By the time Kiki Radermacher, a mental health therapist, arrived at a Missoula, Mont., home on an emergency 911 call in late May, the man who lived there and had called for help was backed into a corner and yelling at police officers.
The place he was renting was about to be sold. He had called 911 when his fear of becoming homeless turned to thoughts of killing himself.
"I asked him, 'Will you sit with me?' " recalled Radermacher, a member of the city's mobile crisis response team who answered the call with a medic and talked with the man that day, helping connect him with support services. "We really want to empower people, to find solutions."
Missoula began sending this special crew on emergency mental health calls in November as a pilot project; next month the program will become permanent. It's one of six mobile crisis response initiatives in Montana — up from one at the start of 2019. And four more local governments have applied for state grants this year to start teams.
Nationwide, more communities are creating units that include mental health professionals as the main responders to psychiatric crises instead of cops, though no official count exists of the teams that are up and running.
More support is on the way. The COVID-19 relief package President Joe Biden signed in March offers states Medicaid funding to jump-start such services. By July 2022, a national 988 hotline, modeled on 911, is slated to launch for people to reach trained suicide prevention specialists and mental health counselors.
Reimagining the 911 response — different approaches
Protests against police brutality in the past year have helped propel the shift across the United States. While one rallying cry has been to "defund the police," these crisis intervention programs — the sort that employ therapists like Kiki Radermacher — are often funded in addition to law enforcement departments, not drawing from existing policing budgets.
Studies suggest such services enable people in crisis to get help instead of being transported away in handcuffs. But moving away from policing mental health is still a national experiment, with ongoing debate about who should be part of the response, and limited research on which model is best. Not all communities can afford to staff separate mental health teams.
"I don't know that there's a consensus of what the best approach is at this point," says Amy Watson, a professor of social work at the University of Wisconsin-Milwaukee who has studied such crisis intervention. "We need to move toward figuring out what are the important elements of these models, where are the pieces of variation and where those variations make sense."
The federal Substance Abuse and Mental Health Services Administration sets minimum expectations for teams, such as including a health care professional and connecting people to more services, if needed. Ideally, the SAMHSA guidelines suggest, the team should include a crisis response specialist who has personally experienced mental health challenges, and the team should respond to the call without law enforcement.
Still, crisis response teams vary significantly in their makeup and approach. For more than 40 years, the Los Angeles Police Department has deployed teams in which police officers and mental health workers respond together. The LAPD boasts it's one of the country's earliest programs to do so. A program out of Eugene, Ore., which has been copied across the U.S., teams a crisis intervention worker with a nurse, paramedic or emergency medical technician. In Georgia, 911 emergency dispatchers steer calls to a statewide crisis center that can deploy mobile units that include professionals with backgrounds in social work, counseling and nursing. In Montana, teams are based within law enforcement departments, medical facilities or crisis homes.
'In some communities it's going to be a church group'
Whatever the specific format, mobile crisis response is becoming more and more the norm, says Kari Auclair, an area director for Western Montana Mental Health Center, a nonprofit treatment program.
"In some communities," Auclair says, "it's going to be the church group that's going to be part of a crisis response, because that's who people go to and that's what they've got."
Defenders of the various models tout reasons for their teams' makeups and match-ups: Medics can recognize a diabetic blood sugar crash, and distinguish it from a substance misuse or a mental health crisis that looks similar; police can watch for danger if tensions escalate; and crews tethered to hospitals' behavioral health units have a team of doctors on standby they can consult.
Many crisis teams still work directly with law enforcement, sometimes responding together when called, or staying on the scene after officers leave. In Montana, for example, 61% of the calls that crisis teams handled also involved law enforcement, according to state data.
Zoe Barnard, administrator for Montana's addictive and mental disorders division, says her state is still establishing a baseline for what works well there. Even after they've worked out a standard, she adds, local governments will continue to need flexibility in how they set up their programs.
"I'm a realist," Barnard says. "There will be parts of the state that are going to have limitations related to workforce, and trying to put them into a cookie-cutter model might keep some from doing something that really does the job well."
In some areas, recruiting mental health workers to such teams is nearly impossible. Federal data shows 125 million people live in areas with a shortage of mental health professionals, a problem exacerbated in rural America. That lack of help can fuel the crises that warrant emergency help.
In Montana's capital of Helena, for example, a crisis crew that formed in November must still fill two positions before services can run round-the-clock. All across the U.S., with these sorts of high-stress jobs often paid through cobbled-together grants, retaining staff is a challenge.
"We're trying to figure our way out of historical inequities in mental health care services," Coots says. "The best thing to do is to run that demonstration project, and then adapt your team based on the data."
'The mental health provider is a godsend'
And for the people in these sorts of crises who need help, having an alternative to a police officer can make a big difference, says Tyler Steinebach. He's executive director of Hope Health Alliance Inc., which offers behavioral crisis training for medics across Montana. Steinebach understands the benefit first hand — he has both bipolar and post-traumatic stress disorders and has had to call 911 when his own mental health has plummeted.
"You know cops are coming, almost certainly," Steinebach says, from his personal experience. "You're trying to figure out what to say to them because you're trying to fight for yourself to get treatment or to get somewhere where you can talk to somebody — but you're also trying to not get hauled off in handcuffs."
Gallatin County Sheriff Dan Springer also noticed the benefits after two mental health professionals started to respond to 911 calls in Bozeman and the surrounding area in 2019. Although deputies in his department are trained in crisis intervention, he says that goes only so far.
"When I hear deputies say the mental health provider is a godsend, or they came in and were able to extend the capabilities of the response, that means something to me," Springer says. "And I hear that routinely now."
Erica Gotcher, a medic on the mental health response team in Missoula, recalls a recent day when her team was wrapping up a call and received three new alerts: A man was considering suicide, a teen was spiraling into crisis and someone else needed follow-up mental health services. They knew the suicide risk call would take time as responders talked to the person by phone to get more details, so they responded to the teen hitting walls first and saw all three people before their shift was done.
Gotcher said being busy is a good sign that her team — and teams like it — are becoming just one more form of first response.
"Sometimes we roll up on a scene and there are three cop cars, an ambulance and a firetruck for one person who is having a panic attack," Gotcher says. "One of the best things that we can do is briefly assess the situation and cancel all those other resources. They can go fight fires, they can go fight crime. We are the ones that need to be here."
But gaps still exist, such as not always having somewhere to take a patient who needs a stable place to recuperate or get more help. The team's shift also ends at 8 p.m., meaning, come nighttime, it's back to police officers responding alone to mental crises calls.
If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting TALK to 741741.
Kaiser Health News is a national, editorially independent newsroom and program of Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.