Transforming Behavioral Health Crisis Services in the US and the Promise of the Marcus Alert System - Isabella Health Foundation

Transforming Behavioral Health Crisis Services in the US and the Promise of the Marcus Alert System

In the past two years, COVID-19 and demands for police reform have both seen rapidly increasing calls for better tools to address behavioral health crises and their severe, often inequitable impacts. The US Centers for Disease Control found that throughout the pandemic, Black Americans have been 1.7 times more likely to die of COVID-19 than White people and are 2.2 times more likely to be hospitalized. The racial disparities for Latinx and Native Americans are even higher.

Amid broader movements against violent policing, law enforcement responses to behavioral health crises also continue to result in tragic killings: one analysis by the Washington Post found that in a single year, 25% of victims in police shootings were experiencing mental illness or crisis. Just over one year ago, Seattle Police shot and killed 44-year-old Derek Hayden as he threatened to harm himself with a knife, yet Washington State still has a net of structures and systems that make it very difficult for authorities to find effective, equitable responses to this type of crisis. At the same time, governments and healthcare professionals have warned of swelling mental health crises amid the pandemic, with multiple studies—including one in the British Medical Journal in January—linking COVID-19 infection to increased risk of anxiety, depression and other diagnoses.

Pressure from disability and police reform activists has now pushed local governments to evaluate whether their emergency response systems are truly meeting communities’ needs: in North and South Carolina, seven cities contracted with RTI International to review data from over a million 911 calls and found that dispatchers flagged only 1 percent of calls as mental health crises. A study by Pew in 2021 also surveyed 233 call centers across the US on their capacity to respond to behavioral health crises and found that few had staff, training or resources explicitly tailored to mental health. Crucially, fewer than half had what are known as mobile crisis response teams—units with mental health professionals who could actually be dispatched to respond to active incidents.

The pandemic and ongoing struggles for police reform have highlighted the longstanding, glaring need to stop relying on armed police responses to mental health crises; instead, advocates push the seemingly simple idea of providing mental health responses to what are clearly mental health crises.

The past few months have seen some tentative progress, as governments and health care authorities across the country have begun adopting new models and implementing hard-won legislation. In July, legislation will finally go into effect making 988 the national hotline for behavioral health crises. The National Suicide Prevention Lifeline network will connect anyone who calls or texts the number to response systems at local centers across the country. This means that the rollout of 988 will depend largely on the models that local governments adopt, with Los Angeles, San Francisco and New York all moving to adopt new crisis response approaches in the last year and a half.

One primary example of these programs is Virginia’s newly-adopted Marcus Alert law, which local governments began rolling out at the beginning of this year. The law is named for Marcus David Peters, a young high school biology teacher killed by a Richmond Police officer in May 2018 while experiencing a mental health crisis. In the years following, racial justice and mental health advocates pushed for structural changes to address the factors that led to the highly controversial shooting and in November 2020, the Virginia General Assembly passed legislation establishing a statewide 988 line. Under the Marcus Alert law, behavioral health response systems—including mobile crisis services—are now being implemented in five regions across Virginia: Regions 1: Orange, Madison, Culpeper, Fauquier and Rappahannock Counties; Region 2: Prince William County; Region 3: City of Bristol and Washington County including the Towns of Abingdon, Damascus, and Glade Spring; Region 4: City of Richmond; and Region 5: City of Virginia Beach.

After the bill was signed, Peters’ sister Princess Blanding called on supporters and politicians to continue pushing for more meaningful police reform, so that having a mental health crisis will no longer mean a death sentence. Officials in charge of implementing Virginia’s systems emphasize that they’re aimed at reducing hospitalization and incarceration: in many cases, law enforcement responses to mental health crisis situations can also push individuals into the criminal justice system unnecessarily or lead to heavy-handed clinical responses where earlier intervention would have been sufficient.

This type of intervention is built on an idea known as Equity at Intercept 0: that early, strategic intervention, with the right kind of support, can both prevent escalation and support more equitable crisis responses—developing behavioral health crisis systems that are geared to dismantle and prevent structural inequities.

“The Marcus Alert is intended to be an opportunity to create a behavioral health response for a behavioral health emergency,” said Rebecca Holmes, executive director of Highlands Community Services, which is managing the Marcus Alert program for Bristol and Washington County. “The intent of 988 is to be the behavioral health equivalent of 911. It will land at these call centers as opposed to with 911, but the call centers and the 911 dispatchers will work hand-in-hand and will transfer calls back and forth as appropriate.”

For Washington County—the area around Bristol—a group of mental health experts, leaders from communities of color and law enforcement collaborated to create a “co-response” model, in which a mental health professional may accompany law enforcement when they respond to calls that involve behavioral health issues. The model is derived in part from a program established in Eugene, Oregon in 1989 known as CAHOOTS (Crisis Assistance Helping Out on the Streets), which allows call center operators to dispatch unarmed responders in cases of mental health crises. Now considered a blueprint for mental health incident response, CAHOOTS has recently begun offering training in mobile crisis response to help other localities address the inequitable impacts of over-policing.

Washington County’s Marcus Alert program also includes building additional in-patient facilities to help give people any support they need to recover and move past a mental health crisis that results in a 988 call.

“We’re able to just give them a soothing environment where they can further de-escalate away from the stress and chaos that might be in their home environment that’s helped contribute to a crisis situation,” added Holmes. As with many of those hurt by inappropriate armed police responses, Peters’ family say he didn’t have a history of mental health crises and an early, strategic response by behavioral health professionals may have prevented the situation from deteriorating.

Across the country, localities are piloting 988 programs to reform their crisis response systems within specific local structures and constraints. In Madison, Wisconsin, local government and UW-Madison have both begun implementing 988 mobile crisis service systems with two similar but distinct approaches: the Community Alternative Response Emergency Services (CARES) program, developed by the government, allows 911 dispatchers to refer non-violent behavioral health crises to two-person responses teams of emergency medical technicians (EMTs) and mental health professionals. UW-Madison’s model however, gives police dispatchers the option to “qualify” a call for a co-response from a university police officer and a university mental health expert. The two-system approach reflects contrasting approaches but also shows that pilot-stage 988 programs still have very limited capacity: UW-Madison’s system only operates three days per week from 10 a.m. to 6 p.m. and only for incidents on or near campus; the CARES program operates five days per week from 11 a.m. to 7 p.m., and only dispatches teams from a single point in the city. But even with this limited rollout, one representative for CARES said the program was already handling around five cases per day.

Coalitions pushing to improve mental health crisis response say that as 988 programs scale up, authorities have to focus on equity, prevention and community-based models. To succeed, these programs need to take the lead from Black and other minority communities who have historically seen inappropriate, often violent crisis interventions and over-policing. As they consistently see negative impacts, rather than support, from law enforcement responses, it’s these local communities who can shape effective, new models amid COVID-19 and ongoing movements for police reform.

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