CAHOOTS, a thirty-year-old Oregon program, has reduced calls to police and saved money. Now it’s going national.
This story was originally published in the June 2021 issue of Health Affairs.
Spencer Merritt thought he was going to die. Voices in his head—angry, insistent voices—told him he’d been poisoned by Ivermex, an antiparasite drug prescribed for veterinary use that his mother kept in the house. Other imagined voices belonging to his mother and stepfather told him they had poisoned his beloved dog, Lulu, who had died a year earlier. He thought they were talking to him through hidden microphones and speakers, although he couldn’t find any in his room.
Merritt, 32, felt like he couldn’t breathe. He thought he was having a heart attack. His cluttered second-story bedroom seemed like a death trap, and he was terrified that his parents were going to kill him. He bolted up from the sofa he used as a bed, ran down the stairs and out the front door. It was 1 a.m. and he was wearing jogging pants and a blue bathrobe. Outside, on the streets, he paced and ran, falling to the ground several times as pain shot to his chest and voices echoed in his head. Maybe he was having a seizure, he thought.
He called his best friend, Brandon Adams, who convinced him to go back home. He returned to the house, locked himself in his room, and slumped on the sofa, managing to sleep for a while. He awakened a few hours later, still in panic mode, and began a desperate broadcast on Facebook live.
On the broadcast, filmed on his cell phone, he sits for long stretches of time, holding his head and staring grimly, his face a picture of misery and distress. He holds up a page from an art pad with a series of messages scrawled in pencil. “I THINK I’VE BEEN being poisoned with Ivermex,” says one. Others, in smaller letters, say “Meth it sux hard” and “I think I had a heart attack.” On the side, another message: “Help please.”
On Facebook live, his plea for help finds a response. During the next few hours more than 150 of Merritt’s Facebook friends view the broadcast; 95 post messages of love and support. “Someone’s on there way now, bro,” Adams writes, forty minutes in. Ten minutes later comes a knock on the door. A female voice—his mother’s—asks whether he called an ambulance. His friends did, Merritt says.
For the next few minutes he paces, debating his voices. “Do I really have to make a ruckus—you’re not going to let me walk outside?” he says. Finally, he unlocks the door and leaves. The broadcast continues in silence. Downstairs on the front porch, emergency medical technicians (EMTs) run a portable electrocardiogram. He hasn’t had a heart attack, they say, but suggest that he come with them anyway. Merritt declines and returns to his bedroom. “My vitals read OK,” he types into the Facebook chat, but the EMTs “didn’t want to hear my concern.”
Eleven minutes later comes another knock. “CAHOOTS?” Merritt says. “Wow.” Two minutes later he opens the door. A voice, off camera, greets him. “Hi, Spencer, I’m Christian and this is my partner, Lo.” They’re from a mobile crisis team called CAHOOTS, which stands for Crisis Assistance Helping Out On The Streets.
Similar to most people in Eugene, Oregon, Merritt knows about CAHOOTS, a service that sends a mental health crisis worker and EMT, rather than police, to people experiencing serious mental health distress. He seems immediately comfortable. For the next twenty minutes the CAHOOTS team talks and—mostly—listens. Merritt tells them he is having “a little bit of anxiety,” has been hearing voices for the past three months, and has “strong gut feelings” that he’s been spied on. “I guess it’s possible my perceptions aren’t OK,” he adds. “I’m well aware of, uh, substance-related psychosis.”
Lo Webb, the crisis worker, takes the lead in engaging with Merritt, asking him questions and empathizing without agreeing with his assertions. After Merritt mentions that Ivermex “may have been slipped into my food,” causing him to have seizures, she encourages him to see a doctor and get more sleep: “If you miss out on that, you start to lose track of what’s real and what’s not.”
The two crisis workers give Merritt a card and tell him he can call the CAHOOTS crisis line any time. White Bird Clinic, the parent agency of CAHOOTS, can also help him get on the state health insurance plan and enroll in counseling, detox, or outpatient programs, they say. “Feel free to call us,” Webb says. “We can come any time, twenty-four hours a day. We can meet you outside, we can meet you inside.”
“That’s incredible,” Merritt says. “I think I’ll be OK.”
Months later, Merritt recognizes how lucky he was that day in June 2020. Lucky that he didn’t encounter police officers while raving in his bathrobe in the middle of the night. Lucky, numerous studies suggest, that he’s white, as Black people are almost three times as likely to be fatally shot by police as whites. Mostly, he was lucky to be living in Eugene, Oregon, the home of this program that has become a national model for how to deliver crisis assistance to people in mental distress without summoning armed officers.
‘Reimagine Public Safety’
Since the beginning of 2015, 1,430 people with a history of mental illness have been shot and killed by police in the US, according to a database created by the Washington Post—almost a quarter of all fatal police shootings. In the eleven months from the murder of George Floyd to the conviction of police officer Derek Chauvin in April 2021, 181 people with histories of mental illness were killed by police. Having a mental illness and manifesting symptoms seems to increase the risk of being killed—the worst possible outcome—in a confrontation with police.
But other bad outcomes are far more common. American prisons and jails are filled with people suffering from mental illness who have been arrested and incarcerated largely because they are seen as public nuisances and no treatment programs are available. Others who don’t end up in jail often find themselves on the streets or in homeless encampments. Confrontations between police and people with mental illness can also lead to less-than-deadly injuries to either party. All of these interactions consume police time, energy, and resources from officers who all too often lack the training and expertise to know how best to deescalate a confrontation.
“For years, we’ve been sending cops to things that we shouldn’t be sending cops to,” Eugene Police Chief Chris Skinner told me. “When they show up, they look like this,” he explained, pointing to his own uniform, “and they’ve got guns and badges. We can soften that, but at the end of the day, people know we’re police officers and know a big part of our job is enforcement.”
In contrast, when a CAHOOTS team shows up, “it has a tendency to almost immediately deescalate a situation,” Skinner said. “That’s the secret sauce.”
Over the course of more than thirty years, CAHOOTS has earned the trust of pretty much all parts of the Eugene community, from homeless people on the street to business owners and rank-and-file police officers. The program was started and is run by White Bird Clinic, a community health center that opened its doors in 1969.
White Bird Clinic’s idea is now taking wing. At a moment of national reckoning over police shootings of people of color, including many with mental illness, cities nationwide are developing plans to start crisis intervention programs, in some cases by shifting funds from enforcement. Some cities, such as Phoenix, Arizona; Denver, Colorado; and Olympia, Washington, started earlier. Others, such as Oakland, California; Chicago, Illinois; and San Francisco, California, are just beginning.
Now, a little-discussed element of the American Rescue Plan, President Joe Biden’s $1.9 trillion stimulus package that became law in March 2021, will make federal funds available to states to establish more such programs. The Biden plan incorporated elements of the so-called CAHOOTS Act, introduced last year by Oregon Democrats Ron Wyden in the Senate and Peter DeFazio in the House. It includes $15 million to provide grants to start mobile crisis intervention programs and will set up three years of enhanced Medicaid funding that will cover 85 percent of the cost of operating them. An estimate by the Congressional Budget Office puts the price tag to Medicaid at about $1.1 billion over ten years.
For Senator Wyden, the issue is deeply personal because his brother, Jeff, suffered from schizophrenia. “Night after night after night, the Wyden family went to bed worried that he would be on the streets, and he would hurt himself or somebody else,” the senator told me. They also became deeply aware of “the tension between the health side and the law enforcement side.” Jeff died in 2002 at age 51.
This push to bring CAHOOTS-like programs to cities across the country “is a direct response to the national call to reimagine public safety,” Senator Wyden said. “The system today calls for a response that is sensitive to what’s really going on in the streets, and that’s not what you get. The result is violence—even fatal violence—particularly for Black Americans.”
The effort to enhance mobile response efforts dovetails with another federal law passed in 2020 that creates a nationwide, three-digit suicide prevention and mental health crisis phone line—988—to take the place of an existing ten-digit suicide prevention line. The law and a companion Federal Communications Commission regulation require telephone carriers to enable calls to 988 and states to set up call center networks by July 2022. Advocates say that the 988 line will provide people in crisis both with an alternative to dialing 911 and with a way to summon mental health responders rather than police.
“The opportunity is enormous” to tie together the two efforts to create a system that provides “people to call, people to come, and places to go,” said Jonathan Goldfinger, CEO of Didi Hirsch Mental Health Services, in Los Angeles County, California. The agency operates the nation’s largest mental health crisis hotline and is preparing for a tripling of calls from 130,000 to 390,000 a year. Without expansion, the county’s now-limited capacity to dispatch mobile mental health responders will be swamped, Goldfinger said. Many other counties have no capacity for such response.
The coming of 988 “is going to highlight where the gaps are,” Goldfinger said. “If people are waiting for someone to pick up that call or answer that text or are waiting for mobile response” personnel to arrive to assist someone, it will become clear how “woefully underfunded” the mental health system is.
CAHOOTS grew out of White Bird Clinic’s “bummer squad,” which helped people who were experiencing bad drug trips, said David Zeiss, a longtime clinic employee who oversaw the program for twenty-five years and is now on the board of directors. The model, which White Bird Clinic first used at events like Grateful Dead concerts, paired a crisis worker trained in mental health response with an EMT, paramedic, or nurse. That way, Zeiss said, “we could deal with both the medical and psychological aspects of overdoses, but also quite a range of other things.”
The clinic hired some of the best members of its concerts and events teams, Zeiss said, “and the city provided us with an old beat-up van that had been retrofitted to be barely suitable for the purpose, and police radios.” CAHOOTS began operations in July 1989.
In those early, experimental days Zeiss felt a sense of responsibility for team members heading out to the front lines. “I was standing on the curb waving the first team goodbye, giving them some last-minute advice,” Zeiss recalls. “One of them said, ‘Thank you, Daddy,’ suggesting I was being too paternal.”
The CAHOOTS program has grown steadily over the years, going from forty hours a week—afternoon and evening hours only—to round-the-clock coverage by one or two vans seven days a week. The number of calls handled by the teams has doubled, from 9,646 in 2014 to 18,583 in 2019, or an average of more than 60 calls a day, according to data compiled by the Eugene Police Department’s Crime Analysis Unit. In 2019 CAHOOTS teams called for police back-up only 311 times.
“We’re handling fifty to sixty calls per day just in Eugene and calling police to help us out less than once a day,” said Tim Black, CAHOOTS director of consulting. Since 2015 CAHOOTS has also served the 62,000 people in neighboring Springfield in addition to the 176,000 people in Eugene.
The Eugene Crime Analysis Unit estimates that CAHOOTS teams divert an estimated 5–8 percent of calls to 911 that would otherwise have been dispatched to police officers and pegs the likely number of avoided police calls at 6,346. Exactly how much time and money this saves the department is hard to quantify, but Skinner put the number at around $1.23 million. Even that number doesn’t tell the full value of the program, Skinner said.
“They’re a tremendous crime-prevention and call-prevention tool,” he explained. “It’s hard to predict how many calls for service they prevent us from having to go to. Say there’s a guy half-clothed, screaming at people. No crime has been committed; it’s just concerning. Left unaddressed, those have a tendency to escalate to the point where there’s a threat of violence and then we do have to go.”
“CAHOOTS can respond; calm the person; and take them to the local detox program, hospital, or other setting.“
Instead, CAHOOTS can respond; calm the person; and take them to the local detox program, hospital, or other setting such as the Hourglass Community Crisis Center, which provides short-term crisis assessment and stabilization. Without CAHOOTS, “people would be ushered in the wrong direction,” said Hourglass program administrator Ami Jerome. “They would bounce around in a way that’s hugely frustrating.” CAHOOTS functions as a critical bridge in the local continuum of care, she said, because its responders get to know the people who go into and out of crisis and can steer and advocate for them.
As the CAHOOTS model gets picked up around the country, the original program in Eugene faces at least one serious issue: The city’s contract provides enough funds to pay the crisis workers only $18 an hour, according to program coordinator Ebony Morgan—an amount she said is simply inadequate. “The people that do this work care very much and deserve to be compensated fairly,” Morgan said. Other cities starting their own programs are offering higher pay, likely complicating CAHOOTS’s ability to retain its workers.
High turnover also inhibits optimal collaboration with Eugene police, Skinner said. “Seeing different faces every six months—it makes it really hard to build a relationship,” he noted. “We have to find a way to build a system for them financially that promotes longevity, so that we see the same people year in and year out and build that relationship.”
Running From Call To Call
“The most common reason for a CAHOOTS call is to check on the welfare of a person who appears to be in trouble or dead.“
The most common reason for a CAHOOTS call is to check on the welfare of a person who appears to be in trouble or dead. Four times a day, on average, CAHOOTS is called to help a suicidal person.
When I spent a day with two different CAHOOTS teams, the calls—more than twenty over the course of twelve hours—ran the gamut. A young homeless man had slipped and fallen into a stream and was freezing and at risk for hypothermia; the team brought him clothes, shoes, food, and encouragement. Another man called and said he was feeling suicidal and was found face down on the sidewalk. The team flipped him over, and he revived, walked to the van with assistance, and accepted a ride to Willamette Family Inc.’s Buckley’s Sobering Services.
Not all of the calls involved homeless people. A pleasant older woman came out of her house when the CAHOOTS team arrived and asked whether machines and sand were coming out of her head. Reassured that they were not, she thanked the team and went back inside. At least two people who called in for help declined assistance when the team arrived at their homes.
Perhaps the most dramatic call came in the afternoon and brought a response from both police and CAHOOTS. The mother of an eighteen-year-old man called 911 to report that he had posted a video showing him pointing a gun at his head. The mention of a gun required police to go to the house where he was living with his godmother, while the CAHOOTS team hung back until the officers radioed an all-clear. The team members then joined the officers on the porch and quickly took charge, telling the police they could leave.
The young man acknowledged posting the video but denied that the gun had been pointed at him or anyone else. His godmother said that she saw the video and agreed there had been no real danger, adding that the gun was now locked up. The young man chatted amiably with the CAHOOTS team, accepted a business card with crisis phone numbers, and then excused himself to go back to sleep.
For a long time CAHOOTS was unique—no other city had such a program. But in 2007 a group of Phoenix-area agencies, each operating their own crisis telephone lines on behalf of health insurance plans, joined forces as the Crisis Response Network, creating a single crisis line available to all. In 2014 the settlement of a class-action lawsuit on behalf of people with serious mental illness forced Maricopa County and the state Department of Health Services to greatly expand community-based mental health services.
Phoenix: Avoiding Bad ‘Power Dynamics’
The settlement and the work of the Crisis Response Network’s hotline collaboration have helped build an integrated system that links crisis lines to mobile crisis units and short-term crisis facilities in Phoenix. The Crisis Response Network is the hub, operating a ten-digit crisis hotline that, when needed, can summon mobile crisis teams operated by health centers such as Terros Health, a provider of primary care, mental health, and substance use services.
“Think of us as like a 911 dispatch center. We’re centralized. We dispatch. We do our best to stabilize on the phone,” said Justin Chase, the Crisis Response Network’s president and CEO.
In one recent—and typical—thirty-day period, the crisis line handled more than 20,000 calls and dispatched mobile crisis teams 2,200 times, Chase said. Trained crisis responders took the calls and were able to stabilize callers over the phone with referrals, advice, or simply calm reassurance 72 percent of the time. But some people needed more, so in 21 percent of cases, the call center dispatched a mobile crisis team, consisting of a mental health professional and a paraprofessional, often a peer with lived experience. In the remaining 7 percent of cases a nonemergency transportation provider picked up the caller and drove them to a service or agency.
“Bringing a uniform and a weapon to the scene creates a power dynamic that is not in the best interest of either party.“
As with CAHOOTS, the mobile crisis teams in Phoenix provide an alternative to police. “We involve law enforcement as little as possible,” Chase said. “Bringing a uniform and a weapon to the scene creates a power dynamic that is not in the best interest of either party.” Police or emergency medical assistance is requested only when needed.
Law enforcement “loves this approach,” Chase said. “They don’t want to be on these calls. Municipalities are overstretched and understaffed. This 911 diversion stuff is really picking up because we’re keeping officers off the scene whenever possible.”
Arizona has already managed to get some federal dollars to support the effort. “We’re one of three states that bill Medicaid for our crisis hotline services,” Chase explained. “Fifty-eight percent of our crisis line revenue is actually Medicaid.”
Late last year the Crisis Response Network placed a mental health specialist in the Phoenix Police Department’s 911 call center to help dispatchers work with callers in mental health distress or divert the calls to the crisis hotline.
Denver: STAR Program Turns One
The Denver Police Department is now one year into the establishment of its own program, called STAR (Support Team Assisted Response), modeled on CAHOOTS, whose staff members hosted a delegation from Denver and also traveled there to assist.
For its first six months of operation, ending November 30, 2020, the STAR program operated from 10 a.m. to 6 p.m. in downtown Denver and nearby areas with a significant presence of homeless people. During that time the STAR van, staffed with a paramedic and a crisis worker, diverted 748 calls, or about 3 percent of all 911 calls for assistance in the area, that would otherwise have gone to police. If the program were citywide, it would eliminate the need for 10,000–13,000 police calls a year, the department estimates.
“It has worked amazingly,” said Denver Police Chief Paul Pazen. “Our officers are seeing the value in this and [asking], ‘When can we get more STAR vans outside the catchment area?’”
On the basis of the pilot’s results, the city allocated $1.4 million to expand the program this year by purchasing four additional vans and adding six two-person teams and a full-time supervisor. The department also operates a co-responder program, which pairs a licensed mental health professional and a police officer, sending them together to situations requiring a mental health response where there’s also a higher risk for violence. That program has grown from four clinicians to twenty-five since its inception in 2015. Another $500,000-a-year program assigns a social work case manager to each of Denver’s six police districts to help people encountered by officers who need social or health services.
“We saw the success of it right away,” Pazen said. “We want the appropriate response or the appropriate call for the appropriate need for the person who’s in crisis, to try to deescalate as much as is humanly possible.”
Despite the clear benefits, alternative crisis response programs do not, on their own, eliminate violent encounters between police officers and people suffering from mental illness. In the past two years officers in Springfield, Oregon, where CAHOOTS has been operating since 2015, have shot and killed two mentally ill people. One of the shootings, in March 2019, claimed the life of thirty-three-year-old Stacy Kenny in bizarre circumstances. An internal review cleared the officers of wrongdoing, but Kenny’s parents filed a wrongful death claim. Ultimately, Springfield agreed to a $4.5 million legal settlement and agreed to cooperate in an independent review of the department’s use-of-force accountability process.
The review, released in March 2021 and written by Michael Gennaco, former chief attorney for the Office of Independent Review in Los Angeles County, found that Kenny’s parents had met with a Springfield police officer several months before the shooting to advise the department that Kenny, who suffered from schizophrenia, had stopped taking medication but was not hostile or violent. At that time the officer entered this information into a database accessible to patrol officers.
‘What Did I Do Wrong?’
Kenny was driving at around 9 p.m. when Officer Kraig Akins began following her without emergency lights, Gennaco’s report says. After Kenny pulled over, tossed a small sound-making device onto the ground, then drove off, Akins requested back-up and pursued Kenny. Three additional officers responded, including Sgt. Richard Lewis, who used his patrol car to partially block Kenny’s vehicle. Kenny, from her car, called 911 herself and repeatedly yelled out the window, “What did I do wrong?”
Although 911 dispatchers announced over the police radios that Kenny was on the line with them, and although she did nothing violent, the four responding officers drew weapons. According to the report, the officers fired Tasers, punched Kenny, and tried to pull her out of the car by her hair. When Lewis jumped in on the passenger side and Kenny began driving again, Lewis punched her, tried to grab the steering wheel, and shot her in the head, causing the car to crash. Kenny died, and Lewis suffered a broken arm.
Gennaco’s report found numerous shortcomings in the handling of the incident and the police department’s internal review. It noted that Lewis was the department’s crisis intervention coordinator yet failed to deploy deescalation techniques. In an interview, Gennaco noted another irony: Springfield is served by CAHOOTS.
“If the officers had recognized that this individual was displaying symptoms of mental illness, as opposed to just defiance to their instructions, they could have deescalated, slowed things down, stayed back, called CAHOOTS, waited till CAHOOTS arrived, and then come up with a better plan,” he said. “They didn’t do any of that.”
That might have been a better approach, said Lieutenant George Crolly, a spokesman for the Springfield Police Department. But the officers responding in real time didn’t know of Kenny’s mental health history and never considered bringing in CAHOOTS.
“In hindsight, the best answer is we slow it down and evaluate the situation” to determine whether the person being stopped is a criminal, potentially violent, or suffering from mental illness, Crolly said. With a person barricaded in a car, “maybe we do bring in CAHOOTS, or maybe a hostage negotiator, as opposed to rushing. It’s an eye-opener. I hope every law enforcement agency learns something from this to not put officers or citizens at risk.”
It’s a refrain heard time and again in police shootings of people with mental illness. When Walnut Creek, California, police officers were summoned in 2019 about a young Black man, twenty-three-year-old Miles Hall, acting bizarrely with a large garden tool in his hands, they began yelling at Hall and then firing their guns at him within one minute of arriving on the scene.12,13 As in the Kenny case, Hall’s parents had met with police officers to notify them of his mental health condition. His mother, Taun Hall, called the day before the shooting to warn officers that Miles was acting erratically but was not a threat.
“I talked to an operator, and she had a police person call me, a sergeant,” Hall said. “He was like, ‘Yes, I remember Miles. I’ll just make sure people know what’s going on.’ So I’m thinking, OK, at least they got our back.”
That didn’t turn out to be the case, and Taun Hall is now channeling her grief into pushing for change. She is a leading advocate for AB 988, a bill now before the state legislature called the Miles Hall Lifeline Act, which would lay the groundwork for implementing a 988 crisis call system in California.14 Trained dispatchers could summon crisis responders such as Lo Webb, the CAHOOTS crisis worker who showed up to help Spencer Merritt in Eugene.
“She heard me out. She made me feel comfortable,” Merritt said of his interaction with Webb. He left his mother’s house that day, helped by friends who stayed with him in a hotel and hunted for detox programs while he went through withdrawal. With no programs available because of the COVID-19 pandemic, he moved to Portland with his friends and enrolled in an online addiction group with White Bird Clinic. Today, he said, he’s clean, rents a shared apartment, and is working as a lead cook in the deli department of a Safeway grocery store.
“I’m so grateful,” he said. “It could have been a tragedy.”