Local governments across the United States are responding to calls to divest police of responsibilities for responding to non-criminal emergencies by creating non-police behavioral health crisis response teams. Although the need for such programs is broadly acknowledged, there is no clear consensus about who, if not police, should respond instead. Miami-Dade County, Florida, is dispatching psychologists. Olympia, Washington, is dispatching trained crisis responders. Oakland, California, is trying teams of peer-support specialists. Alexandria, Kentucky, is sending social workers, while in Denver, Colorado, paramedics and social workers are responding in tandem. Because no professional or specialized group is an ideal fit for this need, municipalities struggle to decide how best to staff behavioral health crisis response programs out of the existing workforce. Instead, we believe, novel behavioral health crisis response programs require a new behavioral health crisis response professional.
The need to establish a novel crisis response professional is underscored by the reality that most of the service professions currently tapped to staff these programs lack the sheer numbers needed to fill these roles at scale. For example, the CAHOOTS program, which has become a national model for non-police behavioral health crisis response, supports staff working (at minimum) a combined 62 hours per day to serve Oregon’s Eugene-Springfield metro area of approximately 170,000 people. To expand Alexandria, Kentucky’s approach of hiring social workers across all of Kentucky (home to more than 4.4 million people) at CAHOOTS-equivalent staffing levels would require hiring 10 percent of the state’s health care and mental health social work labor force full time; that proportion of the available workforce would rise to 25 percent if only social workers specializing in mental health were hired. Similarly, although peer-support specialists may boast the lived experience necessary for effective crisis response, as few as 30,000 peer-support specialists are estimated to be certified in the entire country.
Additionally, training expenses and onerous licensure requirements for achieving many of these professional designations may constitute a significant barrier to entry for many well-suited persons with lived experience of mental or behavioral disorders for entry. This is a concern especially given that the inclusion of people with lived experience as behavioral health care consumers among behavioral health crisis response staff is an established best practice. Equally concerning, the licensed mental health workforce in the US today is disproportionately White, which likely exacerbates existing racial disparities in mental health services use and highlights the need to recruit and train qualified professionals from among populations that have been chronically underrepresented and underserved.
For all these reasons, drawing from the existing professional social and mental health workforce to staff behavioral programs will force an unhappy compromise between what communities need and what our current workforce can provide. For behavioral health crisis response to grow and succeed, we need a professional workforce that simply doesn’t exist—at least not yet.
Here’s how we can build it:
Consider The Skill Set, Not The Professional Role
Conversations about behavioral health crisis response typically center on the question of whether that response should involve law enforcement or someone else—with precious little attention on what that “someone else” should be. Rarely do conversations address the fundamental question of what skills and capacities are truly needed in this role.
At the 2021 Law Enforcement and Public Health Conference, some of us recently convened a panel of stakeholders from law enforcement, mental health, and emergency medicine, as well as people directly impacted by behavioral health concerns. The panel was tasked with identifying skills that behavioral health crisis responders should possess. Together, they identified as a baseline set of qualifications that crisis responders should have the ability to:
- Foster feelings of trust and security, to effectively engage everyone at the scene of an emergent crisis through listening, empathy, transparency, and non-judgmental responses.
- Rapidly assess and connect to appropriate resources to provide appropriate and necessary care: assessing acute risk, recognizing potential triggers, identifying need for immediate intervention, and connecting the person in crisis and their families with existing supports and services
- Evaluate, triage, and de-escalate—whether at the 911 call center or within a behavioral health response team—to quickly and accurately determine the nature of the call, assess and manage emergent risks to those on scene (including members of the response team), and to immediately engage de-escalation strategies for the well-being of all involved.
- Help create and implement a crisis plan for ongoing support beyond the moment of crisis by linking with resources, conducting warm handoffs for the transfer of care, and conducting follow-up.
Finally, the panel discussed the need among responder teams for basic safety skills that may be used to address lower-level safety issues without defaulting to police support. To be sure, a growing number of communities are experimenting with co-responder models that dispatch clinicians to assist law enforcement. However, this approach does not align with the view of experts at Crisis Intervention Team (CIT) International, an organization that promotes and provides technical guidance for the implementation of CIT programs. CIT International does not support such co-responder models. Nor do co-responder models reflect the lessons learned by CAHOOTS, which has demonstrated that police officers are not needed on scene at 99 percent of their crisis calls.
Many of these fundamental skills, defined above, exceed basic law enforcement training; yet, there might be individuals from a variety of backgrounds who possess some and can acquire those they don’t. For example, most of the skills above are learned and practiced by volunteer operators at suicide prevention call centers. They often come to the work without professional credentials and take calls from people in an emergent crisis under clinical supervision.
Importantly, not all of the skills needed for behavioral health crisis response must be represented on every two- or three-person team dispatched to answer calls. On-the-scene responders can receive support through remote consultation with a licensed clinician on-call for expert guidance. Thanks to the ubiquity of telehealth and secure video calling, clinicians could also remotely interface with persons in crisis as needed.
Create Multiple, Equitable Pathways To Enter The Profession
Creating a workforce equipped with the necessary skills for behavioral health crisis response requires charting new pathways into that workforce. It is already possible to gain some necessary crisis response skills through training and licensure in fields such as social work and mental health counseling. Individuals with these qualifications would benefit from additional training in the skills they may not currently possess—perhaps through existing licensing agencies or professional organizations.
At the same time, however, behavioral health crisis response does not inherently demand specialized or post-graduate training in the formal diagnosis and long-term treatment of behavioral health conditions. In particular, requiring Master’s-level training (as is common for many social work and mental health counselor professions) for behavioral health crisis responders limits entry to the field for many of the people best suited for this work and limits our ability to foster a diverse workforce. Indeed, the CAHOOTS program hires staff with a variety of qualifications—from emergency medical technician certification to lived experience with behavioral health concerns—for their crisis response teams. CAHOOTS further promotes efficacy and equity in that workforce by sending each new hire through its own rigorous 500-hour training program.
While the CAHOOTS program takes on responsibility for providing time- and resource-intensive training to all staff persons, many agencies and communities are not able to take this on nor is this an efficient approach. Rapidly scaling-up the needed workforce will require establishing multiple pathways to entry into this workforce. Those with relevant professional licensure should have access to means for gaining the skills they lack. Those without professional licensure, who have less formal education but have worked in direct service environments, for example, should have equal access to training opportunities and professional certifications that complement the skills they have gained through experience. People with lived experience should be actively recruited through all available pathways (including as trainers who can impart specialized competency on responders). Furthermore, the definition of lived experience should be expanded to include not only mental health concerns but also substance use, homelessness, the criminal justice system, the mental and behavioral health treatment systems, ethnic and racial identities, gender identities, sexualities, and beyond. Over-reliance on a single, overly professionalized pathway into this workforce will stifle this much-needed diversity.
Place Leadership And Implementation Oversight In The Hands Of The Community
Developing a shared vision for what makes a qualified behavioral health crisis responder requires, at a minimum, two things:
First, community members must be central in program planning and implementation. Not only must responders have the necessary skills, as described above, they must also reflect community experiences, histories, and values. A community that experiences contentious relationships with child protective services might not want licensed social workers to respond to behavioral health emergencies. A community populated by racialized minorities may prefer to engage with behavioral health crisis responders who look like them and have lived experience within that community. Without clear input into the process, communities may have good reason to distrust any newly implemented program.
Second, conversations must actively conceptualize behavioral health crisis response as aid and treatment, not coercion and control. Bringing these programs into the institutional structure of law enforcement risks imposing preexisting modes of operation, such as law enforcement’s fundamental concern with scene safety. Just as paramedic work is not inherently unsafe and paramedics are not employed by police departments, behavioral health crisis response is not inherently unsafe and should not be established within the purview of the police. The CAHOOTS program requires police back up at about 150 (0.6 percent) of their approximately 24,000 annual calls. Yet, even during public health emergencies, such as pandemics and natural disasters, the need for law enforcement to physically maintain safety and security is broadly assumed. This policing mandate would likely over-determine the necessity of police at the scene of behavioral health emergencies, potentially eroding the capacity of behavioral health crisis responders to be and deliver something truly novel.
Some of us have developed a model law for establishing a local behavioral health crisis response program that takes these concerns into account. The model was created in collaboration with people who have experienced homelessness, mental illness, and substance use and with community advocates for those populations. It includes detailed structures for an advisory board that maintains at least 51 percent representation from key community representatives—a proportional representation that provides them with majority control. The paper accompanying the model law discusses the costs and benefits of housing a behavioral health crisis response program within existing agencies—including public safety—or with an external contractor, so that local communities can determine their own priorities and adapt the law accordingly.
We Must Rush To Meet Resources With Solutions
Eagerness to transfer responsibility for answering behavioral health crisis calls away from law enforcement and onto trained behavioral health crisis responders is palpable, and legislators are heeding the call. A bill is progressing through the California legislature that would steer $250,000 into multiple pilot crisis response programs across the state. Two separate bills have been filed in the US House of Representatives this year, each proposing to support the dissemination of these programs by injecting, in one case, $100 million and, in another, $7.5 billion into communities to staff behavioral health crisis response teams. These are exciting developments; yet, the workforce that these funds would support does not yet exist.
It is unwise to slow down these reforms or to dampen the enthusiasm that is inspiring communities to action. Change is needed. However, alongside this change, agency leaders, policy makers, community advocates, and professional organizations must also define the workforce responsible for implementing that change and establish equitable pathways to entry.
Dr. Amy Watson also serves as the president of the Crisis Intervention Team International Board of Directors.