When People Face a Mental Health Crisis, What’s the Best Response?

This article was published by PEW Trust Magazine on December 19, 2022.

A black SUV pulls up to an empty storefront in Abilene, Texas, where a man is sleeping on the sidewalk. He looks to be 30-something, though it’s difficult to tell. Although his blondish red hair and long beard are matted and his arms and dark clothing are caked with dirt, incongruously his hands and nails are immaculately clean. Three people—a police officer, a paramedic, and a mental health counselor—get out of the vehicle and calmly approach him.

“Does Rolando need anything?” asks Will Claxton, an officer with the Abilene Police Department, offering the man a bottle of water. Claxton has enough experience with Rolando to know to address him in the third person, because he won’t respond otherwise. Claxton also knows that Rolando has schizophrenia and hears voices, some of which threaten to kill him; when addressed, Rolando often talks back in a loud voice, flails his hands, and prepares to defend himself. “Strangers don’t know he’s fighting these voices,” Claxton explains. “They get scared and call the police.”

A grocery store recently barred Rolando because he frightened people there, but Claxton and his team know that Rolando doesn’t beg, steal, or hurt people, and he has money through Social Security Insurance. They don’t know his history or how he ended up on the street, but they know the general area he wanders so they can find him and help him stay on the medications that calm his brain and quiet the voices.

“We meet people where they are,” says mental health clinician Andrea Reyes. Reyes, Claxton, and paramedic Josh Horelica, from Abilene Fire and Rescue, make up one of the city’s two Community Response Teams charged with helping people experiencing a mental health crisis or ongoing mental health challenges.

In the past, people like Rolando would often end up in jail or a hospital emergency room. But both places are ill-equipped to treat people in a mental health crisis. Research shows that people with ongoing mental health conditions are jailed more than 2 million times each year, often for misdemeanor crimes. Three-quarters of these individuals have co-occurring substance use disorders as well. And people of color make up a disproportionate percentage of those in the criminal justice system but are less likely than White people to be identified for signs of potential mental illness and to receive treatment once incarcerated. Meanwhile, if they go to emergency departments while in a mental health crisis, patients can end up waiting for days, weeks, and even months for treatment.

The Abilene teams have no shortage of work in their corner of a nation that is experiencing and recognizing mental health problems more than ever before. Nearly a third of U.S. adults (32.8%) experienced symptoms of depression in the spring of 2021, one year after the COVID-19 outbreak—a threefold increase from pre-pandemic levels. A larger share (37%) of high school students reported that their mental health was not good most or all of the time during the pandemic, according to the Centers for Disease Control and Prevention’s Adolescent Behaviors and Experiences Survey, which was conducted from January to June 2021. People with serious mental illness—such as schizophrenia, bipolar or schizoaffective disorder, and major depression—can struggle more when people around them die, health care is marginalized or has vanished, and sources of socialization and support have come undone—all situations that happened during the pandemic. Even before the pandemic, national survey data in 2019 showed that 57% of people with a mental illness and 80% of those with a substance use disorder did not get needed care.

Failure to recognize mental illness can take fatal turns. In 2017, 1 in 4 people shot by police suffered from mental distress at the time of their encounter with law enforcement. Similarly, a 2015 study also found that at least 25%—and as many as half—of all fatal shootings by police involved people with untreated severe mental illness.

“Rolando is one who could very well be shot, just from noncompliance,” says Horelica, “or if officers are new and don’t know they have to talk to Rolando in the third person.”

In 2019, The Pew Charitable Trusts, in partnership with philanthropic and nonprofit organizations, launched a national effort to encourage communities to create teams such as those in Abilene. Now, Pew is working in Texas to research state policies and develop recommendations for other communities seeking to change their response to mental health crises.

“We want to ensure that police, jails, and emergency rooms are not the default response to people with mental health needs,” says Julie Wertheimer, who leads Pew’s mental health and justice partnerships project. “It’s not an effective intervention to further crowd jails and ERs with people who need help with mental health. These settings often can’t handle the complex needs of people in crisis. And it’s not a cost-effective solution. New approaches, like the one Abilene is taking, are working.”

A typical day for an Abilene response team begins with a review of the overnight 911 calls to see if any involve a mental health issue—such as a suicide threat or public disturbance—and to check if team members recognize any names from past calls. They spend about 40% of their 40-hour workweek responding to crises and devote the rest of their time to following up with people they’ve previously seen or calling on people they may not have interacted with but who are known to the community. They help connect individuals with housing or food services, or with a social caseworker. Horelica will do a medical evaluation, perhaps taking someone’s blood pressure or temperature. Sometimes, the team may spend a half hour just talking to a person—and showing concern—to help diffuse an impending crisis.

“These are people who aren’t often treated well in the general public,” says Jenny Goode, CEO of the Betty Hardwick Center, the local mental health authority that—together with the police department and fire and rescue unit—created, funds, and oversees Abilene’s response teams. “Many of them often lost their family, or burned bridges with family, or treatment centers have told them they can’t come anymore. But when our teams go back, and back, and back to check on them—and are kind—these people eventually do realize they need help.”

She says that most team calls result in people being stabilized and connected to social services. “Transfers to ER, jail, or inpatient psychiatric care are all relatively low,” Goode says. “Instead, these teams make human connections, and the people they visit love these guys.”

On a recent Thursday morning, the team stops to see Cynthia, who is 66 and has schizophrenia and ongoing fixed delusions. She hears voices, speaks in tongues,
and tries to give away money to passersby. She’s been in and out of the state psychiatric hospital numerous times, and for a long time, refused to seek help at the Hardwick Center.

Cynthia smiles when the three get out of their SUV, and she offers them each a chair and a drink. It wasn’t always so easy when the team first started to visit, Cynthia’s husband tried to run them over in his truck and flung his oxygen tank at Reyes. But the team kept coming back every week, offering help, sometimes water and snacks, and now her husband welcomes them with a friendly wave as he leaves with his dog and the team chats with Cynthia.

She needs a monthly dose of medication to help stabilize her condition—it comes in a shot she doesn’t like to take. But the team’s regular visits and coaxing have persuaded her to go to the Hardwick Center to get it. Since she’s been taking the injection, she hasn’t been back to the psychiatric hospital and hasn’t had any disturbing incidents. But her agreement to continue with the monthly shot is tenuous. Cynthia is especially attached to Reyes; she was so distraught when Reyes was on maternity leave that Reyes called her to assure her she hadn’t quit and was still alive. And Cynthia says that if Reyes ever does leave the team, she won’t take the shot.

From Cynthia’s house, the team drives to another home. The man they’re going to see, Grant, has seen them coming and opens his garage door. Out walks a bespectacled man with a red T-shirt, a full head of dark hair, and a cell phone pressed to his ear. “These people came to make sure I’m not dead,” he says into the phone, then sets it down on a car. “Here are my hands,” he says, putting them on top of the car. “No weapons!” He grins.

“You’re good, Grant,” says Claxton. The team chuckles and Grant is visibly relaxed by their smiles.

He’s a high-functioning 35-year-old math whiz who creates award-winning word puzzles. And he has autism and a difficult time processing his emotions. Once, Grant got agitated by a social media post, spiraled into a crisis, and ran into the street threatening suicide.

“You know the patterns of people you visit,” says Claxton. “You build a rapport with them and can talk them down. But most police wouldn’t know to look for signs of autism. They would just see someone ranting, possibly threatening other people, and threatening to kill himself.”

If that happened, police would handcuff Grant and take him to an ER or jail for endangering the public and himself—the previous protocol for the situation. But that approach would tie up patrol units and cost far more than a visit from the response team does. It also wouldn’t help Grant. Says Horelica, “Ninety-nine percent of the time, we can de-escalate the situation just by sitting down and talking.”

Abilene modeled its program after one that began in Dallas in 2018, which brings together licensed mental health professionals, paramedics, and specialized law enforcement officers. Dallas’ first Rapid Integrated Group Healthcare Team, called RIGHT Care, was assigned to the city police district that had the most 911 mental health calls.

A report from the Meadows Mental Health Policy Institute, developed with Pew, looked at a 2½-year period from Jan. 29, 2018, to June 2, 2020, when the Dallas team responded to 6,679 calls. The report found that RIGHT Care minimized the number of arrests and transports to jails or ERs, noting that only 2% of the team’s responses resulted in arrests for new offenses. And though all mental health visits to the ER at Dallas’ Parkland Memorial Hospital increased by 30% from 2017-19, areas that had RIGHT Care saw a 20% decrease in mental health-related admissions. Now, the city has 15 such teams operating around the clock.

Dallas police Sgt. Gerald Parker, a 25-year veteran of law enforcement, has witnessed a remarkable change in how police now approach mental health crises. Before RIGHT Care, “our hands were tied,” he says. “We knew that, often, people needed services, but our choices were to go our separate ways or handcuff and bring them to Parkland and let someone else deal with it.”

Earlier this year, police responded to a call about a man in his late 20s who was acting oddly in a Dallas health clinic, not talking or engaging with anyone. The clinic employees wanted the man arrested for trespassing. The police on the scene suspected a mental health issue and called in RIGHT Care.

Immediately, the team recognized that the man displayed signs of autism. They watched the clinic’s surveillance video, found the Uber that dropped him off by zooming in on the vehicle’s license plate, learned the man’s home address, canvassed the street to find someone who knew him, and got enough information to contact the man’s mother. She confirmed that her son has autism and should have been at the day center for people with intellectual disabilities—located across the street from the health clinic.

“It could have been a bad situation,” says Kristin Peterson, a social worker who helped locate the man’s mother. “He could have become confused and scared. Officers could have handcuffed him if he appeared to be resisting and taken him to the ER—where he’s not able to communicate his needs and would end up sitting there for hours. That would have been totally inappropriate for the situation.”

Instead, the team simply took him across the street to the day center where he belonged.

Police can divert incoming calls to RIGHT Care, and people experiencing a mental health crisis can reach Dallas’ call center by dialing 911 or 988—a new number that replaces the national suicide hotline and is intended to help people with any behavioral health crisis 24/7.

Either way, trained mental health experts answer the line, find out what the caller needs, and arranges responses that range from house calls to telehealth to dispatching a RIGHT Care team.

Residents of Dallas are becoming more aware of the new approach. Todd Pillsbury, an investigator and analyst in the city’s central police division, has a lot of experience responding to calls with people in mental health crises and says there’s been a surge in calls for RIGHT Care. “About a year ago, maybe 2% to 3% of the calls were for RIGHT Care,” he says. “Now I hear it on a daily basis, multiple times.”

In Abilene, the response team members see the effectiveness of this approach to mental health with their own eyes. “If you’re a counselor in a crisis situation, it’s one and done,” says Andrea Reyes. “But with this job, we talk to the person on the worst day of their lives. Then we follow up, see people in the hospital, and see them getting on medication or getting a job. Kids who wanted to die end up sending us an invitation to their graduation.”

The full article is available online here.