suicidal feelings, or a community member concerned about someone sleeping in public. The goal is to de-escalate the situation where police would likely escalate it, providing folks with trauma-informed peer support by talking with them and helping them plan their next steps. As with CAHOOTS, this can sometimes include connecting or transporting them to other services, which is always done at the person’s determination. When not answering calls, volunteers build connections with the community by canvassing the streets, carrying survival supplies for unhoused folks and talking with them.

Boykin says de-escalation is mostly holding space, listening and not having the assumption that someone is dangerous. “Mental health crisis is almost a synonym for dangerous in our society,” she says, “and we tend to approach these situations as if there’s some immediate danger, when that isn’t the situation. I can only imagine, specifically for folks that aren’t holding our shared reality, what it may feel like to be treated like you’re dangerous, when in fact you’re likely very scared.” She says it is also about accepting that they likely will not fix the person’s situation. “Our only job is to mitigate the crisis, helping them get to the next step.”

While they do not make it a requirement that volunteers have lived experience with the mental health system, Boykin says that as an organization, they strongly desire volunteers to be people who are most impacted by police, particularly in the MH First program. A lot of volunteers are medical and mental health professionals, and she believes they have a good mix of professionals and peers. “When we started, we didn’t anticipate that there would be so many medical professionals that would sign up.”

According to Boykin, Mental Health First is different in two ways from community-based first response programs that send people out along with police officers. One is that, unlike police and clinicians, they do not have the authority to place people on a 5150 hold, which is the California law code for a 72-hour involuntary psychiatric commitment. “A lot of people are placed on a 5150 because there’s nothing else, not because they need it. How we differ is that we cannot 5150 anyone, so it’s not an option for us. We don’t have that easy fix.” She says they also differ in that they use interventions that are life-affirming and not the other way around. “I’ve seen so many folks that were feeling helpless, and then they encountered our traditional system, and it only reinforced that helplessness. We do our best to deploy interventions that allow space and that give people a sense of being supported and not managed.”

Boykin says MH First volunteers have never called the police in any situation while responding to calls. “Have we had to ask ourselves, should we? Absolutely. Even for us, folks who are intentionally not involving law enforcement, there is still a certain amount of socialization within us that goes, ‘If we call, this problem will be fixed.’ So, do we grapple with the question? Of course we do. Have we made the decision to call the police? We have not.”

One challenge the organizers of Mental Health First did not foresee when they launched the program was the number of organizations and city officials that would reach out to them in the wake of the George Floyd protests, wanting their help in starting similar programs. With communities across the country calling for their elected officials to defund the police and reinvest in community programs, Boykin believes their model appears to these politicians to provide a clear avenue to answering these calls.

Several of the non-governmental organizations that have contacted APTP about creating similar programs are now in the process of building them. “When you’re building from a place of interacting with city officials, it’s a longer, drawn-out process than just community-based organizations erecting these things on their own,” says Boykin. “What I learned from it is that it’s possible to create our own systems, and that we should take ourselves more seriously as we do so.” APTP has now replicated the MH First program in Oakland, and they are in direct conversation with Alameda County and the city of Oakland about the MACRO program, for which the county has also used Mental Health First as a model.

APTP’s stance on the movement to abolish police is clear. “We’re abolitionists,” says Boykin. “Now, do any of us know what abolition looks like in real time? We absolutely do not. I think our primary goal is to try everything we can until something sticks, to get us closer to abolition.” While they do not have the answers to all the questions on the road to abolition, Boykin says, “We do have full faith that those answers exist in our community already, and that it’s our job to find them.”

Addressing the Roots of the Crisis

While elected officials have recently offered the idea of replacing cops with clinicians in these cases as a solution to police violence, survivors of psychiatric abuse are countering these calls with their own assertions: that the mental health system in the US is part of the carceral state, and that it is a white-dominated, ableist system that takes away people’s freedoms, particularly those of Black and brown Americans. A better solution, they argue, is to abolish it along with police and prisons, replacing it with community-based responses such as peer support.

“I personally think that without psychiatric abolition, we’re not addressing a lot of the much-needed efforts in overall prison abolition,” says Vesper Moore, editor of Madness Network News and COO of Kiva Centers, a peer-run organization in central Massachusetts that provides support for emotional distress, trauma and substance use. “Policing encompasses different forms of authority, which include social workers, psychiatrists and other mental health providers. Prison abolition isn’t just about the physical aspect of incarceration, but also the mental aspect of incarceration.” This, they explain, includes practices such as inpatient psychiatric incarceration, involuntary services, chemical restraints and the lack of informed consent around medication and services as a whole.

The fact that the modern psychiatric survivors movement now finds itself intersecting with the Black Lives Matter movement makes sense in the context of its history. It grew out of other social movements in the 1960s and ’70s, such as the women’s liberation movement, which critiqued psychiatry as a male-dominated profession that oppressed women, and the gay rights movement, which successfully campaigned to have the American Psychiatric Association’s classification of homosexuality as a mental illness removed from the DSM in 1973. Beginning with early groups such as the Insane Liberation Front in Portland, OR, former patients have advocated against forced treatment and controversial practices such as electroconvulsive therapy, while promoting peer-run alternatives to psychiatry. The disability rights movement is the social change movement with which it is most closely aligned in its fight against discrimination on the basis of a mental health diagnosis.

Moore believes that a “social model of disability” is crucial to the discussion of psychiatric abolition. “That means that there’s nothing wrong with our bodies or minds as we are, but that society and systems aren’t accessible to us as we are,” they say. “When we talk about hearing voices, for example, that experience could be disabling. Maybe someone doesn’t identify with it as disabling, and that’s also fully valid. However, the default shouldn’t be that that experience is an illness. We decide for ourselves what these experiences are.”

Like many other activists in the psychiatric survivors movement, Moore would like to see community-based approaches replace psychiatric institutions. “I think as far as a society where we’re replacing psychiatry completely, we would have to address the roots of the dependence our society believes it has on psychiatry.” In the US, they point out, people do not talk much about the fact that the UN issued a resolution in 1991 prohibiting mental health treatment without the informed consent of the patient, or that the World Health Organization is now concentrating on community-based mental health services. Such services include Open Dialogue, used by Will Hall in his practice, which is an approach originating from Finland that involves developing a dialogue around a client’s traumatic or stressful experiences and including members of the client’s social network, as well as peer support networks such as Users and Survivors of Psychiatry in Kenya.

Moore also believes we need more accountability measures for mental health providers, and that ideally, the accountability process would involve groups dedicated to licensure that are at least 51 percent membership of people who have been impacted by the mental health system. “Mad and disabled folks should be at the forefront, providing feedback but also holding those providers accountable.”

“I think it’s valid to have concerns that putting more money into mental health isn’t going to achieve what abolitionists have in mind,” says Morgan, the CAHOOTS Program Coordinator. “What if we look at a proactive society that takes care of itself and its community members before they’re in a crisis? Rather than responding to people once they’re in a crisis, what if we put the money on the front end, and helped people be housed and as healthy as they can be, so that they’re not having those immediate crises? The harm starts so much earlier than when any first responder shows up at your door.”

Hall agrees that our society needs to focus on preventing trauma in the first place, rather than just treating it. “It’s about changing the political, economic and social realities,” he says. “Healthy communities are what create mental health.” The way to create such an environment, he believes, is by providing for basic needs such as universal healthcare, a living wage, strong unions, support for families and support for migrants. The fact that there are more suicides when unemployment rates go up, he argues, is one way in which people who have a mental health crisis signal what has gone wrong in a society. “Instead of seeing them as the weak ones, and treating them with pills and diagnoses, we could see it as a sign that we need to address the whole problem in society.”

In discussing what a truly community-based approach to mental health might look like, Hall points to Alcoholics Anonymous as one successful example of people with lived experience of a particular issue providing each other with mutual support, as well as other well-established models in which survivors support each other. “A woman who’s been raped and is afraid to go out in public — is she going to talk to a male doctor who’s read about this in a book? She’s going to talk with other women who’ve been through the same experience. If you’re LGBT, you go to a community meeting of other LGBT people to compare experiences. If you’re Black or Indigenous, you want to go to other people who’ve experienced racism and oppression.”

He believes the same principle can be applied to many experiences that are treated as mental illness. “If you’re dealing with scary voices and you have so much paranoia that it’s hard to eat food, if you’re so depressed you can’t get out of bed, if you’re suicidal and you think your life is worthless, to make sense of that, you can talk to people who’ve been through it and come out the other side. Not to copy their solutions, but to get ideas for your own.”

Boykin from APTP says she agrees with mental health advocates’ argument that abolition should include psychiatry, because that system also forcibly takes away people’s rights. Having seen extreme cases of mental health issues in her job, she says she would never argue that involuntary psychiatric commitment is never necessary. “But it is definitely overused in a way that we should be ashamed of as a society — how easily, and how with so little consideration, we take away someone’s right to be free in the world. Whether that be in a jail cell or in a hospital, there’s very little difference.” Even environmentally, she says, there is little difference — two beds to a room, fake ventilation, non-nutritious meals, armed men, security, locked doors. “There are folks out there looking to invest money into how to better incarcerate mental health patients, over taking those same dollars and investing them in creating systems of care, because one industry is much more lucrative than the other.”

“It’s common sense to tell our stories, to share our common experiences, to figure out by listening to other people what works for us,” says Hall. “What’s hard to understand is why, in a society where everything is about money and profit, we keep putting money into a mental health system that’s not working.”

Megan McGee

Megan McGee is a writer and activist based in New York City. She works with several mutual aid and community gardening projects.

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Source URL — https://roarmag.org/essays/mental-health-system-abolition/

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