When Lisa Gonzalez saw an encampment of homeless people growing in her Waikiki neighborhood last year, she wanted to direct some assistance their way but wasn’t sure who to call. 

They exhibited troubling behavior, she said, like defecating out in the open. But she didn’t want to dial 911 and have the police respond. She didn’t have much faith they would help. 

Ultimately, she was directed to someone at the Institute for Human Services who said she would pay the site a visit. But every time the IHS worker came by, the homeless people had already moved on, only to come back later. 

“She’s never been able to make contact with them because by the time she comes out, they’re gone,” Gonzalez said. “It would definitely help if there were someone who could respond quicker. They’d reach them and be able to have a dialogue.” 

Honolulu lacks a crisis response team that can be dispatched immediately to address mental health crises and behavioral health issues. Instead, the task often falls to a patchwork of social services providers whose work is supported by temporary grants. Or to Honolulu police officers, most of whom are not trained in crisis intervention or de-escalation for the mentally ill. Behavioral health calls make up 10% to 30% of HPD’s call volume, the department said. 

A growing number of American cities are embracing another way: sending mental health first responders instead of police. 

The teams are made up of unarmed crisis workers, such as social workers and health care personnel, who advocates say are better equipped than police to handle cases that don’t involve violence or crime. 

The concept was pioneered in Eugene, Oregon, more than 30 years ago. CAHOOTS – or Crisis Assistance Helping Out On The Streets – is embedded in the area’s 911 system. Dispatchers who receive calls about mental health crises, homelessness, substance abuse and other welfare checks direct the information to CAHOOTS. 

“On a fundamental level, the CAHOOTS program is designed to send the right kind of first responders into emergent crisis situations where there’s not a crime being committed, there’s no medical emergency, no fire to be put out, but where there is still somebody who’s in profound need,” said Tim Black, the consulting director of the White Bird Clinic, which runs CAHOOTS.

CAHOOTS team members help de-escalate conflict, refer individuals to services and even transport them to shelters, stabilization sites or medical clinics – avoiding unnecessary stays in jail or the emergency room, Black said.

The program handles about 17% of the Eugene Police Department’s call volume every year, which saves the police department an estimated $8.5 million annually, according to the White Bird Clinic. CAHOOTS budget is only $2.1 million. 

The team can always call for backup if workers need police assistance – they’re on the police radio system – but those occasions are rare. Of the 24,000 calls CAHOOTS responded to in 2019, only 360, or 1.5%, required police backup, Black said. Half of those cases only required police to conduct an involuntary psychiatric hold. 

Interaction with CAHOOTS is voluntary, Black said. 

“We enter into our interactions with community members on a foundation of mutual trust and with an objective of the least intervention necessary to find immediate de-escalation and stabilization,” Black said.

“That’s different from an officer who was trained through the academy, and this mentality is ingrained in them as a patrol officer, that they are a warrior and that they need to assume that every interaction they have with a community member could potentially become fatal, and to assume that it will become violent and potentially fatal.” 

Cities across the country are increasingly adopting the CAHOOTS model. It has gained particular momentum in the last year as protests nationwide have called for police reform, including shifting police responsibilities and resources toward social services agencies.  

San Francisco recently started sending personnel from its health and fire departments to behavioral health crises in lieu of police. New York City announced last week that it plans to pilot the concept in Harlem and East Harlem, areas that produce the most mental-health related emergency calls. 

Denver started a similar program last summer. Around the same time, Albuquerque, New Mexico created a new city department to pursue the idea. Orlando, Florida launched its mental health team this month, as did Portland, Oregon. 

There’s even federal legislation aimed at helping states adopt the CAHOOTS model, introduced by senators from Oregon and Nevada, and legislators are working to include a pared down version of that bill in the upcoming COVID-19 relief package. 

Several mental health advocates in Honolulu told Civil Beat it’s a concept the city should consider. 

“People who are having mental health problems are generally not criminals,” said Marya Grambs, a longtime advocate for mental health and people experiencing homelessness. 

“While they may be breaking some kind of misdemeanor law, being a nuisance or behaving oddly, they’re generally not committing (serious) crimes. But their behavior can be very disconcerting and unpleasant. But that’s not the kind of thing police are really trained to handle. That’s not what their job description is.” 

‘They Have The Skills’  

Honolulu Police Chief Susan Ballard is open to the idea of handing some police responsibilities to social workers. 

Following Black Lives Matter protests last year, the chief said at a press conference she agreed with activists that society relies too much on the police to address social ills. HPD should not be the primary respondents to matters involving homelessness and mental illness, she said.

“Those are all social issues that should be handled elsewhere,” she said. “Unfortunately when nobody else steps up, and there is nowhere else to turn to, people always turn to the police to take care of whatever the problem is.”

Ballard said she would much prefer social workers to take homelessness and mental illness off her department’s plate. 

“I think it would be fantastic because they have the skills,” she said.  

Ballard declined to be interviewed for this story. In a statement, she said HPD has advocated for the involvement of social services providers and the department is open to finding “alternate ways of responding to scenes.” 

“While we have looked at the programs being used in other cities and reached out to different agencies, we are not starting our own program at this time due to the pandemic and fiscal constraints,” she said. 

However, replacing police with unarmed crisis responders has the potential to save money, according to CAHOOTS. 

Beyond reducing the police department’s call volume, the White Bird Clinic estimates it saved over $14 million for ambulance rides and emergency room visits in 2018.  

Honolulu started training officers in crisis intervention in recent years, but only 58 officers have completed the training so far, according to the department’s latest strategic planning update. The pandemic interrupted an effort to train more officers, the department said.

The department also runs the Health Efficiency Long-term Partnerships program, which pairs officers with homeless outreach workers to help connect unsheltered people to services. 

Could Honolulu Adopt This Model?

Police responses to mental and behavioral health calls can sometimes devolve into violence or even death. 

Mental health cases make up 13% of use-of-force incidents, according to the Honolulu Police Department’s latest force report. And in recent years, incidents in which island police injured or killed a person in mental distress have made headlines.

That includes a Waipahu man with schizophrenia who was killed by police in 2013, a man on methamphetamine who died in 2015 after officers pepper-sprayed him and shot him with a Taser and a man who suffered from paranoia killed by police in 2017 after he allegedly threatened officers with a knife.  

Even in a CAHOOTS model, police would still need to respond to situations involving a weapon or aggressive behavior, but Black said crisis workers do sometimes respond in tandem with police to help with de-escalation.  

In Alameda County, California, which started a modified version of CAHOOTS last year, the crisis workers respond alongside police officers. That collaboration is important for the safety of the mental health responders, according to Karl Sporer, the county’s emergency medical services director. 

“My concern is everyone is jumping on the bandwagon of trying to take PD out of this equation, and there will be people who will get hurt who work for me,” he said. 

Some mental health advocates in Honolulu also expressed support for the CAHOOTS concept but were concerned about crisis responder safety. 

“It’s definitely a good option to explore,” said Alicia Rodriguez, a former HPD psychologist who is now in private practice. “The hard thing is it can go from zero to 60 really quick and a crisis worker isn’t comfortable with that.”

Another challenge in Honolulu is the lack of stabilization facilities and affordable housing for people in crisis, according to several advocates. So even if crisis workers were able to calm people down and get them to accept help, there are few places to bring them for long-term care. 

“We don’t have anywhere to take them,” said Kumi Macdonald, executive director of the National Alliance for Mental Illness Hawaii. “There really are no stabilization beds. There really is no place for them to go … If we don’t have a stabilization center, we can’t really do this project.” 

CAHOOTS’ strength is in being a facilitator for people in crisis, Black said. But without a place to bring people that will address their needs, the program would fail.  

“The only reason that CAHOOTS is as successful as we are at keeping folks away from jail or out of the hospital is because we have a network of other resources in our community to rely on,” Black said. 

“If we didn’t have those other resources available, we would just be helping cycle people through the hospital, and folks would still be going to jail. If a community like Honolulu is really considering mobile crisis (response) inspired by CAHOOTS, there also really needs to be an evaluation of what resources are lacking in the community for folks in crisis.”