Meet the 911 first responders who are providing emergency on-the-scene mental health support.
BY MATT LEVIN / PUBLISHED: JUL 29, 2022
A man, silently, was struggling. I was walking down Broadway, in New York. People flowed gracefully around and past him and did not stop to look. Then gradually, a small group of concerned passers-by formed around him in a patchwork semi-circle. Any attempt to help him up, or to speak with him, he waved away dismissively. Each time he tried to stand, his legs buckled, and he sank back down to his odd equipoise.
A collective, halting conversation began among us strangers, voicing ambivalent suggestions to nobody in particular, asking half-rhetorical questions. I noticed, though, that calling 911 was referred to almost entirely in vague euphemism, as “calling somebody.” There was no uncertainty as to who we were talking about, rather a reluctance to say it explicitly. The man was not violent, but he was incapacitated, and he needed some sort of help. How much unraveling would it take to right what was wrong? Our discomfort emerged from the gulf between the situation before us and the tool we had at hand.
CALLING 911 WAS REFERRED TO ALMOST ENTIRELY IN VAGUE EUPHEMISM, AS “CALLING SOMBODY.”
A personal crisis is often just that—personal, posing no imminent threat to public safety. Yet by calling the police, that personal struggle is dragged into the realm of public safety, beneath the lens of the law, and the law’s stark and unforgiving categories of human action. The person in crisis is, most of the time, either sent to the ER or either hauled off in a squad car by the police—whose presence can often itself escalate a situation into violence.
Since June 2020, the city of Denver has been running a pilot program known as STAR (the Support Team Assisted Response program), designed to provide a response service for precisely those personal crises. Inspired in part by the success of the long-running CAHOOTS service (Crisis Assistance Helping Out on the Streets) in Eugene, Oregon, each STAR unit is composed of a paramedic and a licensed clinician from the Mental Health Center of Denver. Integrated into Denver’s 911 system, STAR is dispatched to low-risk, low-acuity incidents—mental health episodes, trespassing, substance abuse, resource and transport requests—without police involvement. Though the public can specifically request STAR, all calls coming into 911 deemed STAR-appropriate by the call taker are routed to the service.
STAR is concerned with the question of how best to respond to a personal crisis for which, often, there is no immediate answer. If an EMT call tends, gravitationally, toward the hospital, and a police call toward the precinct, a STAR call tends toward one among the galaxy of community organizations in Denver, selected specifically for the person and their individual situation. The objective is to set the person on a path to a solution, with the necessary institutional support. “It really is a two-pronged approach,” says Carleigh Sailon, who has been with STAR since its inception and is now its operations manager. “There’s the social worker and the medic who show up in the van and mitigate the immediate crisis. But then the second prong, which is really important, is our community partners, who we can rely on to make those referrals and connect folks to those ongoing supports and services so that they’re not popping up on an emergency response system, hopefully, in the future.”
A successful STAR call relies primarily upon open communication, allowing and encouraging people to explain their situation with minimal self-consciousness or worry of consequence. To that end, STAR teams carry few markers and accoutrements of authority. The clinicians work in casual street clothes. The STAR van is unmarked. Among the people they encounter, the immediate response to STAR’s expansive service is often shock, and occasionally tears, the emotional outflow that accompanies the laying down of a burden.
Once STAR arrives, explains Sailon, the plan of action is almost entirely at the discretion of the team on the ground. There is no set protocol for the work they are doing. The goal of a STAR call is simply to solve, or begin to solve, the crisis itself—and each crisis is as unique as the person around which it revolves. While traditional emergency response services are provided under severe time pressure, STAR is designed for open-ended commitment. Sailon, speaking to a central concern of STAR, says: “We’re very solution-focused, and want to make sure people feel empowered to let us know what that solution is. And we’re happy to work on it.”
The course of a STAR call can vary widely, from simple transport to an on-the-street counseling session to the multi-day coordination of a major transition. STAR’s near-comprehensive connection to local organizations and services provides the readiness to follow an encounter in nearly any direction. During one call, Sailon got in contact with an employee at Veterans Affairs on behalf of an unhoused veteran struggling with a broken wheelchair. The VA, it turned out, had been attempting to contact the man for months—if STAR would give him a ride to the VA hospital, they would medically clear him and reconnect him with his housing team. That call ended in permanent housing for the man. In another case, they coordinated the entrance of a young man into an in-patient treatment center for alcohol misuse. Among other things, they got in touch with his family, at his request, arranged short-term care for his dog, and drove him to the treatment center.
The people drawn to work with STAR are, like the activities of STAR itself, immensely varied, yet united by a certain ethic, a resilient capacity for improvisation. “This type of crisis work is kind of not typical of what clinicians are used to. You know, you don’t have the luxury of two to four sessions to build rapport with someone you’re doing therapy with—you kind of have to do it in two to four minutes. And sometimes it’s in the park, or on the side of the road, or in a place where clinical work doesn’t usually take place.” Above all, Sailon says, it is dedication that marks out a STAR team member. “It has to be the sort of a person who really wants to support vulnerable members of the community who are in crisis.”
The Denver Police Department, far from bristling at the intervention of STAR, has been an enthusiastic partner. STAR is not competition, but a complement. At the root of much of STAR’s work is the management of mental health crises. The majority of its calls, Sailon estimates, involve some sort of underlying mental health issue—a complex and unpredictable task even for professionals. Not only are the police largely unprepared to deal with a mental health crisis, but their involvement also introduces the risk of incarceration, introducing a new crisis: imprisonment itself, and all the problems that accompany it. Beyond being often ineffective, if not outright harmful, the police response is also undesired by both the person in crisis and the officer. As Sailon says, “I’ve never spoken to an officer who said, ‘I wanted to become a cop to deal with mental health crises.’” In handling crises for which the police are ill-equipped, STAR is also freeing up finite police personnel and time, allowing them to focus more exclusively upon crime and issues of public safety, their areas of expertise.
Sailon’s own professional path to STAR ran through the juncture of mental illness and the criminal justice system. After moving to Denver and working as a case manager for a high-intensity treatment team, she found a job in the city jail, where she was tasked with helping to connect people who were cycling in and out of the jail while suffering from serious and persistent mental illness to social and mental health services. There she saw how tasking police with the frontline response to mental health crises might serve merely to perpetuate them. “I had a front-row seat to what the criminalization of mental illness looks like, and how the most mentally ill, the most vulnerable members of our community find themselves in jail so frequently. Through that work and through that program, it sparked my interest in doing bigger work in the criminal justice system and public safety,” she says. After her time at the jail, she helped manage the high-acuity co-responder program, in which a clinician accompanied a police officer on violent mental health calls, and through that immersion in the 911 system came to recognize the existence of a large class of low-acuity calls, for which no adequate response was available.
The proposition that there was a gap in the emergency response system, a class of calls for which clinicians were needed, and police unnecessary, has been borne out. The response to the pilot was overwhelmingly positive, and in the nearly two years STAR has been in operation, they have not once called for police backup. STAR is now in the process of expanding to a 24-7, citywide response capability, with financial investment from the city and the Caring 4 Denver foundation. Places beyond Denver are taking notice as well. Sailon and STAR met with officials from New York about their own crisis intervention program, known as B-HEARD, which, after a months-long pilot period, expanded in March 2022 from its base in Harlem to northern Manhattan and the South Bronx.
To walk through most American cities is to be inundated with people in long-term crisis, people to whom, as fellow citizens, as fellow humans, we owe something, some mercy, some effort, some recognition of their existence in its complexity. There are simply too many for any one individual to take on themselves—someone needs to be called. We want someone—anyone—who will devote themselves wholly to the crisis at hand. With STAR, and CAHOOTS, and B-HEARD, we are provided a someone closer to that ideal, more attuned to the knotty, deep-rooted crises that mark nearly every human life.