Kindness, not handcuffs: A national model for behavioral-health crisis response

Editor’s note: The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team. As part of this project, editorial writer Alex Fryer has been examining issues related to behavioral health and substance use disorders.

As Seattle and other cities explore alternatives to sending officers with guns and badges to interact with people in crisis, one Oregon college town has decades of experience doing just that: Eugene.

Crisis Assistance Helping Out on the Streets, or CAHOOTS, is a mobile intervention team founded in 1989 by the White Bird Clinic, a community health provider once known for helping newbies navigate bad trips at Grateful Dead shows.

The strong community reputation of CAHOOTS highlights the need for kind, calm approaches to those with mental illness and substance use disorders. That led Seattle elected officials to specifically cite CAHOOTS as a way to reduce law enforcement. But while the program can greatly assist individuals in crisis, it isn’t intended to solve most public safety troubles, or replace police.

CAHOOTS, a nonprofit contractor with Eugene, is part of the city’s emergency response system. Dispatchers route 5% to 8% of the 1,300 daily 911 and nonemergency calls to its medics and mental health counselors. That means the vast majority of calls are still handled by police.

Because it does not have dedicated behavioral health or permanent housing resources, CAHOOTS cannot provide long-term fixes. Sometimes, its emergency interventions save lives. Other times, what CAHOOTS offers — granola bars, blankets, referrals to social services, words of encouragement — improves things for a few days, or just hours.

Despite these challenges, CAHOOTS serves as a national model for an alternative crisis response, and tells a different narrative than conflict and arrest. It begins with the people who do this for a living.

For every CAHOOTS van, there is a two-person crew, one member with mental health expertise, the other with medic training. On a recent Wednesday night, that was Liz Mitchell, 30, and Michael Williams, 36.

Originally from Portland, Mitchell worked for a homeless-service provider in Seattle and volunteered at a needle exchange before joining CAHOOTS about 18 months ago. She wears a black CAHOOTS T-shirt and jeans. Williams has worked on the vans for about three years. He’s from the Los Angeles area, has medic training and once worked in restaurants. He opts for a dress shirt, khakis and CAHOOTS vest.

Their joint shift is no scheduling coincidence. They work well together, they say, able to almost read each other’s thoughts about how to navigate difficult situations.

After checking medical and other supplies in the CAHOOTS van, they pull out into traffic and take the first call of the night, which is radioed from staff working the phones in a nondescript building on the other side of town.

The dispatchers and call-takers in the Eugene emergency communications center have written policies for when to tap CAHOOTS members, who are not trained in self-defense. The subjects in crisis should not be violent or hostile. Domestic violence calls are off-limits, and so are incidents involving weapons.

This information is gleaned from three questions asked at the beginning of every 911 call: “Where are you calling from? What’s the number to reach you? Tell me what is happening?”

During a call about someone sleeping in a doorway, for example, the call-taker will ask if the complainant is willing to file charges for trespassing. If not, CAHOOTS is dispatched instead of police to help the person move on.

“Sometimes we get CAHOOTS on the radio and say, ‘We have this call, are you comfortable dealing with this?’ ” said Stephen King, communications specialist with the Central Lane Communications Center. “Sometimes they’ll say ‘No,’ sometimes it’s ‘Yes.’ ”

The Eugene Police Watch Commander has final say over CAHOOTS, which has a van on the streets 24-hours a day, and two vans operating for a 12-hour stretch.

“I don’t think CAHOOTS is necessarily a replacement for police,” said King. “We have police officers, we have firefighters, we have EMTs. CAHOOTS is just another one of those things.”

Pandemic stress and substance use are big contributors to the region’s behavioral health challenges, said Janet Perez, manager of the behavioral health team in Eugene’s largest hospital, PeaceHealth.

The region’s housing problems often make tough situations worse. Eugene, with a population of 176,000, has a per capita homeless rate of 414 per 100,000 residents. That’s the highest in Oregon, and higher than Seattle at 365 per 100,000.

Every 24 hours, CAHOOTS and police each bring in two to three people to the medical center’s psychiatric emergency department near the University of Oregon campus.

Officers must use handcuffs or other restraints when transporting someone to the hospital. Not so with CAHOOTS, so patients often arrive in a better frame of mind.

“Handcuffs for someone experiencing mental health crisis is humiliating, that loss of power,” said Perez, of PeaceHealth. “For the majority of people who are having a hard time, when you see someone in law enforcement gear, it just ups the ante. When you see CAHOOTS, they’re pretty laid back. That helps to de-escalate.”

The first assignment Mitchell and Williams receive on their 5 p.m. to 5 a.m. shift involves someone they know, which is fairly typical. A woman with schizophrenia called the nonemergency number to request counseling. She had smoked marijuana, which made her symptoms worse, and she heard voices telling her to hurt herself. Mitchell and Williams leave when the woman talks herself down from her anxiety. Later, the team responds to multiple 911 calls about a man in his 40s flailing around a sidewalk. They know him, too, and take him to a neighborhood where he has a tent nearby. On the way, he screams in the back of the van that he hears voices.

“He self-medicates with street medication, meth probably,” said Williams later, adding that the man is a “sweet guy” typically. Mitchell agreed.

A grandfather called, concerned about his grandson with schizophrenia. He wants to have him committed to a hospital, but the team explains that’s a high hurdle. The grandson seems stable when they leave.

Along with Eugene police, they responded to a report of a suicidal subject living in public housing. The officers take off when the situation reveals a guy sitting quietly in a closet.

“We have so much leeway with them (police) most of the time. They don’t generally want to deal with the mental health stuff,” said Mitchell later. “They were happy to get out of there, I’m sure.”

They talk the man out of the apartment, give him snacks and water, and leave when he says he feels safe.

The dispatcher radios the next calls: a woman in a fight with her suicidal partner, a woman with mental illness who wants to go to the emergency department, a woman likely on meth who insists there are bodies in the crawl space of her home, a man who needs assistance leaving detox.

“I walked away from most of those calls feeling pretty good about it,” said Mitchell at the end of her shift.

“There’s something to be said for when you’re really upset and someone coming in and talking to you for a while and then being OK. Sometimes you just need some extra support.”

Most of the calls they handled would have once gone to police, who are already stretched too thin, she said.

“Officers can’t sit there for an hour and have a counseling call with someone. They have a different skill set. To ask them to also respond to all mental health, I think it’s a huge and unreasonable ask.”

King, the Eugene police dispatcher, has fielded inquiries about how to set up a program like CAHOOTS from cities around the country, including Seattle.

Interest increased after the George Floyd murder in 2020, when communities wanted alternatives to traditional policing.

In 2020, Seattle City Councilmember Andrew Lewis announced legislation to set up a new first-responder program modeled after CAHOOTS “ … and fund it by cutting SPD’s budget.”

The administration of Mayor Bruce Harrell is currently researching how to create a new public safety department, separate from police and fire, to provide alternative responses to certain emergency calls.

For this service to function well in Seattle, say those involved with CAHOOTS, several things have to happen: There needs to be community support; clarity on whether this is a new city department or nonprofit; established responsibilities; and the recognition that money, resources and attention should not be drained from police or other services to make it happen.

“With CAHOOTS, we’re not out here trying to take jobs away from law enforcement,” said Dan Felts, 29, who has been with the organization for five years. “We’re saying there’s a wide swath of call types that don’t require a team of paramedics or guys and gals with guns. There’s a vast need for community members with knowledge and awareness of how to talk to folks, how to build relationships, and with the knowledge of behavioral and financial support systems to make informed referrals.”

Eugene is a small college town, known for its artsy, collective spirit. The Beat writer Ken Kesey lived and taught here for many years. It is no coincidence that CAHOOTS got its start in this place, and that it has become a valued and necessary part of the community.

To replicate it in Seattle and other cities will take capturing CAHOOTS’ positive energy and goodwill. It will take careful negotiations with the police and fire departments, as well as behavioral health and housing providers. Community expectations must be calibrated to public safety realities — the crime rate, for example, won’t suddenly drop.

CAHOOTS stands as a shining example of what’s possible if a city considers improving the quality of life of its most vulnerable residents as an emergency tantamount to any other. It is worth emulating, and making uniquely Seattle.

Correction: This column, originally posted on April 22, 2022, was updated on April 26, 2022, to correct the spelling of the last name of CAHOOTS team member Dan Felts.