Crisis Response Models Report | 42
2. Significant Role for Peers,
3. Trauma-Informed Care,
4. Zero Suicide/Suicide Safer Care,
5. Safety/Security for Staff and People in Crisis and
6. Crisis Response Partnerships with Law Enforcement, Dispatch, and Emergency Medical Services.
Addressing Recovery Needs
Crisis providers must address the recovery needs of individuals and families to move beyond their mental health and substance use challenges to lead happy, productive and connected lives each and every day.
Implementation Guidance
1. Commit to a no-force-first approach to quality improvement in care that is characterized by engagement and collaboration.
2. Create engaging and supportive environments that are as free of barriers as possible. This should include eliminating Plexiglas from crisis stabilization units and minimal barriers between team members and those being served to support stronger connections.
3. Ensure team members engage individuals in the care process during a crisis.
Communicate clearly regarding all options clearly and offer materials regarding the process in writing in the individual’s preferred language whenever possible.
4. Ask the individual served about their preferences and do what can be done to align actions to those preferences.
5. Help ensure natural supports and personal attendants are also part of the planning team, such as with youth and persons with intellectual and developmental disabilities.
6. Work to convert those with an involuntary commitment to voluntary so they are invested in their own recovery.
Significant Role for Peers
A transformative element of recovery-oriented care is to fully engage the experience, capabilities and compassion of people who have experienced mental health crises. Including individuals with lived mental health and substance use disorder experience (peers) as core members of a crisis team supports engagement efforts through the unique power of bonding over common experiences while adding the benefits of the peer modeling that recovery is possible.
Implementation Guidance
1. Hire credentialed peers with lived experience that reflect the characteristics of the community served as much as possible. Peers should be hired with attention to common characteristics such as gender, race, primary language, ethnicity, religion, veteran status, lived experiences and age.
Crisis Response Models Report | 43
2. Develop support and supervision that aligns with the needs of your program’s team members.
3. Emphasize engagement as a fundamental pillar of care that includes peers as a vital part of a crisis program’s service delivery system. This should include (1) integrating peers within available crisis line operations, (2) having peers serve as one of two mobile team members and (3) ensuring a peer is one of the first individuals to greet an individual admitted to a crisis stabilization facility.
Trauma-Informed Care
The great majority of individuals served in mental health and substance use services have experienced significant interpersonal trauma. Mental health crises and suicidality often are rooted in trauma. These crises are compounded when crisis care involves loss of freedom, noisy and crowded environments and/or the use of force. These situations can actually re-traumatize individuals at the worst possible time, leading to worsened symptoms and a genuine reluctance to seek help in the future.
On the other hand, environments and treatment approaches that are safe and calm can facilitate healing. Thus, we find that trauma-informed care is an essential element of crisis treatment. In 2014, SAMHSA set the following guiding principles for trauma-informed care:
1. Safety;
2. Trustworthiness and transparency;
3. Peer support and mutual self-help;
4. Collaboration and mutuality;
5. Empowerment, voice and choice; and
6. Ensuring cultural, historical and gender considerations inform the care provided.
Trauma-informed systems of care ensure these practices are integrated into service delivery. Developing and maintaining a healthy environment of care also requires support for staff, who may have experienced trauma themselves.
Implementation Guidance
1. Incorporate trauma-informed care training into each team member’s new employee orientation with refreshers delivered as needed.
2. Apply assessment tools that evaluate the level of trauma experienced by the individuals served by the crisis program and create action steps based on those assessments.
Zero Suicide/Suicide Safer Care
Two transformational commitments must be made by every crisis provider in the nation: (1) adoption of suicide prevention as a core responsibility, and (2) commitment to dramatic reductions in suicide among people under care. These changes were adopted and advanced in the revised National Strategy for Suicide
Crisis Response Models Report | 44
Prevention (2012), specifically via a new Goal 8: “Promote suicide prevention as a core component of health care services” (p. 51).
The following key elements of Zero Suicide or Suicide Safer Care are all applicable to crisis care:
1. Leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care, that includes survivors of suicide attempts and suicide loss in leadership and planning roles;
2. Developing a competent, confident, and caring workforce;
3. Systematically identifying and assessing suicide risk among people receiving care;
4. Ensuring every individual has a pathway to care that is both timely and adequate to meet his or her needs and includes collaborative safety planning and a reduction in access to lethal means;
5. Using effective, evidence-based treatments that directly target suicidal thoughts and behaviors;
6. Providing continuous contact and support; especially after acute care; and
7. Applying a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.
Safety/Security for Staff and People in Crisis
Safety for both individuals served and staff is a foundational element for all crisis service settings. Crisis settings are also on the front lines of assessing and managing suicidality and possibly violent thoughts or aggressive behaviors, issues with life and death consequences. While ensuring safety for people using crisis services is paramount, the safety for staff cannot be compromised. Keys to safety and security in crisis delivery settings include:
• Evidence-based and trauma-informed crisis training for all staff; • Role-specific staff training and appropriate staffing ratios to number of clients being served;
• A non-institutional and welcoming physical space and environment for persons in crisis, rather than Plexiglas “fishbowl” observation rooms and keypad-locked doors. This space must also be anti-ligature sensitive and contain safe rooms for people for whom violence may be imminent; • Established policies and procedures emphasizing “no force first” prior to implementation of safe physical restraint or seclusion procedures; • Pre-established criteria for crisis system entry;
• Strong relationships with law enforcement and first responders; and • Policies that include the roles of clinical staff (and law enforcement if needed) for management of incidents of behavior that places others at risk.
Providers must establish environments that are safe for those they serve as well as their own team members who are charged with delivering high quality crisis care that aligns with best practice guidelines. The keys to safety and security for
Crisis Response Models Report | 45
home visits by mental health staff include:
• No mental health crisis outreach worker will be required to conduct home visits alone.
• Employers will equip mental health workers who engage in home visits with a communication device.
• Mental health workers dispatched on crisis outreach visits will have prompt access to any information available on history of dangerousness or potential dangerousness of the client they are visiting.
Implementation Guidance
1. Commit to a no-force-first approach to care.
2. Monitor, report and review all incidents of seclusion and restraint with the goal of minimizing the use of these interventions.
3. Remember that barriers do not equal safety. The key to safety is engagement and empowerment of the individual served while in crisis.
4. Offer enough space in the physical environment to meet the needs of the population served. A lack of space can elevate anxiety for all.
5. Incorporate quiet spaces into your crisis facility for those who would benefit from time away from the milieu of the main stabilization area.
6. Engage your team members and those you serve in discussions regarding how to enhance safety within the crisis program.
Law Enforcement and Crisis Response—An
Essential Partnership
Law enforcement agencies have reported a significant increase in police contacts with people with mental illness in recent years. Some involvement with mental health crises is inevitable for police. Police officers may (1) provide support in potentially dangerous situations when the need is assessed or (2) make warm hand-offs into crisis care if they happen to be first to engage.
In many communities across the United States, the absence of sufficient and well-integrated mental health crisis care has made local law enforcement the de facto mental health mobile crisis system. This is unacceptable and unsafe. The role of local law enforcement in addressing emergent public safety risk is essential and important. With good mental health crisis care in place, the care team can collaborate with law enforcement in a fashion that will improve both public safety and mental health outcomes. Unfortunately, well-intentioned law enforcement responders to a crisis call can escalate the situation solely based on the presence of police vehicles and armed officers that generate anxiety for far too many individuals in a crisis.
Implementation Guidance
1. Have local crisis providers actively participate in Crisis Intervention Team training or related mental health crisis management training sessions.
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2. Incorporate regular meetings between law enforcement and crisis providers, including EMS and dispatch, into the schedule so these partners can work to continuously improve their practices.
3. Include training on crisis provider and law enforcement partnerships in the training for both partner groups.
4. Share aggregate outcomes data such as numbers served, percentage stabilized and returned to the community and connections to ongoing care.
Psychiatric Advance Directives
A psychiatric or mental health advance directive (PAD) is a legal tool that allows a person with mental illness to state their preferences for treatment in advance of a crisis. They can serve as a way to protect a person's autonomy and ability to self-direct care. Crisis providers are expected to always seek to understand and implement any existing PAD that has been developed by the individual during the evaluation phase and work to ensure the individual discharges from crisis care with an updated and accurate psychiatric advance directive whenever possible. PAD creates a path to express treatment preferences and identify a representative who is trusted and legally empowered to make healthcare decisions on medications, preferred facilities, and listings of visitors.
The full Crisis Services Best Practice Toolkit document contains specific strategies on how a community can fund each of the core crisis system elements in single and multiple-payer environments. Additionally, recommendations on service coding already being reimbursed by Medicaid in multiple states are made available; including the use of HCPCS code H2011 Crisis Intervention Service per 15 Minutes for mobile crisis services and S9484 Crisis Intervention Mental Health Services per Hour or S9485 Crisis Intervention Mental Health Services per Diem for crisis receiving and stabilization facility services.
Many members of the crisis services delivery team are licensed mental health and substance use professionals operating within the scope of their license and training with supervision delivered in a manner consistent with professional expectations of the licensing board. Licensed professionals are expected to strengthen their skills and knowledge through ongoing CEU and CME professional advancement opportunities focused on improving team members’ ability to deliver crisis care.
Providers also incorporate non-licensed individuals within the service delivery Funding Crisis Care
Training and Supervision
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team; creating the need for additional training and supervision to ensure services are delivered in a manner that advances positive outcomes for those engaged in care. Verification of skills and knowledge of non-professional staff is essential to maintaining service delivery standards within a crisis program; including the incorporation of ongoing supervision with licensed professionals available on site at all times. Supervision and the verification of skills and knowledge shall include, but is not limited to, active engagement strategies, trauma-informed care, addressing recovery needs, suicide-safer care, community resources, psychiatric advance directives and role-specific tasks. tasks.
Crisis services must be designed to serve anyone, anywhere and anytime.
Communities that commit to this approach and dedicate resources to address the community need decrease psychiatric boarding in emergency departments and reduce the demands on the justice system. These two benefits translate into better care, better health outcomes and lower costs to the community. The National Guidelines for Crisis Care – A Best Practice Toolkit delivers a roadmap that can be used to truly make a positive impact to communities across the country.
Conclusion
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Appendix B. Sample Outlines of Types of Scenarios for
Crisis Response Teams
Appendix B-1. County and City of San Francisco’s Crisis Response
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Appendix B-2. County of Los Angeles’ Behavioral Health Crisis Triage
Crisis Response Models Report | 50
Appendix C. Crisis Response Programs Researched by RDA – Summary of Key Components
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Albuquerque Community Safety
Department – Albuquerque, NM
911 Mental health, inebriation,
homelessness, addiction
TBD Clinicians or peers TBD TBD
B-HEARD (the Behavioral Health
Emergency Assistance Response
Division) – New York, NY
911
dispatch
Mental health Daily 16
hours per
day
2 EMTs or
paramedics + social
worker
Non-transport
vehicles
Connect with
services if
transported;
heat team does
follow-up
(clinician and
peer for follow-
up connection to
services)
Boston Police Department’s Co-
Responder Program – Boston,
MA
911
dispatch
Mental health crisis Unknown Co-responder
(police + clinician)
Police car Unknown
Crisis Assistance Helping Out On
The Streets (CAHOOTS) –
Eugene, OR
911 calls
dispatched
on radio
Non-emergency calls 24/7 Unlicensed crisis
worker and EMT or
paramedic
3 vans with logo Not currently
part of services
Crisis Assessment & Transport
Team (CATT) – Alameda County,
CA
911
dispatch
Mental health Daily 7am-
12am
Licensed clinician +
EMT, co-responding
with police
Unmarked
vehicles, barrier,
custom locks
and windows,
locked storage
cabinets
Unknown
Community Paramedicine –
California (statewide)
911
dispatch
Non-emergency health and
mental health calls
Unknown Paramedics Unknown Unknown
Crisis Call Diversion Program
(CCD) – Houston, TX
911
dispatch
Non-emergency mental
and behavioral health calls
Daily,
morning and
evening
shifts
Mental health
professional tele-
counselors at 911
call center
N/A Unknown
Crisis Response Models Report | 51
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Crisis Now – National model (via
SAMHSA)
Regional
crisis call
hub
Mental health 24/7 Licensed clinician +
behavioral health
specialist
Unmarked van Program staff
follows up to
ensure
connection to a
resource
Crisis Response Pilot – Chicago,
IL
911
dispatch
Mental health M-F 9:30-
5:30
Paramedic, crisis
counselor, CIT
officer, peer
recovery coach
2 vans Unknown
Crisis Response Unit – Olympia,
WA
911 or
alternate
number
Mental health,
homelessness
Daily 7am-
9pm
Nurse + behavioral
health specialist
Van owned by
the City
Repeat clients
get referred to
peer navigation
program
(Familiar Faces)
Cuyahoga County Mobile Crisis
Team – Cuyahoga County, Ohio
National
Suicide
Prevention
Hotline
Mental health 24/7 Licensed clinicians Unknown Unknown
Department of Community
Response – Sacramento, CA
911 or
alternate
number
Mental health,
homelessness, youth and
family crisis, substance use
24/7 Social workers 6 vans CBO partner will
provide
connection to
longer term care
and follow up
services
Department of Community
Solutions and Public Safety –
Ithaca, NY
TBD Non-violent calls TBD Unarmed first
responders
TBD TBD
Downtown Emergency Service
Center (DESC) Mobile Crisis
Team – King County, WA
911
dispatch
Mental health, substance
use
24/7 Mental health
professional
Unknown Unknown
Crisis Response Models Report | 52
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Expanded Mobile Crisis
Outreach Team (EMCOT) –
Austin, TX
911 or
alternate
number
Mental health 24/7 Field staff: two
person teams of
clinicians
Call center staff:
mental health
professionals
Unmarked
vehicles
Post-crisis
services available
for up to 3
months after
initial contact
Georgia Crisis & Access Line
(GCAL) – Georgia (statewide)
Alternate
number,
app
Non-emergency mental
health, substance use
24/7 Mental health
professionals
Unknown Unknown
Los Angeles County Department
of Mental Health - ACCESS
Center – Los Angeles County, CA
Alternate
number
Mental health 24/7 Unknown Unknown Unknown
Los Angeles County Department
of Mental Health - Co-Response
Program – Los Angeles County,
CA
911
dispatch
Emergency mental health Unknown Co-responder
(police + clinician)
Police car Unknown
Los Angeles County Department
of Mental Health - Psychiatric
Mobile Response Team (PMRT)
– Los Angeles County, CA
Alternate
number
Mental health crises Unknown Psychiatric mobile
response team
Unknown Unknown
Mobile Assistance Community
Responders of Oakland
(MACRO) – Oakland, CA
911
dispatch
Non-emergency calls 24/7 Unlicensed
community member
+ EMT
Vehicle with
radios, mobile
data terminal,
cell phones
Community
Resource
Specialist to
connect to
resources
Mental Health Acute
Assessment
Team (MHAAT) – Sydney,
Australia
Ambulance
Control
Center
Acute mental health crises Unknown Paramedic + mental
health nurse
Ambulance Contacted within
3 days, follow up
with referral
facility
Mental Health First / Anti-Police
Terror Project – Sacramento and
Oakland, CA
Alternate
number,
social
media
Mental health, domestic
violence, substance use
Fri-Sun 7pm-
7am
Peer first
responders
Use personal
vehicles and
meet at the
scene; have an
RV with supplies
Have relationship
with CBOs, staff
work to get folks
into longer term
services
Mental Health Mobile Crisis
Team (MHMCT) – Nova Scotia,
Canada
911
dispatch
Mental health 24/7 Co-responder
(police + clinician)
and telephone
clinician support
Unknown Unknown
Crisis Response Models Report | 53
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Mobile Crisis Assistance Team
(MCAT) – Indianapolis, IN
911
dispatch
Mental health, substance
use
M-F, not
after hours
or overnight
Co-responder
(police + clinician +
paramedics)
Unknown Conduct follow
up visits to
encourage
connection to
care
Mobile Crisis Rapid Response
Team (MCRRT) – Hamilton,
Ontario, Canada
911
dispatch
Mental health Unknown Co-responder (CIT-
trained police +
clinician)
Police car Unknown
Mobile Emergency Response
Team for Youth (MERTY) –
Santa Cruz, CA
Alternate
number
Mental health calls for
youth
M-F 8am-
5pm
Clinician + family
specialist
Van with
wheelchair lift,
comfortable
chairs, TV,
snacks
Continue to
provide services
until patient
connected with
long-term
services
Mobile Evaluation Team (MET) –
East Oakland, CA
911 or
alternate
number
Mental health Mon-Thurs
8am-3:30pm
Co-responder (1-2
mental health
clinicians + police
officer)
Unmarked
police car
Unknown
Psykiatrisk Akut Mobilitet
(PAM) Unit, the
Psychiatric Emergency Response
Team – Stockholm, Sweden
Alarm
center
Acute risk of suicidal
behavior
Daily 2pm-
2am
2 psychiatric nurses
and ambulance
driver
Ambulance Unknown
Police and Clinician Emergency
Response (PACER) – Australia
(several locations)
Dispatched
by police
Mental health Varies Co-responder
(police + clinician)
Unknown Unknown
Portland Street Response –
Portland, OR
911 or
alternate
number
Low-acuity mental health,
substance use, welfare
checks
M-F 10am-
6pm
EMT and LCSW
dispatched to
scene; 2 CHWs
called in for follow-
up
Van with logo CHWs connect to
services;
partnerships
with CBOs for
outreach in
encampments
REACH 24/7 Crisis Diversion –
Edmonton, Alberta, Canada
Alternate
number
(211)
Non-violent, non-
emergency calls
24/7 2 crisis diversion
workers
Have van to
transport
Connector role
for connection to
long-term
services
Crisis Response Models Report | 54
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Seattle Crisis Response Team –
Seattle, WA
911
dispatch
Mental health,
assault/threat/harassment,
suspicious circumstance,
disturbance
Unknown Co-responder (CIT +
clinician)
Unknown Clinicians can
follow up with
clients
Supported Team Assisted
Response (STAR) – Denver, CO
911
dispatch
Mental health,
homelessness, substance
use
M-F 10am-
6pm
Mental health
clinician (SW) +
paramedic
Civilian van with
amber lights,
bucket seats on
each side with
standard front
seat
Can hand off to
case managers
Street Crisis Response Team
(SCRT) – San Francisco, CA
911 calls
dispatched
on radio
Non-emergency mental
health
Daily, 12
hours a day
Social
worker/psychologist
+ paramedic + peer
Van with lights
and sirens,
currently using
old fire
department
vehicles
Office of Care
Coordination
provides linkages
to other services
Street Triage – England (several
locations)
Emergency
dispatch
Mental health Varies Mental health nurse Unknown Unknown Therapeutic Transportation Pilot
Program/Alternative Crisis
Response – Los Angeles City and
County, CA
911
dispatch
Mental health crisis 24/7 Mental health
experts co-respond
or take the lead on
MH calls
Plan to have van
for transports
Level 1 calls will
be referred to
non-crisis follow
up services, folks
can step down
from crisis
receiving to
residential
program
Toronto Crisis Response –
Toronto, Ontario, Canada
TBD Non-violent, non-
emergency calls
TBD Mental health
professionals
TBD TBD
City of Berkeley
Mental Health Crisis Response Services and
Stakeholder Perspectives Report
City of Berkeley Mental Health Crisis Response & Perspectives | 2
City of Berkeley
Specialized Care Unit Model Recommendations
City of Berkeley Mental Health Crisis Response and Stakeholder Perspectives Report
Sarah Ferrell
Caroline de Bie
Sasha Gayle-Schneider
Jamie Dorsey
Nicole Gamache-Kocol
Kevin Wu
This report was developed by Resource Development Associates under contract with the City of Berkeley Health, Housing & Community Services Department.
Resource Development Associates, October 2021
City of Berkeley Mental Health Crisis Response & Perspectives | 3
Table of Contents
Executive Summary 4
Introduction 6
Communitywide Data Collection 7
Overview of Berkeley Crisis Response 11
Stakeholder Feedback 23
Community Aspirations 46
Appendices 51
City of Berkeley Mental Health Crisis Response & Perspectives | 4
Executive Summary
The City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study to inform the development of Specialized Care Unit (SCU) pilot to respond to mental health crises without the involvement of law enforcement. RDA’s feasibility study includes community-informed program design recommendations, a phased implementation plan, and funding considerations. RDA’s first report from this feasibility study was a synthesis of crisis response programs in the United States and internationally. This second report details RDA’s synthesized findings from speaking with and collecting data from a myriad of City of Berkeley and Alameda County agencies, community-based organizations (CBOs), local stakeholders and community leaders, and utilizers of Berkeley’s crisis response services.
This report has two focus areas: 1) describing the City of Berkeley’s current mental health crisis response system, including the roles and responsibilities of the various agencies involved and basic quantitative data about the volume of mental health crisis calls received; and 2) sharing key themes from RDA’s qualitative data collection efforts across the Berkeley community.
Presently, callers experiencing a mental health crisis typically call 911, Mobile Crisis Team (MCT) phone line, or the Alameda County Crisis Support Services phone line. Depending on the assessment of the call, phone or in-person services are deployed. All these points of access could result in a police response.
In Berkeley, while there are a variety of programs and service provided by Berkeley Mental Health, Berkeley Police, Berkeley Fire, and an array of community-based organizations, there is an overall insufficient level of resources to meet the volume and types of mental health crisis needs across the city. Stakeholder participants urged that the concept and definition of a mental health crisis and crisis services be expanded to include the full spectrum of a mental health crisis, including prevention, diversion, intervention, and follow-up. Through this lens, stakeholders identified strengths and challenges of the existing crisis response system, described personal experiences, and shared ideas for a reimagined mental health crisis response system.
Key Themes from
Stakeholder Feedback
Perceptions of the urgent need for a non-police mental
health crisis response in Berkeley
City of Berkeley Mental Health Crisis Response & Perspectives | 5
Perceptions of varied availability, accessibility, and
quality of crisis response services
Perceptions of insufficient crisis services for substance use emergencies
Perceptions of a need for a variety of crisis transport options
Perceptions of a lack of sites for non-emergency care
Perceptions around supporting the full spectrum of
mental health crisis needs
Perceptions of a need for post-crisis follow-up care
Perceptions of barriers to successful partnerships and
referrals across the mental health service network
Perceptions of needs to integrate data systems and
data sharing to improve services
Perceptions of a need for increased community
education and public awareness of crisis response
options
Participants were asked to share their ideas for alternative approaches to mental health and substance use crises as well as to share community needs for a safe, effective mental health and substance use crisis response. Such perspectives illuminate the perceived gaps in the current system that could be filled by a future SCU. These perspectives are summarized as guiding aspirations for reimagining public safety and designing a response system that promotes the safety, health, and well- being of all Berkeley residents.
Community Aspirations
Stakeholder-identified opportunities to address the root causes that contribute to mental health, homelessness,
and substance use crises
Stakeholder-identified opportunities for centering BIPOC communities in crisis response
Stakeholder-identified opportunities for community
oversight to ensure equitable and transformative crisis care
City of Berkeley Mental Health Crisis Response & Perspectives | 6
Introduction
In response to the killing of George Floyd by Minneapolis police in May 2020 and the ensuing protests across the nation for this and many other similar tragedies, a national conversation emerged about how policing can be done differently in local communities. The Berkeley City Council initiated a broad-reaching process to reimagine policing in the City of Berkeley. As part of that process, in July 2020, the Berkeley City Council directed the City Manager to pursue reforms to limit the Berkeley Police Department’s scope of work to “primarily violent and criminal matters.” These reforms included, in part, the development of a Specialized Care Unit (SCU) pilot to respond to mental health crises without the involvement of law enforcement.
To inform the development of an SCU, the City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study that includes community-informed program design
recommendations, a phased implementation plan, and funding considerations. RDA’s first report from this feasibility study was a synthesized summary of its review of the components of nearly 40 crisis response programs in the United States and internationally. This second report details RDA’s synthesized findings from speaking with and collecting data from a myriad of City of Berkeley and Alameda County agencies, community-based organizations (CBOs), local stakeholders and community leaders, and utilizers of Berkeley’s crisis response services.
With the guidance and support of an SCU Steering Committee (led by the Director of City of Berkeley’s Health, Housing and Community Services Department), RDA conducted a large volume of community and agency outreach and qualitative data collection activities between June-July 2021. The goal of this immense undertaking was to understand the variety of perspectives in the local community regarding how mental health crises are currently being responded to as well as the community’s desires for a different crisis response system that would better serve its populations and needs. The City of Berkeley will be implementing an SCU that consists of a team of providers – that does not include law enforcement representation – who will respond to mental health crisis situations in Berkeley. Given that this is happening, RDA’s data collection focused on obtaining perspectives that could inform the development of Berkeley’s SCU; in contrast, RDA’s data collection was not targeted at understanding the validity or utility of having a SCU in Berkeley.
RDA’s outreach and data collection efforts yielded a large volume of information. In order to ensure this report is accessible to a wide audience - in both the length and breadth of findings - RDA’s analysis of all the information it collected was led by a clear goal of identifying common themes across its many data sources. Additionally, RDA sought to distill all findings into manageable pieces that could be succinctly written about in this report.
This report has two focus areas: 1) describing the City of Berkeley’s current mental health crisis response system, including the roles and responsibilities
City of Berkeley Mental Health Crisis Response & Perspectives | 7
of the various agencies involved and basic quantitative data about the volume of services provided; and 2) sharing the common themes from RDA’s qualitative data collection efforts across the Berkeley community. It is important to note upfront that given the limited quantitative data available about Berkeley’s historical mental health crisis response calls – as documented and described in much depth by the Berkeley City Auditor’s study (released in April 2021) entitled “Data Analysis of City of Berkeley’s Police Response”
1 – this report is focused on qualitative data. That data allows for a better understanding of what this set of stakeholders feels about the current crisis system and their hopes for an improved system.
After sharing information about Berkeley’s current mental health crisis response services, this report shares information from RDA’s qualitative data collection activities with local agencies, CBOs, stakeholders, and utilizers of crisis response services.
Communitywide Data Collection
In order to fully understand the current state of the mental health crisis system in the City of Berkeley, RDA engaged a variety of stakeholders in gathering both quantitative and qualitative data. As this is a community- driven process, much of the data collection was through engaging members of the Berkeley community. These methods will be described below.
Note: Please refer to the following section,
What is the current mental
health crisis call volume in Berkeley? for a description of the project’s quantitative methods.
Community Engagement Planning
Process
To bring resident and other stakeholder voices into community planning efforts, RDA worked closely with the SCU Steering Committee 2 to develop a comprehensive, inclusive, and accessible outreach and engagement plan. The goal of this plan was not to reach a group that was “representative” of all Berkeley residents, but rather to hear from those that receive crisis response services, those that call or initiate crisis
1 https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20Pol ice%20Response.pdf
2 Berkeley Specialized Care Unit Steering Committee members: Colin Arnold, Paul Kealoha Blake, Jeff Buell, Caroline de Bie, Margaret Fine, Maria Moore, Andrea Pritchett, David Sprague, David McPartland, Marc Staton, Lisa Warhuus, and Jamie Works-Wright.
City of Berkeley Mental Health Crisis Response & Perspectives | 8
response, and those whose voices are commonly omitted from city planning efforts. The plan focused on those who are most marginalized by the current system and are most at risk of harm. These groups include, but are not limited to the following:
● Individuals who are frequently targeted by policing, including:
○ Black and African Americans
○ Native Americans
○ Pacific Islander Americans
○ Latinx Americans
○ Asian Americans
○ SWANA (Southwest Asia and North Africa)
● People who have experienced a mental health crisis
● People experiencing or at risk of homelessness
● People who use substances
● Gay, Lesbian, Bisexual, Queer, Transgender and Non-Binary people ● Seniors and older adults
● Transition age youth (TAY)
● People with disabilities
● Survivors of domestic violence and/or intimate partner violence ● People returning to the community from prison or jail ● Veterans
● Immigrants and undocumented residents
RDA and the steering committee also reached out to a wide range of advocates, service providers, and CBOs. In addition to wanting to understand the current state of crisis services from a provider perspective, one of the objectives for reaching out to these advocacy and community organizations was to leverage their community and client connections to reach the target populations.
Once the target groups were identified, RDA and the SCU Steering Committee developed a specific outreach plan and interview guides for each group. The outreach strategy was designed to maximize accessibility by providing multiple opportunities for engagement. Interview guides
3 were customized to each group but followed the same set of four core questions:
1. People’s experiences with, and perceptions of, the current mental health and substance use related crisis response options;
2. Challenges and strengths of current mental health and substance use related crisis response options;
3. Ideas for an alternative approach to mental health and substance use related crises; and
4. Needs identified by the community for a safe, effective mental health and substance use related crisis response.
3 For an example interview guide, see Appendix A.
City of Berkeley Mental Health Crisis Response & Perspectives | 9
This set of four questions was also used to create a survey distributed to providers unable to attend focus groups, their clients, other service utilizers, and the broader Berkeley community.
It is important to note that mental health crisis affects everyone. RDA purposefully focused engagement efforts on groups that are most often marginalized and at risk of harm from the current crisis system, but in so doing, was an approach that may not have brought in all voices impacted by mental health crisis. The key themes brought out by stakeholders, therefore, may not be fully representative of the broader Berkeley community. Instead, the key themes reflect the perspective of those most impacted by the current system.
Data Sources
All outreach activities occurred between June and July 2021. RDA engaged the community in a variety of in-person and virtual mediums including interviews, focus groups, shadowing, and surveys. In total, RDA conducted 18 focus groups, 51 individual interviews, 1 full day of shadowing dispatch at BPD, and administered 1 online survey.
The CBOs and community members that were targeted for outreach skewed towards either agencies serving unhoused populations in Berkeley or individuals who were unhoused. This was an intentional strategy to reach a population that is generally underrepresented in community-wide data collection efforts. But, as mentioned above, mental health crises can affect anyone, not just those who are unhoused.
Below is a list of groups that were engaged in interviews or focus groups as part of this process.
Type of Group Organizations/Departments (# individuals) City of
Berkeley &
Alameda
County
1. Berkeley Fire Department
2. Berkeley Fire Department – Mobile Integrated
Paramedic (MIP)
3. Berkeley Mental Health
4. Berkeley Mental Health - Mobile Crisis Team
5. Berkeley Mental Health – Crisis, Assessment, and
Triage (CAT)
6. Berkeley Mental Health - Homeless Full Service
Partnership
7. Berkeley Mental Health – Transitional Outreach
Team (TOT)
8. Berkeley Police Department - Key Informants
9. Berkeley Police Department – Dispatch
10. Berkeley Police Department - Community
Services Bureau
11. Berkeley Police Department - Public Safety
Officers
12. City of Berkeley - Aging Services
13. Alameda County Behavioral Health Care
Services
14. Alameda County Crisis Support Services
City of Berkeley Mental Health Crisis Response & Perspectives | 10
Type of Group Organizations/Departments (# individuals) Community-
Based
Organizations
1. Alameda County Network of Mental Health
Clients
2. Alameda County Psychological Association
3. Anti Police-Terror Project
4. BACS - Amber House
5. Berkeley Free Clinic
6. Dorothy Day House
7. Harm Reduction Therapy Center
8. LifeLong Medical Care - Ashby Health Center,
Behavioral Health
9. LifeLong Medical Care - Street Medicine
10. Needle Exchange Emergency Distribution
(NEED)
11. Pacific Center
12. UC Berkeley School of Social Welfare
13. Women’s Daytime Drop-In Center
Service
Utilizers
1. People’s Park
2. Seabreeze encampment
3. Planting Justice
Demographics of Participants of RDA’s
Data Collection Efforts
RDA was able to reach a large demographic of providers, service utilizers, and community members across these engagement efforts. These data collection efforts were not focused on providers of mental health care, substance use disorder care, or insurance companies like Kaiser Permanente or the Alameda Alliance. This was a purposeful decision to gain the insight of those who are outside of the current system of care.
Demographic information was not gathered for City of Berkeley or Alameda County staff.
Overall, RDA received information from more people in the 30-44 range than any other age range. As compared to Berkeley’s overall population, service utilizers and providers who identified as Black or African American were overrepresented in RDA’s data collection efforts. There were far more cisgender participants than transgender participants overall, though a higher proportion of service utilizer respondents were transgender compared to survey respondents and provider respondents. RDA collected feedback from more than double the number of female- identifying participants than male identifying participants. Overall, there were very few genderqueer or nonbinary participants. The most common zip codes of participants were 94710, 94702, 94703, and 94704. For more a more detailed description of participant demographics, see Appendix B .
City of Berkeley Mental Health Crisis Response & Perspectives | 11
Impacts of COVID-19 Pandemic on Data
Collection
The COVID-19 pandemic made it challenging for this project to engage with participants for data collection. The rise of the Delta variant in August 2021 further complicated matters. Many non-medical social service providers in Berkeley had suspended or limited their in-person services with clients due to the pandemic, so RDA was unable to connect with clients in-person. Invitations were sent to case managers and group/individual counselors to forward to their clients in hopes of interviewing clients, but this did not prove to be effective. Aside from being unable to connect with participants in-person, many providers were overwhelmed with ongoing COVID-19 emergency response and unable to participate in focus groups or the survey. Eleven agencies were in conversation with RDA but were unable to attend any focus groups or submit a survey, and 34 agencies did not respond to attempts to connect. Despite these challenges, RDA found considerable themes and patterns in the data that was collected for this project and feel strongly that the data and perspectives presented here represent the scope of the issues pertinent to mental health crisis response in the City of Berkeley.
Overview of Berkeley Crisis
Response
What is the current mental health crisis
response system in Berkeley?
To understand where the gaps are in the mental health crisis response system in Berkeley, it is important to understand each component and the surrounding landscape of providers and services. The following section describes the process of a mental health call, key city and county entities involved in the crisis system, and other community-based organizations who provide crisis services. This information was gathered during key informant interviews with city and county staff, CBO provider focus groups, and consulting online materials.
Process of Response to a Mental Health Call4
When someone makes a call for a mental health crisis, they will typically call 911, the Mental Health Division’s Mobile Crisis Team (MCT) phone line,
4 See Appendix C for a flowchart of this process.
City of Berkeley Mental Health Crisis Response & Perspectives | 12
or Crisis Support Services of Alameda County. The caller is often a family member, friend, or bystander.
If the call goes to 911, the staff member at Berkeley dispatch receives the call. They use the Emergency Medical Dispatch (EMD) protocols to assess whom to deploy to the scene: fire, police, or an ambulance. When assessing a call for the presence mental health issues, they consider many factors including the possibility of violence against the caller or others, certainty or uncertainty of violence, whether the person is using substances and what type of substance, the coherence of the person’s thoughts or behaviors, and background noises. Callers can specifically request MCT, in which case dispatchers may call MCT on the radio and request an MCT call-back for the caller.
If they determine that services can be delivered over the phone, they can transfer the call to Alameda County Crisis Support Services (CSS). If CSS cannot resolve the crisis, they will send the call back to dispatch for an in- person response. If an in-person response is required, they will transfer the call to the appropriate dispatcher staff. Calls with a potential for violence or criminal activity are transferred to police dispatch. Police can call the Berkeley Mobile Crisis Team (MCT) for backup if it is clear that there is a mental health component to the situation. Calls that involve mental health are sent to police dispatch. Police will then alert the MCT that they are needed on-scene. The police will arrive first to secure the scene, then mobile crisis will provide mental health crisis services while police are still on-scene. If the individual needs to be transported to a secondary location, the police will call for an ambulance. Calls that involve a medical or fire issue are transferred to fire dispatch. If fire staff need to place an involuntary hold on the person, they can call police to place the hold.
If the caller decides to call MCT directly, their call will be sent to a confidential voicemail. An MCT staff member will listen to the voicemail, call the person back, and provide services over the phone. If no further services are required, the call is resolved. If an in-person response is required, MCT will call police dispatch to have police secure the scene.
After MCT calls dispatch, they will travel to the scene of the incident.
Once the scene is secured, MCT provides services and may call an ambulance through dispatch if transport is needed.
If the caller decides to call CSS directly, staff will first attempt to resolve the crisis over the phone. If they are able to de-escalate the crisis over the phone, they will provide referral services to additional resources or, on rare occasions, contact Berkeley Mental Health for follow-up care. If they are unable to resolve the crisis, they will send the call to 911 dispatch.
After the incident, the Berkeley Transitional Outreach Team (TOT) will follow-up with the client to ensure that options for longer term care have been offered. TOT can provide referrals and linkage to long-term services, bridging the gap between a moment of crisis and ongoing mental health care.
City of Berkeley Mental Health Crisis Response & Perspectives | 13
City and County Teams that Respond During a Crisis
There are several teams within the City of Berkeley and Alameda County that provide services to someone experiencing a mental health crisis.
These include programs within Berkeley Mental Health, Berkeley Police Department, Berkeley Fire Department, and Alameda County Behavioral Health Care Services. Although, as mentioned later in this report, the community does not see these services as sufficient or linked.
Berkeley Mental Health Crisis Programs:
The City of Berkeley is contracted by Alameda County to deliver mental health services to Berkeley residents. In general, Berkeley Mental Health programs are funded to serve individuals with severe mental health needs who have major impairments in their functioning and are covered by Medi-Cal. However, Crisis Services teams (not including Homeless FSP) can serve any Berkeley resident, regardless of diagnosis or insurance status. It should be noted that residents covered by private insurance are eligible for services through their insurer and are not eligible for most Berkeley Mental Health programs.
The Crisis, Assessment, and Triage (CAT) program is a key access point for a wide range of Berkeley residents to get connected to mental health services. They are a team of clinical staff—licensed clinicians, paraprofessionals, peers, and/or family members—that conduct mental health screenings and assessments, mental health planning/consultation, and linkages to county or community-based care. They are also the official entry point for Berkeley Mental Health’s Homeless Full Service Partnership (HFSP), Adult Full Service Partnership (AFSP), and Comprehensive Community Treatment (CCT) programs. As previously noted, these programs have strict eligibility requirements driven by their funding. Most callers are referred to non-city resources. They offer both remote as well as in-person, walk-in assessments, and linkages to appropriate care. If someone is in crisis, they can suggest or facilitate linkage to 911, MCT, Amber House, or other crisis resources. CAT can also provide limited outreach and transportation services to people experiencing homelessness or people with disabilities who also want to engage in mental health services.
The Mobile Crisis Team (MCT) is a team of licensed clinicians that provide crisis intervention services to people in crisis within the Berkeley city limits.
These services include de-escalation and stabilization for individuals in crisis, consultation to hospital emergency personnel, consultation to police and fire departments, hostage negotiation, and disaster and trauma- related mental health services. When fully staffed, MCT can operate 7 days a week from 11:30am-10pm. Due to persistent staff shortages, MCT is currently unable to operate on Tuesdays or Saturdays. They primarily receive referrals from Berkeley Police Department, Berkeley Fire Department, hospital emergency rooms, and directly from residents. Most calls for MCT are received on the police radio directly from BPD for 5150 evaluations. Calls can also come directly through the MCT voicemail.
The Transitional Outreach Team (TOT) follows up with individuals after an interaction with MCT. The TOT team consists of one licensed clinician and
City of Berkeley Mental Health Crisis Response & Perspectives | 14
one unlicensed peer team member. The function of the TOT team is to offer linkages to appropriate resources and help navigating the system of care after someone has experienced a crisis. TOT assesses the individual’s eligibility for services, including insurance status, before making referrals to care. During the pandemic, their services have been mostly limited to phone calls. Pre-pandemic, they regularly connected with service utilizers after they were discharged from the hospital. Most often, TOT connects people with homeless service provider agencies, the CAT team for connection to BMH programs, case management services at other clinics, or any other community provider that would meet the client’s needs. Due to a recent division restructuring, TOT and CAT have been combined into one unit to allow more community members to access information and referrals provided by TOT.
The Homeless Full Service Partnership (HFSP) is Berkeley Mental Health’s newest program. They are a team of two behavioral health clinicians, two social service specialists, one mental health nurse, one part-time psychiatrist (0.5 FTE), and one clinical supervisor. HFSP serves adults who are homeless or at risk of homelessness and have major functional impairments related to a mental health diagnosis. They provide a wide array of services based on the client’s needs including support applying for benefits, connection to short-term and long-term housing, harm reduction for substance use, and support with physical health needs.
Berkeley Police Department: The Berkeley Police Department (BPD) is made up of patrol teams, Communications Center (i.e., dispatch) staff, other sworn officers, and non-sworn professional personnel. In total, the 2020 budget included 181 sworn officers and 104.2 professional staff. [1] BPD patrol team duties include responding to emergency and non- emergency calls for service or criminal activity, enforcing the law, responding to community needs, and directing traffic. The role of BPD patrol teams in mental health crises is to assess the situation to determine if there is a threat of public safety, assess how volatile the situation is, and secure the scene. Oftentimes, police officers will then provide crisis intervention services themselves, either because MCT is unavailable or the officer believes they can adequately respond with their experience and skillset. Otherwise, they will bring in another service team, such as MCT or Fire/ambulance to provide additional mental health or medical services. Officers may on-view incidents, but primarily receive assignments from the Communications Center. Officers may also coordinate with the other City Departments on some cases. All officers also receive a minimum of eight hours of advanced officer training in de- escalation and crisis intervention per year; and many officers are trained in a full week CIT-training course. The Department continues to assign
[1] Berkeley City Auditor. (2021, July 2). Data Analysis of the City of Berkeley’s Police Response.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20P olice%20Response.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 15
officers to this full week training as staffing allows and course space is available.
BPD’s Communications Center is staffed by dispatchers who handle the following: community calls, records checks, fire dispatching, and police dispatching.
[2] Call takers receive non-emergency and 911 calls, assess the call (including using the emergency medical dispatch (EMD) protocol, enter data into the computer aided dispatch (CAD) system to be dispatched to either police or fire personnel where appropriate. Other calls may be directed to other City Departments or BPD work units. The dispatchers deploy the appropriate response to the scene and maintain radio contact until personnel arrive at the scene.
Other sworn officers in BPD include area coordinators, a bike unit, detectives and traffic enforcement unit, and other sworn non-patrol officers. Area coordinators are situated within the Community Services Bureau and work with patrol officers in their area and seek to address community needs. Officers on the bike unit are assigned to patrol specific areas, where they address public safety issues and other community safety concerns. Detectives follow up on criminal investigations, conduct search warrants and work with the District Attorney’s Office on charging. The traffic enforcement unit responds to traffic related complaints, investigates serious injury and fatal collisions, and analyzes and provides state mandated reporting on collision data. Other sworn, non-patrol officers include special assignments in personnel and training, policy, and police technology.
The remaining staff are non-sworn, professional personnel including community service officers, crime scene technicians, and parking enforcement officers. Community service officers work in jail and as crime scene technicians who collect and document evidence from crime scenes. Parking enforcement officers enforce parking violations and support traffic safety related matters. Many of these functions are also supported by Police Aides and Reserve Police Officers.
Berkeley Fire Department: The Berkeley Fire Department (BFD) is comprised of 7 fire stations, 130 sworn fire suppression personnel and paramedic firefighters.5 BFD provides 24/7 response to emergencies including fires, medical emergencies, and disasters. The department operates 4 24/7 Advanced Life Support ambulances that are primarily responsible for all emergency medical transport within the City of Berkeley to local emergency departments.
[2] Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads to Excessive Overtime and Low Morale.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
5 City of Berkeley Fire Department. (n.d.). History of the Berkeley Fire Department. Retrieved October 5, 2021, from
https://www.cityofberkeley.info/Fire/Home/Department_History.aspx
City of Berkeley Mental Health Crisis Response & Perspectives | 16
BFD also participates in care coordination for high utilizers of services as part of the Community Accessing Resources Effectively (CARE) Team. This team is a multidisciplinary group of practitioners made up of both staff from community organizations as well as City of Berkeley staff. The group is facilitated by the EMS division of the department and aims to connect residents using high amounts of emergency services to more appropriate and/or long-term care options.
During the COVID-19 pandemic, BFD operated a Mobile Integrated Paramedic (MIP) unit for a six-week pilot. The MIP unit provided community paramedicine as a diversion from hospitals during the early days of the pandemic. This team did proactive street outreach in the community to help meet basic needs and provide referrals to community organizations, based primarily on 9-1-1 callers who ended up not seeking care at an Emergency Department.
For people experiencing a mental health crisis, the City of Berkeley contracts with Falck Ambulance, which is also the private provider for emergency medical transport for Alameda County. Falck provides treatment, stabilization, and transports to hospitals, including voluntary and involuntary psychiatric hospitalizations. BFD firefighters can call Falck directly when an individual needs to be transported for mental health issues, although most transport requests are through requests from Mobile Crisis. The current collaboration with Falck began July, 1 2019, and the contract is overseen by BFD.
Alameda County Behavioral Health Care Services Crisis Programs:
Alameda County Behavioral Health Care Services (AC BHCS) operates both crisis and long-term mental health service programs.6 Some key crisis programs include Crisis Support Services, Acute Crisis Care and Evaluation for Systemwide Services, Mobile Crisis Team, Mobile Evaluation Team, and the Community Assessment and Transport Team.
The Alameda County Mobile Crisis Team, Mobile Evaluation Team, and the Community Assessment and Transport Team do not serve the geographic area of the City of Berkeley; despite this, we include brief information about them below to describe the types of mobile crisis services available to the other cities in Alameda County.
Crisis Services Eligible to Berkeley Residents
Crisis Support Services (CSS) is a county contracted program that provides several services for individuals experiencing a mental health crisis , including a 24-hour crisis phone line, text messaging, therapy groups, therapy services for older adults, school-based counseling, grief therapy,
6 Alameda County Behavioral Health Care Services. (n.d.). Acute & Integrated Health Care – Acute & Crisis Services. Retrieved October 5, 2021, from http://www.acbhcs.org/acute-integrated-health-care/acute- crisis-services/
City of Berkeley Mental Health Crisis Response & Perspectives | 17
and community education.7 CSS coordinates closely with mobile crisis teams in Oakland and Alameda County and often refer clients to mobile crisis. They are staffed by trained crisis counselors, both licensed and unlicensed. Most often calls to CSS are direct from someone experiencing a crisis. Berkeley dispatch can transfer calls to CSS for phone support if they deem an in-person response is not required. CSS fields over 40,000 calls annually and spends an average of 25-30 minutes per call.
Acute Crisis Care and Evaluation for Systemwide Services (ACCESS) is the main entry point for Alameda County residents to get connected to acute and longer-term mental health and substance use services. 8 The
phone line is staffed by licensed mental health clinicians and administrators who screen and assess the client’s needs, provide information about available options, and refer to an appropriate service.
Clinicians also screen clients to see if they meet medical necessity criteria for Specialty Mental Health Services (SMHS). Calls that come in after 5pm or on weekends are routed to CSS.
Crisis Services Not Eligible to Berkeley Residents
The Alameda County Mobile Crisis Team responds to mental health crisis calls either in-person or over the phone.9 They are staffed by two licensed clinicians. Calls can come directly to the mobile crisis team, or they can be dispatched by 911 or CSS. The Alameda County Mobile Crisis Team responds in a police co-responder model.
The Mobile Evaluation Team (MET) is a co-responder program; one Oakland police officer and one licensed clinician respond to calls in an unmarked police car. They respond to mental health calls that come through 911 dispatch.
The Community Assessment and Transport Team (CATT) provides community-based crisis intervention, medical clearance, and transport services. Administered through Bonita House, a licensed clinician and an EMT will be dispatched to a scene where the individual needs to be transported to a higher level of care. CATT currently utilizes a police co- responder model.
Other Service Providers in the Mental Health Crisis Response System: In addition to services provided by the City of Berkeley and Alameda County, there is an array of community-based services and other providers within the mental health crisis response system in Alameda
7 Crisis Support Services of Alameda County. (n.d.). 24-Hour Crisis Line.
Retrieved October 5, 2021, from Alameda County Behavioral Health Care Services. (n.d.). Acute & Integrated Health Care – Acute & Crisis Services.
Retrieved October 5, 2021, from http://www.acbhcs.org/acute- integrated-health-care/acute-crisis-services/
8 Alameda County Behavioral Health Care Services. (n.d.). ACCESS program. Retrieved October 5, 2021, from
http://www.acbhcs.org/providers/Access/access.htm
9 In this report, the acronym “MCT” is only used in reference to the City of Berkeley’s Mobile Crisis Team, not Alameda County’s Mobile Crisis Team.
City of Berkeley Mental Health Crisis Response & Perspectives | 18
County. These generally fall into four categories: crisis response providers, crisis stabilization units, drop-in centers, and medical service providers.
The agencies listed below are not meant to be a comprehensive list, rather these were the organizations that were mentioned most frequently by focus group participants, interviewees, and survey respondents. There are many organizations and individuals who contribute to crisis prevention and stabilization by addressing other needs such as housing, substance use, ongoing mental health support, or domestic violence. Though not enumerated in this report, the ecosystem of services in Berkeley and surrounding areas help prevent community members from escalating into crisis.
Crisis Response Providers: Crisis response providers accompany individuals while they are experiencing a crisis, work with the client to de-escalate, and connect them to resources to meet their needs. It should be noted that ongoing mental health service providers, such as therapists or clinical case managers, de-escalate and divert mental health crises every day. In this report, we are focusing on providers who respond to acute crisis situations that are outside of long-term supports. The two key crisis response providers mentioned most often by the community are Mental Health First and UC Berkeley.
Mental Health First is a project of the Anti Police-Terror Project (APTP).
Based in Oakland, this volunteer-run crisis line provides crisis support, de- escalation, mediation, and connection to resources to anyone who calls.
They are available on Friday and Saturday nights, 8pm to 8am, when other crisis services are unavailable. Community members can access services via phone, text, or social media. About half of callers are calling for themselves, while the other half are calls from friends or family members concerned about a loved one. Mental Health First can help people navigate the complicated mental health system and get them connected to services.
When a student is experiencing a mental health crisis on the UC Berkeley camp
us, UC Police Department (UCPD) ar
e often the ones who arrive on
scene. UCPD employs a mix of sworn and non-sworn personnel including 49 police officers, 10 dispatch and records staff, 31 security patrol officers, and 12 professional staff.10 UCPD police officers are currently the ones who respond during a mental health crisis. However, the University has publicly stated plans to phase out involvement of police during a crisis and shift to having its Tang Center counselors respond to mental health
10 Berkeley UCPD. (n.d.). Department Demographics. Retrieved October 5, 2021, from https://ucpd.berkeley.edu/department-demographics
City of Berkeley Mental Health Crisis Response & Perspectives | 19
calls.11 They are currently in the process of planning and developing a new mental health response team.12
The UC Berkeley Tang Center offers health, mental health, and crisis services to all UC Berkeley students, regardless of insurance. Their staff, which include licensed psychologists, psychiatrists, and psychiatric nurses, respond to urgent mental health concerns.13 They also provide services after a sexual assault or incident of domestic violence and respond to campus crises (e.g., when a student passes away). 14 As of the Fall 2021 semester, students can access these services by calling the Tang Center’s urgent phone or after-hours support lines. But as previously mentioned, UC Berkeley is currently redesigning their crisis response model so students can more easily get connected with Tang Center staff during a crisis.
Crisis Stabilization Units and Psychiatric Facilities
Crisis Stabilization Units and psychiatric facilities provide a safe location for people to de-escalate from crisis, receive psychological support, and get connected with mental health services. There are no crisis stabilization units within the City of Berkeley, so Berkeley residents in crisis are often transported or referred to the facilities noted below.
John George Psychiatric Hospital (JGPH, or John George) is a locked facility where patients can receive short-term psychiatric care from doctors, psychiatrists, and counselors. Once a patient receives medical clearance (i.e., they do not have any acute medical needs), they can be transported to JGPH. John George is the main facility that individuals are transported to when they are under an involuntary hold. Many patients are referred and/or transported by emergency services and mobile crisis teams across the County.
Willow Rock Center operates both a 12-16 bed crisis stabilization unit as well as an inpatient unit for adolescents ages 12-17.15 A team of psychiatrists, nurses, group and individual therapists and counselors provides assessment, counseling, medication administration, group,
11 Public Affairs. (2021, August 18). UC Berkeley to shift comes campus services away from UCPD. Berkeley News.
https://news.berkeley.edu/2021/08/18/uc-berkeley-to-shift-some- campus-services-away-from-ucpd/.
12 Berkeley Business Process Management Office. (n.d.). Mental Health Response. Retrieved October 5, 2021, from
https://bpm.berkeley.edu/projects/active-projects/reimagining-uc- berkeley-campus-and-community-safety-program/mental-health 13 University Health Services. (n.d.). Meet the CAPS Staff. Retrieved October 5, 2021, from https://uhs.berkeley.edu/mental-
health/counseling-and-psychological-services-caps/about-caps/meet- caps-staff
14 University Health Services. (n.d.). Crisis Counseling for Urgent Concerns.
Retrieved October 5, 2021, from
https://uhs.berkeley.edu/counseling/urgent
15 Telecare. (n.d.). Willow Rock Center. Retrieved October 5, 2021, from https://www.telecarecorp.com/willow-rock-center
City of Berkeley Mental Health Crisis Response & Perspectives | 20
family, individual therapy, and connections to resources. The locked, inpatient unit is the main transport facility for adolescents under an involuntary hold. Their patients are often referred from Kaiser Permanente, schools, and emergency services. They also accept walk-ins for voluntary services.
Cherry Hill Detoxification Services Program provides services for adults needing to detox from substances.16 Their sobering unit has 50 beds for patients to stay 23 hours or less. The detox unit has 32 beds for patients to stay 4-6 days. Trained staff screen patients, provide medical services and psychological support, and link patients to services to meet their needs before discharge. Both units often get referrals from emergency services but also can accept self-referrals.
Amber House, operated by Bay Area Community Services (BACS), is a 23- hour mental health crisis stabilization unit (CSU) that provides a quiet environment for clients to receive short-term psychological support and have their basic needs met. The team is a clinician, a nurse, a supervisor, and an on-call psychiatrist, who provide voluntary services for people experiencing an acute mental health crisis. Many of their clients are transported or referred by mobile crisis teams, Oakland’s CATT program, and occasionally police. Before a client is discharged, a staff member will provide referrals for long-term mental health care and other resources to meet their needs. Amber House also operates a crisis residential treatment (CRT) program in the same facility (which is Alameda County’s only combined CSU and CRT), providing clients the option for a longer stay.
Drop-In Centers
The City of Berkeley has three drop-in centers for residents: the Berkeley Drop-In Center, Berkeley Wellness Center, and the Women’s Daytime Drop-In Center. While not all sites have specific services for individuals in crisis, they can be an entry point for mental health services.
The Berkeley Drop-In Center is a peer-run, walk-in community center that provides drop-in time, service advocacy, and housing advocacy. 17 Clients can have their basic needs met, find a place to socialize, get connected to benefits, receive a referral for subsidized housing, and get linked to mental health services.
The Berkeley Wellness Center, operated by Bonita House, provides art classes, employment services, connection to benefits, primary care, counseling, case management, and evidence-based support groups for
16 Horizon Services. (n.d.). Cherry Hill Detoxification Program Services.
Retrieved October 5, 2021, from https://www.horizonservices.org/cherry- hill-detoxification
17 City of Berkeley. (n.d.). Berkeley Drop-In Center. Retrieved October 5, 2021, from
https://berkeleycity.networkofcare.org/mh/services/agency.aspx?pid=Be rkeleyDropInCenter_670_2_0
City of Berkeley Mental Health Crisis Response & Perspectives | 21
adults with mental health and co-occurring disorders.18 The Berkeley Wellness Center serves as an entry point to recovery and supportive services for people with a broad range of mental health needs and co- occurring conditions.
The Women’s Daytime Drop-In Center (WDDC) provides similar services for homeless women and their children.19 A small team of case managers, managers, and volunteers provide various services including case management, food, groceries, and hygiene kits. Clients can also receive referrals to additional services that are beyond the scope of WDDC.
Medical Service Providers
Because a mental health crisis and substance use crisis can co-occur, medical service providers play an important role in crisis stabilization and prevention. The two medical outreach teams mentioned by the community were Lifelong Street Medicine and Berkeley Free Clinic’s Street Medicine team.
LifeLong Street Medicine is a program contracted by Alameda County Health Care for the Homeless Street Health.
20 Multidisciplinary teams
provide street psychiatry and substance use recovery services for people experiencing homelessness in Berkeley. They can also provide connections to primary care, social services, housing, and other resources.
Berkeley Free Clinic’s Street Medicine team is a volunteer-run collective where volunteers are trained as medics and provide services in the community.
21 Their services include HIV and STI testing and treatment, first aid, vaccinations, hygiene kit distribution, and substance use supplies and training. The teams regularly do proactive outreach to connect to new clients.
What is the current mental health crisis
call volume in Berkeley?
In addition to its deep community engagement process, RDA also reviewed quantitative data on the volume of calls related to mental health issues and who is making those calls. As noted previously, quantitative data from City of Berkeley agencies conducting crisis response (i.e., Mobile Crisis Team, Berkeley Police Department, and Berkeley Fire Department) currently have a variety of limitations. Because
18 Bonita House Inc. (n.d.). Berkeley Wellness Center. Retrieved October 5, 2021, from https://bonitahouse.org/berkeley-creative-wellness-center- cwc/
19 Women’s Daytime Drop-In Center. (n.d.). Women’s Daytime Drop-In Center. Retrieved October 5, 2021, from https://www.womensdropin.org/ 20 Alameda County Health Care for the Homeless. (n.d.). Street Health.
Retrieved October 5, 2021, from https://www.achch.org/street-health.html 21 Berkeley Free Clinic. (n.d.). Street Medicine Team. Retrieved October 5, 2021, from https://www.berkeleyfreeclinic.org/street-medicine-team
City of Berkeley Mental Health Crisis Response & Perspectives | 22
of these limitations, RDA suspects that the available data is generally an underrepresentation of the true volume of mental health related calls in Berkeley. Given these limitations, RDA explored the available data for trends that can support the community in building its understanding of who is currently utilizing Berkeley’s crisis services.
It is important to note that the City of Berkeley has contracted with the National Institute of Criminal Justice Reform (NICJR) to lead the City’s current Reimagining Public Safety work. As a part of its current engagement, NICJR collaborated with Bright Research Group (BRG) on a large community engagement effort to better understand the local community’s perspectives across a variety of issues pertaining to public safety in Berkeley. NICJR and BRG shared their findings on July 29, 2021 at Berkeley’s Reimagining Public Safety Task Force (RPSTF) meeting; the slide deck presentation of key findings can be found online.
22 The overarching
findings from this presentation align with RDA’s community-wide data collection efforts.
Key Mental Health Call Volume Trends
• MCT has responded to a declining number of 5150s since 2015, in part due to staff vacancies and the pandemic.
• The most frequent incident types of all 5150 calls to BPD were disturbance, welfare check, mentally ill, and suicide.
• Around 40% of BPD’s welfare check calls included a mental health related facet to the response, followed by around 20% of disturbance calls, and around 10% of calls regarding suspicious circumstances.
• Falck has been contracted to conduct the large majority of 5150 transports in Berkeley, most often taking service utilizers to Alta Bates Medical Center and John George Psychiatric Emergency Services.
• BFD conducted fewer 5150 transports in Berkeley and only took service utilizers to Alta Bates, Oakland Children’s Hospital, and Kaiser Hospital.
• The time required for a 5150 is, in part, determined by geography and the destination of transport.
• Calls for 5150s are most frequent from 10:00am to midnight and least frequent from 2:00am to 8:00am. There are no notable differences in the frequency of calls by day of the week.
For a deeper description of call volume and data, demographics of calls, and methods please see Appendix D
.
22 City of Berkeley’s Reimagining Public Safety Task Force. (2021, July 29).
Berkeley Reimagining Public Safety – Community Engagement Report. https://www.cityofberkeley.info/uploadedFiles/Clerk/Level_3_- _Commissions/CE-presentation-Final.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 23
Stakeholder Feedback
Mental health crises vary in severity along a spectrum. A crisis can present as someone in immediate danger to themselves or others, someone that needs regular support to address their basic needs, or someone that is generally able to manage their needs but needs occasional support to prevent a future crisis. Many stakeholders expressed that in order to effectively address the challenges of the current system, solutions and changes must engage with the nuance and spectrum of mental health crises.
Many stakeholders shared that by broadening our concept or definition of a mental health crisis, we can better design the mental health crisis response system and related services. Stakeholders provided several examples of the nuance and spectrum of mental health crises:
Some forms of crisis are readily visible (such as people presenting to hospitals or experiencing a crisis while in public) while others may be unseen (such as a homeless-but-sheltered individual recovering from intimate partner violence).
Some forms of mental illness or neurodivergence are reported by a bystander as a crisis, but there is not an acute crisis situation and should not result in a forced transport just because of a bystander’s concern.
Some forms of crisis are a result of community members not knowing where to access services even if they are able to identify their needs.
Some forms of emergency service utilization stem from an ongoing unmet need for basic goods and services, such as a high utilizer that regularly presents at the hospital emergency department because they need food.
Overall, there is wide consensus among interviewed stakeholders that the current mental health, substance use, and homelessness crisis systems in Berkeley are under-resourced and unable to meet both the volume of need and the various ways in which crisis presents.
Expectations for different types of crisis responders varied greatly by stakeholder. Stakeholders shared mixed experiences with BPD’s ability to successfully de-escalate situations and respond empathetically to people in crisis, and often attributed the quality of interaction to the traits of an individual officer. Stakeholders often held low expectations for BPD to intervene non-violently and expressed positive perceptions when BPD “didn’t do anything.” On the other hand, stakeholders shared high expectations for other crisis service providers including MCT responders or county case managers. Negative feedback from stakeholders was often because providers were not meeting these high standards. As a result, understanding stakeholder praise and criticism of crisis responders – such as MCT, BPD, and other CBOs – requires understanding stakeholders’ varied expectations.
City of Berkeley Mental Health Crisis Response & Perspectives | 24
In discussing their experiences as well as the strengths and challenges of existing crisis response system, interviewed participants and survey respondents also shared ideas for a reimagined mental health crisis response system. The following sections detail key themes that were elevated across stakeholder participants.
Illustrative quotes from survey respondents are included alongside key themes. Due to concerns with anonymity and limitations of data collection, quotes from interviews and focus groups were unable to be included.
Key Themes from
Stakeholder Feedback
Perceptions of an urgent need for a non-police mental
health crisis response in Berkeley
Perceptions of varied availability, accessibility, and
quality of crisis response services
Perceptions of insufficient crisis services for substance use emergencies
Perceptions of a need for a variety of crisis transport options
Perceptions of a lack of sites for non-emergency care
Perceptions around supporting the full spectrum of
mental health crisis needs
Perceptions of a need for post-crisis follow-up care
Perceptions of barriers to successful partnerships and
referrals across the mental health service network
Perceptions of needs to integrate data systems and
data sharing to improve services
Perceptions of a need for increased community
education and public awareness of crisis response
City of Berkeley Mental Health Crisis Response & Perspectives | 25
Stakeholder perceptions of the urgent need for a
non-police mental health crisis response in Berkeley.
Overall, there was a strong sense of urgency for a change in the response to mental health crises in Berkeley. Service providers indicated that they routinely use creative interventions and provide services for clients multiple times and consider calling the police a last resort. Service providers shared that if there were an SCU, they would prefer to use a non-police option for crisis response.
Service providers and crisis responders expressed a sense that the current system is “broken,” that they see the same service utilizers on a frequent basis. Providers shared examples of clients unable to access existing services, not engaged in services they are enrolled in, or not willing to receive offered treatment for a variety of reasons. Stakeholders felt that most people need support accessing resources in addition to immediate crisis response or de-escalation. However, they believe the existing crisis response system often relies on police to respond to calls. This is not the specialty of the police, nor are they able to provide a full range of follow- up linkages and referrals to trauma-informed social services.
There is strong consensus across city staff, service providers, service utilizers, and survey respondents that police do not best serve the needs of those who are experiencing a mental health or substance use crisis.
Stakeholders emphasized that a mental health crisis should not be equated with violence, though there is often the misconception that any display of mental illness is violent or a threat to public safety.
Stakeholders shared that there are scenarios in which the presence of police can increase the danger for service utilizers or bystanders. In the context of intimate-partner and domestic violence, there is often a fear of retaliatory violence if the police are called in to respond to the abused partner seeking help. Stakeholders shared examples police presence and visible weapons escalating a mental health crisis, causing an increase in erratic or unpredictable client behavior. Particularly for service utilizers with traumatic histories from interactions with police officers, they felt the presence of police can escalate a crisis or emergency. Service providers shared stories of clients that have suffered through immense psycho-social harm and/or medical complications before reaching out to 911 due to their fear of the police.
Survey respondents and service providers shared the perception that sometimes police think a weapon is present on an individual when it is not, and felt that police use unnecessary violence and force, which overall decreases their sense of safety. Stakeholders felt that this context results in an environment in which they do not call for emergency help because of “My perception is that
mental health issues,
substance use, and
homelessness are
*rampant* in Berkeley -
now more than ever -
and police are simply
not the right people to
deal with these issues.”
- SCU Survey Respondent
“I think a carceral
approach creates more
trauma and fear. I have
been traumatized by
being in jail. I do not
wish to be incarcerated
when all I need is
support.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 26
a fear of police, leaving community needs for crisis support unmet. Service providers also elevated that there are ways to disarm someone without using force or weapons which would improve the safety for both service utilizers and providers alike.
For these reasons, Crisis Support Services of Alameda County (CSS) crisis line providers shared that they prepare callers for interactions with the police by telling them what to expect when the police arrive and providing options to keep themselves safe (e.g., stepping outside, double checking that there are no weapons or illicit substances on their person, and closing their front door). However, they did mention that service utilizers using substances or experiencing a break with reality may not be able to follow close directions and are at increased risk of police violence due to the heightened probability of misunderstanding or miscommunication.
Stakeholders shared a few strengths of police involvement in the existing crisis response system. They shared that police may provide a useful resource for people who need documentation of a crime for future legal reference. A police report with these details can later be used in a court setting or provided as proof to an insurer. Additionally, many service providers indicated police presence can protect the safety of crisis responders and bystanders when weapons are present. Some stakeholders elevated that the presence of police can be supportive when community members or service providers are attempting to de- escalate a crisis.
The overwhelming importance and immediacy of changing the mental health crisis response system was emphasized in stakeholders’ references to the violence committed against a woman killed by BPD during a mental health crisis in 2013 and a man shot by BPD during a mental health crisis in 2021. Stakeholders shared that providing a non-police mental health crisis response option could increase the acceptability and accessibility of crisis response by addressing this fear, thereby promoting the safety and well-being of community members and service utilizers.
There were differing perspectives of whether police should have any involvement in crisis response. The expressed perspectives included: there should be no police involvement; police should be called as back-up only if SCU de-escalation efforts were unsuccessful; police should be called as back-up only if the presence of weapons was confirmed; or police should be involved through a co-responder model like MCT.
Stakeholders offered important considerations for police involvement.
Some stakeholders suggested that police should be dressed in plain clothes to avoid their presence further escalating a community member in crisis. Other stakeholders shared that if police are involved in the SCU model of crisis response, then they should be in uniform; they elevated that community members should understand who they are speaking to, given that a police officer can arrest, detain, and/or incarcerate them.
Additionally, because community members expressed that they have the right to identify a police officer’s badge number and last name -- which is particularly important if a community member needs to report any “I desperately needed
help for a friend who
was experiencing a
mental health crisis. She
was adamant that I not
call police because she
is scared of them and
feared that they would
be violent with her.
There were no
alternatives available in
Berkeley. I have
watched police
respond to people in
crisis many times. Some
cops are aware that
their presence can
escalate people. Some
of the cops are
oblivious of how they
impact a situation and
make it worse.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 27
misconduct -- police should be in uniform. Furthermore, stakeholders elevated their fear of being targeted by certain police officers as someone that experiences mental health emergencies and/or someone who uses drugs; for this reason, stakeholders shared that it is important for police to remain in uniform to mitigate the criminalization of mental health crises and drug use and for public awareness.
Stakeholders shared considerations for protecting and enhancing the safety and well-being of crisis responders, service utilizers, and community bystanders alike. The presence of weapons is a primary safety consideration for many stakeholders. Stakeholders reported concerns about determining and dispatching the appropriate intervention team in order to prevent injury or assault to crisis responders, especially when there are weapons present. Many stakeholders also emphasized that the safety of the person in crisis must be protected too.
Stakeholders provided many ideas for how a non-police crisis response system could best support Berkeley residents. Community members and providers suggested a crisis response team include mental health practitioners such as peer workers, therapists, direct patient care specialists, social workers, medical providers and/or psychiatrists. They also suggested several trainings that would support crisis responders to better meet the needs of people in crisis, such as trainings on trauma-informed care, de-escalation, and crisis neutralization. Finally, given the types of crises service providers and service utilizers most often experience, stakeholders elevated specific technical knowledge that crisis responders should be prepared to employ, including basic first aid, domestic-violence crisis response training, and specific knowledge on DSM-5 mental health diagnoses, and co-occurring drug-induced states.
Additional Perspectives from the SCU Survey
“The police response here is among the most
professional that I have seen in any jurisdiction in the nation - yet the bottom line is requiring police to
respond to crisis situations in which they do not have
the requisite training is a disservice to both the
officers and those on the other side of the
response.”
“I don't feel unsafe in the community. My homeless
neighbors are much more unsafe than I am
because they are consistently interacting with
people who hate them, with some bad cops
including the campus cops.”
“There is a huge crisis in our city of homelessness and mental health and the police only ever make things
worse. Sweeps, seizures of possessions, harassment
and intimidation of unhoused residents is all too
common. The violent detention of mentally ill
people seems to be a day to day reality. Heavy
restraints and spit hoods being used in the place of
de-escalation and care. The Berkeley police shot a
man in crisis through the mouth this year and that is
beyond unacceptable!!!”
“I need to know that if I, or someone I love, is
experiencing a mental health crisis that there is a
trained mental health professional that I can call
who will come, without a gun, and that I will receive
care, not a cop, and that I will not end up dead.
Knowing I won't be shot dead by a cop for the
"crime" of living with mental illness, for being poor, or for having a substance use disorder would help me
to feel safe.”
“I have had police
response in an
emergency crisis. It only
made the crisis more
terrifying and
traumatic.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 28
Stakeholder perceptions of varied availability,
accessibility, and quality of crisis response services
Perceived Strengths
• MCT provides quality
services
• Positive experiences
with individual BPD
officers
• BFD created a
resource list to better
provide referrals
Perceived Challenges
• Lack of 24/7 crisis
services
• Requiring service
utilizers to keep
appointments
• Slow response times for
MCT due to limited
staffing
• Long waitlists for
services
• Few options for de-
escalation or non-
emergency care
• Poorer quality of
services provided to
people of color and
unsheltered people
Stakeholder Ideas
• Proactively
co
mmunicate service
availability & h
ours of
operation
• Increase 24/7 service
options
• Increase training on
racial justice, cultural
sensitivity, harm
reduction, and de-
escalation
Stakeholders identified a few strengths of the availability, accessibility, and quality of crisis services. Many reported that there is general knowledge of the existing crisis response options in Berkeley. Some providers reported positive experiences with police, and many reported positive experiences with MCT. Another strength shared by stakeholders is that BFD’s ability to refer and link service utilizers to resources has increased since they created a list of CBOs and local programs.
A common challenge elevated by stakeholders is the lack of 24/7 response options. A mental health crisis can happen at any time, but many crisis programs operate during standard business hours. The limited hours of operation of MCT were elevated by stakeholders as a significant challenge that increased the risk of police interaction with service utilizers who call 911 when MCT is not staffed.
Stakeholders frequently mentioned limited MCT staffing as a major barrier to accessing quality crisis response services. For the last two years, two of four crisis staff positions have been vacant. Because MCT responds to calls in pairs, only one team is available to respond at a time. This can result in long wait times if the team is responding to another call. Additionally, if there is a high call volume, MCT will prioritize high acuity calls where someone is showing imminent signs of crisis or distress. The reduction in staffing also led to a reduction in hours. This has caused confusion among providers and service utilizers. Service providers elevated this as a source of uncertainty and distrust that can reduce the likelihood of someone accessing services in the future.
“Berkeley MCT is only
open on weekdays
during certain hours. I
have never had an
incident where I
needed help with a
client coincide with
their open hours.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 29
Stakeholders believe these challenges and barriers to accessing services or ensuring the availability of services are ultimately challenges to the overall safety and well-being of potential service utilizers, community bystanders, and service providers.
A Berkeley City Auditor’s report in 2019 elevated that the understaffing of the 911 Communications Center has led to staffing levels that cannot meet the call volume and increased call wait times.23 Increased call wait times have negative implications for the safety and well-being of service utilizers and community members, as well as the service providers and crisis responders that are responding to a potentially more advanced state of crisis. Additionally, inadequate staffing levels have caused BPD to rely on overtime spending to fund the Communications Center, which increases the cost of the entity.
There was consensus among participants that many facets of the crisis response system feel understaffed, which can lead to decreased service availability and slower responses. Under-resourcing can create challenges to service availability across the providers and programs throughout Berkeley and Alameda County. Service utilizers and community members reported long waiting lists for permanent supportive housing units, a key stabilizing factor that could reduce the incidence of mental health crises overall. There was also a perception among stakeholders that service utilizers are faced with long waits to access healthcare, case managers, and temporary congregate shelters.
Some CBOs also identified a need for more multilingual services, especially Spanish-speaking providers. They also indicated that a fear of ICE or 911-corroboration with ICE is a barrier for undocumented community members to call 911, especially for undocumented residents that are unhoused. Service providers suggested that more culturally competent services would increase the likelihood of someone seeking services when they are experiencing a crisis.
Stakeholders believe that these challenges to availability and accessibility can reduce the quality of available services. When police must respond to a mental health crisis because it is outside MCT business hours, community members do not feel the response was adequate or of the highest quality. Crisis responders expressed that they frequently provide medical solutions when the service utilizers they encounter have mental health needs and are most affected by broader societal problems.
When MCT is not operating, CSS indicated that they do more de- escalation over the phone prior to calling for police support to prepare
23 Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads to Excessive Overtime and Low Morale.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
“Mobile Crisis folks are
good. It's just that they
always come with the
cops, and sometimes
they can't come for
many hours because
they're busy.”
- SCU Survey Respondent
“It's a revolving door
(with Santa Rita, John
George, etc.) where
crises are sometimes
averted, but almost no
one is truly healed and
set on a good path of
recovery or even
stability.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 30
the service utilizer and reduce their risk of harm; however, they shared that phone support may not always be sufficient for every mental health crisis.
Overall, there was consensus among stakeholders that there is a lack of successful linkages and connection to follow-up services beyond John George Psychiatric Hospital. Many participants felt that hospitalization may not be appropriate care for everyone experiencing a mental health crisis. Crisis responders and providers reported service utilizers requesting to not be sent to John George, but that as service providers they do not feel they have other options. For service utilizers, trauma histories can be re- triggered by congregate shelters, psychiatric care or hospitals, and police interactions. Stakeholders elevated a need for increased options for where people can be transported during a crisis.
Finally, there is a perception that the quality of the City’s first responder crisis response services is inhibited by a lack of training that sufficiently addresses harm reduction, racial justice and cultural sensitivity training, and successful de-escalation. Service providers shared examples of clients’ needs not being taken seriously, such as instances of individual EMTs not responding to unsheltered clients and/or clients of color. These examples demonstrate how stigma, dehumanization, and racism decrease quality of services.
Given the constraints of how the existing crisis system is funded and resourced currently, stakeholders elevated that any changes to program hours of operation, locations, staffing, phone numbers, and/or other logistical/programmatic decisions be shared regularly and distributed to the partnership network in order to improve availability, accessibility, and quality of service provision. They felt that the ideal alternative crisis response options would include 24/7 mental health crisis response and should address the desired competencies of harm reduction, racial justice and cultural sensitivity, and de-escalation to increase community safety and promote health and well-being.
Additional Perspectives from the SCU Survey
“They tend to exist in ways that are
the most convenient for the service
providers, not for the person in need.
Mental Health Services don't really
happen outside of their offices. How
can disordered, homeless people be
expected to make and keep
appointments at some unfamiliar
address? The drug epidemic is
complicating things and I have seen
no evidence that this city wants to
commit to rehab on demand which is
what we need. We need to be able
to offer help when it is needed- not
when it is convenient.”
“I’ve been doing outreach work for
more than a year in Berkeley now
and access to mental health crisis
support is almost nonexistent. It is
highly needed as many individuals
are experiencing some level of
mental health issues.”
“… My experience with the police
response has been that the City of
Berkeley crisis team has been
understaffed or not working the day
that I phoned, or my report of the
need for crisis support was minimized,
and it was explained that the person
"wasn't breaking any law." Crisis
doesn't often intersect with law
breaking, nor does an individual
always meet the criteria for a 5150.
There are trained individuals who can
help with this, and police often offer
heavy handed threats of arrest, or
physical violence, in attempt to stop
a behavior.”
“The resources we have
are helpful, but we
need more. We
especially need
affordable housing
units. The mobile street
medicine teams have
been very helpful.
Shelters are ok for some
people, but often
exclude people with
disabilities who need
assistance the most.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 31
Stakeholder perceptions of insufficient crisis services for substance use emergencies
Perceived Strengths
• EMTs respond well to
substance overdoses
• EMTs are well-trusted
by many unsheltered
communities and
encampments
Perceived Challenges
• Not enough SUD
training for clinicians
providing complex
mental illness care
• High rates of transport
to emergency facilities
for substance use
emergencies
• Infrequent referrals to
substance use
management services
• Too few resources to
meet high volume of
substance use
emergencies and
management needs
Stakeholder Ideas
• Incorporate harm
reduction framework
into all crisis response
• Distribute NARCAN
• Distribute harm
reduction supplies
(e.g., sharps disposal,
clean needles, etc.)
Stakeholders explained that mental health crises often include substance use emergencies, but they felt that variety and uniqueness of substance use emergencies is often overlooked and not adequately served in the existing crisis response. Stakeholders described many examples of physical and psychosocial health needs related to substance use that do not involve an overdose. Service providers shared that substance use emergencies and mental health crises are often co-occurring as substance use is common among people with histories of trauma and is used as a form of self-medicating.
Substances can alter someone’s mental state and contribute to or exacerbate what is perceived as a mental illness. Stakeholders elevated that when a person is in distress, providers should assume that something is triggering that distress, be it an event or intoxication. One of the most frequently and emphatically emphasized points by service providers was the need to address mental health and substance use in tandem. “Decriminalization is
key to "illegal" drug use
and harm reduction
methods of dealing
with addiction and
drug use save lives
and alleviate the
stigma.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 32
In the event of a substance overdose, stakeholders felt that Berkeley EMTs are well-trained, follow protocols, and administer effective treatment for users that have overdosed. Stakeholders reported that EMTs are well- trusted by marginalized substance-using communities, including homeless encampments. Seabreeze encampment residents shared that they avoid calling 911 for any emergencies except to specifically request an EMT during an overdose.
Stakeholders described many challenges to how the system currently addresses substance use emergencies. They felt that the physical health and mental health needs of a service user experiencing a substance use emergency are treated as separate needs. Service providers explained that whichever presents as more immediately pressing often dictates the classification for the call; they felt that this results in inadequate service provision during a crisis.
Community-based providers elevated that when seeking care for clients with complex trauma or chronic mental illness, they are rarely put in contact with a provider that has SUD training. Service providers expressed a need for an integrated approach to substance use emergencies, with providers working together to tend to both the psychological and physical health needs of their clients.
Substance users reported frequent transport to hospitals and sobering centers when emergency providers respond to crises. Interviewed substance users shared that they were only informed of other substance use management options when other case managers shared those options (not emergency services personnel prior to transport).
Stakeholders suggested ways that the current crisis response system could better address the needs of substance use emergencies, including incorporating a Harm Reduction framework into first responder's approach to drug use, distributing Narcan, and distributing harm reduction supplies such as clean needles, pipes, and safe sharps disposal kits.
Additional Perspectives from the SCU Survey
“I am a Nurse Practitioner... Some camps in Berkeley have agreements internally not to call the police on each other. If someone does, there is retaliation, sometimes in the form of lighting the person's tent on fire. This means people do not call 9-11 when there is a mental health emergency. While I
completely understand why the mobile crisis unit has police officers, it is not used as often as it could be because of that fact...Many unhoused folks we meet use meth in part to stay up all night so they will not get raped or robbed during the night.
This is of course not the only reason folks use meth and other drugs--there are mental health issues, addiction, etc. But until people are housed, it is very, very hard for them to cut down or quit, because the risks can outweigh the benefits in their minds.”
“...Offering safe use and drug checking
sites, so we can reduce harm that comes
from unsafe drug use. Creating
accessible, affordable, and temporary
housing for each phase of a person's
recovery from crisis. Ensuring people
have access to food, safe shelters, and
access needs are met.”
“The people with
mental illness should
get treatment. In crisis,
they should be housed
with treatment. those
with substance abuse
should have treatment
available. Being
homeless probably
makes people mentally
ill. I think I would be
mentally ill if homeless.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 33
Stakeholder perceptions of a need for a variety of
crisis transport options
Perceived Strengths
• Transport is provided
to emergency sites
during medical
emergencies
Perceived Challenges
• High rates of
involuntary transports
(5150s) do not align
with service needs
• Lack of options for
transport to non-
emergency sites
• Ambulances and
emergency services
can be cost-
prohibitive for service
utilizers
Stakeholder Ideas
• Provide voluntary
transport to non-
emergency sites
• Provide services and
supplies during
transport process
Crises can vary in levels of acuity, and not everyone calling in to report a mental health emergency needs transport to a psychiatric facility, hospital emergency department, or inpatient setting. Both EMTs and police shared that they provide free transport to a medical facility, which is important in the event of medical health emergencies. However, Alameda County has the highest rates of 5150s per capita in California. 24 Service providers described full emergency departments and service utilizers not being admitted upon arrival. There are also financial implications for being transported in an ambulance, which providers suggested may deter service utilizers from requesting emergency services.
Stakeholders felt that there are few to no options for service utilizers to request transport to a different, non-medical facility or location.
Stakeholders did provide some examples of CBOs and non-emergency programs that provide transportation to their clients, though they shared that these services are not for the general public and barriers to transportation persist.
Given the need for addressing a variety of transport needs, stakeholders elevated the importance of an SCU team to have the ability to provide voluntary transport services to any secondary location, such as a sobering center or a public location. Service providers and community members suggested that the transport vehicle should have available supplies to provide care during a transport, such as one-off doses of psychiatric medicines, food, and water. There was a shared sense that providing
24 California Department of Health Care Services. (2017, October).
California Involuntary Detentions Data Report; Fiscal Year (FY) 2015-2016. https://www.dhcs.ca.gov/services/MH/Documents/FMORB/FY15- 16_Involuntary_Detentions_Report.pdf
“With all the services
available, as a
firefighter, all we can
really do is take
someone to the ER,
which is not definitive
care for homelessness.
Mobile support of
homeless services
would be a game
changer, much the
way mental health
comes out into the
field.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 34
transport options that meet the mental health needs at varying levels of acuity has important implications for the safety and well-being of crisis responders and service utilizers.
Additional Perspectives from the SCU Survey
“...Another challenge is the lack of options for
people in crisis either hospitalization or nothing
which is very harmful. Another issue are people
who feel terrible but are not exactly in crisis but
because there are not enough mental health
providers they are forgotten or left to their own
devices.”
“I need to know that if I call for help, a
compassionate response will arrive and be able to
take a person to a humane location, respite of
some kind. Not forcing them into a hospital where
they are stripped of agency, but giving them a
place where they can stabilize without adding to
their feeling of trauma and powerlessness.”
Stakeholder perceptions of a lack of sites for non-
emergency care
Perceived Strengths
• Drop-in centers, day
centers, sobering
sites, and respite
centers provide
essential non-
emergency services
Perceived Challenges
• No drop-in site for
mental health
emergencies or crises
in Berkeley
• Too few drop-in sites
for non-emergencies
to meet the volume
of need
• Lack of support for
people released
from a psychiatric
hold
Stakeholder Ideas
• Offering drop-in sites
with counselors and
Pe
er Specialists, a
phone line, and no
service/time limits
• Offering office hours
and/or relationship-
building opportunities
between the SCU
and service utilizers
Stakeholders shared examples of sites that can support non-emergency care and felt that they are effective for mitigating further crises. These examples include drop-in centers, day centers, sobering sites, and respite centers. Services providers believe that such spaces allow individuals to meet their basic needs – including access to restrooms, showers, clothing, food, and rest – as well as have a safe space for self-regulation and self- soothing. Stakeholders, particularly service providers, feel that these types of resources are essential for harm reduction, crisis intervention, health promotion, and crisis prevention. Stakeholders shared that these sites can be a safe and trusted source for someone to access so that a primary caregiver can have a break, such as a parent that provides an adult child behavioral health support and care. Participants mentioned other CBOs
City of Berkeley Mental Health Crisis Response & Perspectives | 35
that operate drop-in sites, such as the Women’s Drop-In Center or Berkeley Drop-In Center, but service providers indicated that there is still an unmet need for more sites that serve sub-acute needs. Because there is not a drop-in center for emergencies, service utilizers and community service providers described relying on either 911 or the CSS 24/7 phone line. Similarly, stakeholders felt that the availability of non-emergency drop-in centers for individuals to have non-emergency, indoor downtime is too limited to meet the volume of need. CBO service providers as well as crisis responders described situations of individuals being released from psychiatric holds without adequate support upon their release. They felt that these individuals would greatly benefit from the availability of additional drop-in centers.
Service utilizers and community-based service providers emphasized that it would be useful for the SCU to have an office available for community members to develop relationships with the team, like Aging Services’ Senior Centers. They suggested that a drop-in site could have a social worker or peer counselor to accept and direct phone calls, answer questions, and support those accessing the drop-in site.
Additional Perspectives from the SCU Survey
“…addressing the connection to community in the
long term - spaces for people to gather publicly
without needing to pay money, so we can get to
know our neighbors.”
“… We need wrap- around services, a halfway
house or drop-in center for people being released
from a psychiatric hold, to ease them back into
their lives and connect them with ongoing
services.”
City of Berkeley Mental Health Crisis Response & Perspectives | 36
Stakeholder perceptions around supporting the full
spectrum of mental health crisis needs
Perceived Strengths
• Relationship building
is important in crisis
response
Perceived Challenges
• Wages, retention,
and union
agreements may
affect type of staff
on crisis response
team
• Crisis response
lacking sufficient
supplies and
expertise for SUD
treatment, de-
escalation, and
system navigation
• Crisis responders are
not often
representative of
service utilizers
Stakeholder Ideas
• Incorporate
c
linicians, social
workers, and peer
counselors on crisis
response team
• Increase
compensation for
Peer Specialists and
non-clinical staff
St
akeholders shared many strengths of crisis responders across a spectrum of non-clinical and clinical background and expertise, emphasizing the importance of empathy and building trusting relationships. For instance, TOT staff received positive feedback across stakeholder groups for their follow-up work post-crisis, especially due to their diverse staff and rigorous training in preparation for field work. Service providers emphasized the importance of Peer Specialists to support service utilizers by reassuring them from their own background of lived experience, especially during transport or if the team applies physical restraints.
Crisis responders and service utilizers shared that the pre-existing relationships paramedics have with community members, particularly those that repeatedly need crisis response services, allows paramedics to deliver better care. Some CBOs have observed similar success when incorporating Nurse Practitioners on their street outreach teams. Overall, stakeholders believe that the ability for the same personnel to be providing crisis response services over an extended period can lead to positive outcomes of relationship building and knowing a client’s background.
However, stakeholders raised some potential challenges that must be considered when deciding how to staff a crisis response team. Crisis responders explained that paramedics often have a higher salary than other crisis responders and their skills can be under-utilized during a mental health crisis. They felt that this could make staffing a crisis response “A response team
targeted at de-
escalation and risk
reduction would be
best; it would be best
staffed by those who
can actually connect
people in need to
resources rather turning
a crisis into a criminal
matter, such as police
do.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 37
program with paramedics less financially efficient. On the other hand, they shared that other crisis responders, such as peer specialists, can be underpaid for their level of contribution, which they suggested might make retention a challenge. One additional consideration shared by crisis responders is that staff can have different union agreements that restrict the number of hours that can be worked per shift, which would affect the program’s overall staffing model and schedule.
Stakeholders felt that some of the services most important for mental health are not always standard practice among current crisis response teams. The types of clinical services that stakeholders reported as most important for mental health crisis response include prescribing psychiatric medicines, administering single-dose psychiatric medicines, quick identification of a substance overdose and/or the need for Narcan intervention, as well as a nuanced understanding of drug-psychosomatic interactions. The types of non-clinical services that stakeholders reported as most important for mental health crisis response included de- escalation, resource linkages and handoffs, system navigation, providing perspective from providers with shared identities or experiences, building ongoing relationships with frequent utilizers, and overall building trust and rapport with the community.
Given the considerations around the types of needs that various specialties can address during crises, as well as the implications for financial feasibility, stakeholders elevated additional ideas for how to staff crisis response teams. Stakeholders expressed support for a crisis response team with a medical provider (e.g., advanced practice nurses, psychiatric mental health nurse practitioners, EMTs, or paramedics), social workers, and especially peer counselors. Stakeholders expressed that non- clinical staff are equally valuable to clinical staff in a crisis response team, a value which should be reflected in their salaries.
Additional Perspectives from the SCU Survey
“We need a crisis response team with trained
social workers, case managers, and clinicians
trained in de-escalation techniques. This team
should be able to connect people in crisis with
emergency shelter and other services.”
“I do not believe that the police are trained to
respond to the needs of an individual, homeless,
or otherwise, experiencing a crisis. Mental health,
substance use, and homelessness related crisis are
best responded to by someone who has been
trained to work with these issues, or a peer who,
along with a trained professional, can provide
support and most importantly, follow up.”
“I think professionals
who are trained to
resolve these crises
non-violently is key. For
example, social
workers.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 38
Stakeholder perceptions of a need for post-crisis
follow-up care.
Perceived Strengths
• Positive experiences
with existing referral
services (i.e., TOT
and CAT)
Perceived Challenges
• Existing programs do
not meet the volume
of need
• Difficulty contacting
service utilizers for
follow-up care
• Lack of warm
handoffs to follow-up
providers
• Limited long-term
service availability
• Strict missed
appointment policies
Stakeholder Ideas
• SCU provides follow-
u
p care
• SCU builds
relationships to
s
upport before,
during, and after a
crisis
• Providers should be
familiar with case
history, triggers, etc.
a
For crisis services provided by the City of Berkeley, the Transitional Outreach Team (TOT) is the primary resource for post-crisis follow-up care.
Service utilizers and community-based service providers elevated many strengths about the TOT team, including their ability to connect service utilizers to longer-term care options and social services when interested.
At the same time, stakeholders uplifted a need for additional follow-up care after a mental health emergency. TOT staff and Berkeley Mental Health leadership described many challenges TOT face in meeting the level of need across the crisis spectrum. The team is not adequately staffed to meet the current demand for their services. TOT is a team of only two staff with limited business hours for providing linkage to care. TOT staff also shared that the service provider that responds during a crisis (i.e., MCT) is not the same provider that makes follow-up connections (i.e., TOT), and that there are many potential providers to provide ongoing, long-term care (e.g., Berkeley Mental Health, Alameda County Behavioral Health, or private providers). They felt that this can create challenges for them to provide successful referrals and handoffs to post-crisis follow-up care, sharing background information on clients, and building trust and establishing rapport.
TOT staff also shared many challenges they face in reaching clients, particularly those leaving an inpatient or emergency facility, such as John George or Alta Bates Hospital. They explained that clients are sometimes discharged prior to their connection with TOT, often outside of TOT’s hours of operation. They find it particularly difficult to connect with service utilizers that do not have a cell phone or a consistent residence, which they explain is common among high-utilizer community members, such as those with severe mental illness or those experiencing homelessness. “I think police officers
already deal with so
much, there's often an
acute need they're
responding to when in
fact these individuals
need long-term care.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 39
In general, many people that experience mental illness or mental health crises require or are recommended to long-term therapy or extended sessions. However, it is the perception of stakeholders that services are primarily devoted to high-acuity and short-term and service utilizers are unable to access long-term therapy. Stakeholders felt that the providers who do offer therapy or counseling are unable to meet the volume of weekly appointment needs of service utilizers due to budget and billing constraints. Therapy is not only a form of post-crisis care but also a pre- crisis prevention tool; service providers suggested brief intervention therapy in non-emergency settings (such as a service utilizer walking in during a crisis) to augment the existing crisis response system.
Outside of Berkeley Mental Health services, there are often strict policies around missing appointments, largely tied to insurance and billing requirements, that result in service disruption or termination for service utilizers. Service providers and service utilizers feel that these strict missed appointment policies are inaccessible to many low-income service utilizers and often result in the discontinuation of services. Stakeholders described some barriers that service utilizers may face in maintaining their appointments, including working more than one job (especially during standard business hours), having a reliable cell phone, having access to a calendar, and/or having a reliable mode of transportation.
The importance of follow-up care was elevated by all stakeholder groups as a priority for the SCU. Service providers argued that there may be benefits to having the same people providing care before, during, and after a mental health crisis, to build relationships, establish trust, and understand an individual service utilizer’s care history, behaviors, triggers, and needs.
Additional Perspectives from the SCU Survey
“I would like for the police to be removed from
crisis services and to have a rapid response
available when I call...I would like for there to be
more connection to services and follow up as part
of the planning. There is often not a resource
available for the person, and living on the streets is
stressful, so repeated contact is essential. It can’t
be a one and done and often would mean an
increase in FSP teams.”
“Alternative trained individuals, such as social
workers or mental health professionals as part of this
time, increased community-based mental health
care services, social and rehabilitative services that
highlight social reintegration, such as Supported
Housing, Supported Employment, and Supported
Education.”
We need clean, safe
shelters for people to
spend the night if
they're homeless
and/or under threat.
Kicking them out of
shelters doesn't make
the problem go
away.
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 40
Stakeholder perceptions of barriers to successful
partnerships and referrals across the mental health
service network
Perceived Strengths
• Providers know the
referral options
available for their
clients
Perceived Challenges
• Limited coordination
and information
sharing between
providers of shared
clients
• BPD engages with
many high utilizers
but is not connected
to the network of
providers
• Lack of trust and
understanding across
service providers
Stakeholder Ideas
• Engage providers in
discussions on system
improvement
• Increase
collaboration
between cities,
counties, and
providers
• Address systemic
factors of crises
• Increased outreach
and care
coordination of
referrals
There was consensus among stakeholder groups that the existing mental health and crisis service network is complex, involves many providers, and can be a challenge for both clients and providers to navigate. Across these entities, establishing partnerships and referral pathways can be done informally (such as knowing which organization provides which types of services) or can be formalized (such as holding regular case management meetings for shared clients). Among community-based service providers, interviewees shared that they typically do know the scope of options available to their clients.
In general, stakeholders elevated a perceived lack of coordination between service entities in Berkeley. For example, a single client might receive emergency services from John George or Highland Hospital, but also have a primary care provider, have engaged frequently with the LifeLong Street Medicine Team, and have a case manager at the Women’s Drop-In Center for wraparound services. Stakeholders shared that there is not active collaboration across all these entities or an established infrastructure to facilitate an understanding of all the touch points between providers and a service utilizer. Ultimately, stakeholders feel that this obstructs the visibility of how a service utilizer moves through various points in the system. Some providers explained that they may not share the full case history or behavior details of a client with other service providers initially because they fear the client will be rejected or denied service, particularly for violent behaviors. They feel that this prevents informed and well-placed referrals and service provision.
TOT staff shared that service coordination is lacking between hospitals and TOT for post-crisis follow-up care. To connect with an MCT service “A 24-hour crisis
line/team or at least a
team more available
than currently. Police
and that team should
attend the regular city
coordination meetings
with the current teams
that are doing
outreach.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 41
utilizer at the hospital, TOT explained that they must rely on the discharging facility to contact them and coordinate the release of the shared client. TOT staff reported needing to spend time in hospitals to establish relationships with new case managers, front desk staff, nurses, and orderlies to facilitate this information sharing and warm handoff of clients; they described a lack of standardized protocol for such coordination.
BPD also reported feeling disconnected from the care continuum and lacking coordination with trusted CBOs and behavioral healthcare providers around shared clients. BPD routinely engages with frequent crisis service utilizers and sometimes carries supplies like food and clothing, though there is not an existing pathway for BPD to identify, contact, and coordinate with a case manager. BPD elevated that these frequent utilizers would be better served by a case manager.
Service providers also reported that BPD does not routinely bring service utilizers to their locations for support, and some questioned whether BPD know that their programs and services exist. Still, others felt that police presence at their sites is disruptive and may prevent potential service utilizers from coming if they witness police officers around the premises.
Stakeholders offered possibilities to enhance the referral pathways and partnerships across the crisis response network at both structural and provider levels. At a structural level, stakeholders suggested having a regular convening of local care providers to discuss opportunities to improve the mental health crisis system. Stakeholders also suggested having more inter-county and inter-city coordination on systemic issues related to housing and healthcare. Stakeholders suggested that the crisis response system should be expanded and augmented to include more non-mental health related service provision on the spot and not only connections or linkages to resources. Additionally, stakeholders expressed a desire for more outreach and partnerships with long-term care to enhance coordination and referrals across the service network.
At a provider level, stakeholders suggested having more coordination between providers and outreach teams. Service providers also expressed an interest in having regular meetings with the SCU to discuss shared clients, which could improve care coordination as well as client outcomes.
Additional Perspectives from the SCU Survey
“The challenge is, and has been, to have adequate staffing to provide services to those in crisis, with severe mental health diagnosis and/or dual diagnosis in the moment and following a crisis response.
Successful efforts have been proven by street health teams to engage and provide treatment on the street, which often include de-escalation. The struggle lies on helping folks transition into care in the clinics, recovery programs, or a combination of both: with adequate staffing to provide long term services. So, challenges would fall under budget & funding to expand staffing and programming, including crisis residential, and Board and Care Homes...The City appears open and willing to try an approach that will better meet the needs of its citizens.”
City of Berkeley Mental Health Crisis Response & Perspectives | 42
Stakeholder perceptions of needs to integrate data
system and data sharing to improve services
Perceived Strengths
• Some medical
clinics use the
same EHR
• Some agencies
use a shared
Alameda County
Community
Health Record
Perceived Challenges
• Limited data
integration across
providers inhibits
care coordination
Stakeholder Ideas
• Expand data
integration across
providers and
provider access to
case history
• Increase care
coordination across
providers
• Notify case
managers after
discharge from
hospital
Service providers feel that better system integration and data sharing across the service provider network can support providers in meeting the needs of service utilizers. Stakeholders feel that system integration and data sharing are strongly related to the successes and challenges of partnerships, referrals, and connectivity across the service network.
The numerous entities that span the mental health, substance use, and homelessness service network include CBOs and government agencies across the City of Berkeley, Alameda County, and other cities and counties. Service utilizers also move across these regions, accessing services in multiple cities or counties. As a result, system integration could happen at many levels.
Fortunately, subsets within the service network do have data integration and sharing capabilities. For instance, providers shared that all federally - qualified health centers (FQHCs) are on the same network as hospital Emergency Departments.
Some program directors also discussed a recent effort at the county level to integrate data into one Community Health Record for service utilizers. 25 This system integrates medical, mental health, housing, and social service data into one platform. There are currently over 30 organizations within
25 Alameda County Care Connect. (n.d.). Why AC Care Connect? Why Now? Retrieved October 11, 2021, from https://accareconnect.org/care- connect/#faq-item-5
“I would also feel safe
knowing that the City
and County were
working together to
identify ways to
increase funding for
mental health services
in conjunction with
housing to meet the
mental
health/substance use
recovery needs of the
community.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 43
Alameda County who are using the community health record, with a goal of every agency being onboarded onto the system.26
Until then, the current multitude of agency data systems are not yet fully integrated. Providers explain that they are unable to identify shared clients or high utilizers of multiple systems, track those service utilizers’ touchpoints across the service network, or view patient history across those service touchpoints. Case managers share that they are not notified when a client is discharged from a medical facility or community provider of care. Service providers feel that this lack of data integration affects collaboration, referrals, and, ultimately, client outcomes. The limited visibility of a service utilizer’s prior history was raised by service providers as a challenge to supporting safety when trauma histories, triggers, and recent mental health crises cannot be incorporated into care planning.
Additionally, except for diagnosis and treatment purposes, HIPAA privacy regulations require service utilizers to give consent and Release of Information (ROI) to providers for external case managers’ names, information, and service documentation to be included in medical records. This limits the collaboration between case managers and other providers on a case-by-case basis.
Stakeholders elevated that it would be ideal to have all service providers, including an SCU, utilizing the same data platform. They also indicated that non-medical CBO providers and case managers should have contact with the client’s health home (if established), especially for substance use management and medication management. Case managers could then be notified when a service utilizer is engaged or discharged from care. Service providers emphasized the importance of understanding someone’s medical and social history to provide appropriate care and anticipate what could trigger or escalate them.
Service providers also warned to not overburden the SCU with documentation requirements.
Additional Perspectives from the SCU Survey
“… Secondly, we need significantly greater inter-municipal and inter-county collaboration in order to tackle structural problems that homeless and mentally ill clients face…Increasingly, our clients are more mobile, have longer commutes, and with gentrification and sprawl, landscapes of poverty and wealth are shifting. We need to be able to be responsive to clients across municipalities and communities, as people who seek services in Berkeley, particularly homeless and low -income clients, often no longer have the means themselves to be able to live in Berkeley.”
26 Raths, D. (2021, October 4). Alameda County’s Social Health Information Exchange Expands. Healthcare Innovation.
https://www.hcinnovationgroup.com/interoperability-hie/health- information-exchange-hie/article/21240807/alameda-countys-social- health-information-exchange-expands
“… But we need more
training in mental
health, de-escalation
and interagency
training and
coordination. We
have a lot of great
people working these
issues, we just need a
little more cross
pollination of effort.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 44
Stakeholder perceptions of a need for increased
community education and public awareness of crisis
response options
Perceived Strengths
• 911 is well-known by
the general public as
a crisis response
option
Perceived Challenges
• Lack of clarity that
MCT responds with
police, undermining
trust
• Limited knowledge
around services and
availability
• Distrust of system can
prevent people from
calling 911
• Incidents of
unnecessary use of
911
Stakeholder Ideas
• Launch a public
a
wareness
campaign for new
SCU and clearly
distinguish it from
MCT
• Work with partners
and service providers
to advertise SCU
• Increase community
education on use of
911 and techniques
for conflict resolution
A common perspective among stakeholders is that the general public is un
clear around when police will or will not be involved in a response.
Many service providers and service utilizers do not know the current options and availability of services in Berkeley to support during a mental health crisis. Overall, stakeholders share that there is a lack of understanding of what services are available and which entity provides those services. They feel that this undermines a sense of safety and contributes to distrust of the current mental health crisis response system.
One common challenge raised by many stakeholders has been the lack of understanding of MCT’s co-responder model. Many providers shared that they have contacted the MCT line specifically to avoid calling 911 and were surprised when MCT was accompanied by police. Many providers, therefore, stopped calling MCT because of its collaboration with BPD. Similarly, service utilizers shared that there is a lack of trust that MCT can manage a crisis without police presence. Service utilizers are concerned that their safety is endangered in these instances and that they may experience retaliation or police surveillance after requesting service provision from MCT, especially when they request help during substance use emergencies.
Stakeholders spoke to the importance of promoting community education and public awareness to address these challenges. They feel that the success of an SCU would be contingent on community education and public awareness around whether there would be police involvement in an SCU response. Service providers shared that connecting with local CBOs, leveraging existing partnerships, and building trust will be essential for an SCU to have buy-in among service providers to call a new “In the past, I have
witnessed unsafe
situations or people
who look like they
could use support, but I
am too afraid to call
the police in those
situations, for fear that
they could show up
and harm or kill the
person.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 45
service that they have not used before. Service providers are interested in understanding more closely how services will be provided, the techniques that will be used for de-escalation and crisis intervention, and the SCU’s relationship with the police.
Stakeholders also shared challenges around the general public’s use of 911 and ideas for how to increase responsible use of 911. Stakeholders shared many instances of inappropriate use of 911, such as during disputes among neighbors or because a housed person or business does not want an unhoused neighbor to be near them. For these reasons, stakeholders emphasized the importance of a community education campaign around appropriate uses of 911. Stakeholders suggested that such a campaign could include strategies and techniques for managing conflicts and disputes without calling for crisis responders as an additional form of promoting community safety through methods that do not require law enforcement.
Additional Perspectives from the SCU Survey
“Merchants in the shopping districts should not be able to call the cops like they're calling customer service when a homeless person is not breaking any laws. It would be great if crisis services were more friendly and less coercive (cops), if the mental health delivery system was more robust, if crisis teams could respond in a timely way, if clinicians didn't use police radios on mobile crisis calls, if actual risk assessments were done on calls where no one would ever need a cop (when the person is willingly ready to go to the hospital), if hospitals would actually keep and treat the most ill patients rather than turning them away after 24 hours in a waiting area, if there were more mental health respite beds run by people who aren't ready to call the police if someone is agitated.”
“More trained & well-
compensated and
insured crisis response
staff, especially at night,
around the full moon, or
public events, & other
times of increased
disturbances, & more
info put out there about
what they do to help.”
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 46
Community Aspirations
Throughout stakeholder engagement, participants were asked to share their ideas for alternative approaches to mental health and substance use crises as well as to share community needs for a safe, effective mental health and substance use crisis response. These perspectives help illuminate the gaps in the current system that could be filled by a future Specialized Care Unit.
The following perspectives provide guiding aspirations for reimagining public safety and designing a response system that promotes the safety, health, and well-being of all Berkeley residents.
Community Aspirations
Stakeholder-identified opportunities to address the root causes that contribute to mental health, homelessness,
and substance use crises
Stakeholder-identified opportunities for centering BIPOC communities in crisis response
Stakeholder-identified opportunities for community
oversight to ensure equitable and transformative crisis care
City of Berkeley Mental Health Crisis Response & Perspectives | 47
Stakeholder-identified opportunities to address the
root causes that contribute to mental health,
homelessness, and substance use crises
Stakeholders unanimously pointed to the context surrounding the conversation on mental health crises: there are intersecting, state-wide crises of homelessness due to the lack of affordable housing 27 and the opioid epidemic. When reflecting on alternative ideas and community needs, stakeholders expressed desires for addressing the root causes that manifest in the present-day rates of mental illness, homelessness, and substance misuse and abuse. Stakeholders discussed possibilities for shifting funding away from the criminal system and policing to overall community infrastructure (such as jobs, housing, and education) and increasing preventative healthcare to address the root causes of mental health, homelessness, and substance use emergencies more adequately.
Stakeholders also emphasized how stigma and criminalization of drug use and/or mental illness continue to exacerbate crises. Stigma and criminalization are barriers to accessing care and addressing these crises at both the individual and structural levels. At the individual-level, stakeholders identified that internalized stigma around mental illness, homelessness, or substance use, can prevent individuals from seeking care and that service providers can reinforce stigma through their actions and/or withhold care. They described instances of criminalization of mental illness, homelessness, and substance penalizing individuals who do seek care, preventing or terminating employment or housing, and consequently perpetuating a cycle of these experiences. At a structural level, stakeholders emphasized that stigma and criminalization shape the prioritization of funding and budget allocations away from quality healthcare, affordable housing, and evidence-based harm reduction approaches that promote community safety and health. Stakeholders also identified that the gaps in the existing crisis response system are because the crisis response system was designed around the stigma and criminalization of these experiences rather than designed to provide care and promote well-being.
27 In 2019, Berkeley passed a resolution calling on the Governor to declare homelessness a state of emergency.
https://www.cityofberkeley.info/Clerk/City_Council/2019/02_Feb/Docume nts/2019-02-19_Item_10_Declaring_a_California_Homelessness.aspx “Berkeley should
decriminalize the use
of all drugs, it needs
to create housing for
the chronically
mentally disturbed, it
needs to have very
well-trained people
responding to crises.
Berkeley together
with Alameda
County, should be
providing
wraparound services
for the mentally
disturbed and
substance abusers. It
needs to stop
criminalizing people
who are homeless.
- SCU Survey Respondent
City of Berkeley Mental Health Crisis Response & Perspectives | 48
Additional Perspectives from the SCU Survey
“As with every other part of the United States, we
too are dealing with a rather poorly run medical
care delivery system. We are also dealing with the
war on drugs which is a total failure and has
criminalized for too many people for a drug
related problem, which is a public health issue and
should never have been a criminal justice issue.”
“Honestly we need more than just mental health
crisis teams. We need a holistic approach. One
that considers not just the crisis but also everything
before. We need to address the underlying cause -
child abuse, domestic violence, individualism and
lack of community.”
“The system is overwhelmed. It has been
extraordinarily difficult to link clients to shelter or mental health consistently in Berkeley. The
problems that most clients suffering from mental
illness in the region face are primarily systemic in
nature, and there is an extreme lack of resources
available in the way of permanent housing,
shelter, or frontline community mental health
services. Furthermore, for clients who are low-
income, learning disabled or struggle with
executive functioning, or homeless, engaging in
the kind of time-intensive, linear, multi-step
bureaucratic processes necessary to enter into the
shelter and mental health systems is often all but
impossible without intensive agency advocacy
and persistency. Homeless clients in particular
struggle with agency-based barriers to care, often
move between counties and municipalities, lack
targeted outreach, and experience outreach
primarily as criminalization, a tragedy given that
cost of living, region-wide housing shortages, and
past failures of criminal justice policy are
disproportionately responsible for endemic
homelessness in the Bay Area.”
“Firstly, funding priorities need to shift. We need to
address the root causes of mental illness,
substance use, and homelessness - trauma, often
created or exacerbated by decades of failed
criminal justice policy and lack of investment in
community infrastructure and social services,
criminalization of drug users as opposed to
investment in substance use counseling and harm
reduction programs, and the legacy of a
suburbanized and disjointed approach to regional
housing policy and governance. We need to shift
funding priorities in Berkeley and the region
towards funding social services, especially mental
health and substance use rehabilitation,
education, parks and transit infrastructure, and
encourage policies that protect renters and the
working poor, especially families. We need to not
only shift towards social workers and mental health
responders as the primary agents in engagement
with clients suffering from mental illness, and not
only increase homeless outreach - we also need to
acknowledge the history of homeless-led political
engagement in Berkeley and the region, and
employ a model that politically values the voices
of homeless clients themselves…”
City of Berkeley Mental Health Crisis Response & Perspectives | 49
Stakeholder-identified opportunities for centering
BIPOC communities in crisis response
Stakeholders emphasized that people of color, particularly Black or African American people, are most often harmed by police. They also named that in Berkeley, the structures that put people at risk of homelessness disproportionately affect Black residents, which results in Black Berkeley residents disproportionately experiencing homelessness. 28 Some service providers also shared incidences of racial bias and discrimination by BPD against their Black clients. For example, at a CBO provider of non-emergency services, case managers reported calling 911 because MCT was closed; the case managers reportedly gave specific instructions that a young White woman was threatening staff and refusing to leave the premises. Yet, upon arrival, BPD harassed and threatened to arrest a Black client.
Black service utilizers and service providers alike elevated their own experiences navigating systems with entrenched racism, including interactions with police and medical facilities. For example, one Black clinician shared the important and unique ways that Black personnel promote a sense of safety, security, and trust for Black service utilizers. The provider shared that the comfort and reassurance of a shared identity increases the opportunities to be more honest, especially during medical or mental health crises.
Stakeholders shared that reducing contact between police and Black residents, especially Black unsheltered residents, is important to public safety. Stakeholders also shared that Black residents and other community members of color should provide input and feedback as an SCU is designed and implemented in Berkeley.
Additional Perspectives from the SCU Survey
“less arrests and escalation by police, I worry
because the homeless population is mostly African
American.”
“…The proportion of folks who are Black among
those homeless in Berkeley is much higher than the
general population. We know that police
interacting with POC is a dynamic that all too
often leads to harm.”
28 City of Berkeley. (2019). City of Berkeley Homeless Count & Survey – Comprehensive Report. Retrieved October 11, 2021, from
https://everyonehome.org/wp-
content/uploads/2019/09/2019HIRDReport_Berkeley_2019-Final.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 50
Stakeholder-identified opportunities for community
oversight to ensure equitable and transformative crisis care
Due to system distrust and the current climate around Berkeley’s Reimagining Public Safety efforts, stakeholders expressed a desire and need for ongoing community input and oversight of crisis response, especially by those most impacted by crisis services.
Stakeholders suggested leveraging the Mental Health Commission, which they feel is currently underutilized. They also expressed the importance of ensuring that engagement and oversight opportunities are accessible for the most structurally marginalized residents and residents utilizing SCU and crisis response services.
Additional Perspectives from the SCU Survey
“Crisis response that reaches out to the
community to ask what they want; particularly
communities of color, and enlist this community in
the creation of the programs…”
Thoughtful, constructive ways for integration and
engagement of the challenged community with
the community of Berkeley residents and workers.”
City of Berkeley Mental Health Crisis Response & Perspectives | 51
Appendices
Appendix A. Sample Interview Guide
CBO Staff Focus Group Guide
Focus Group Details
Date
Facilitator
Community groups in attendance
Overview
[Introduce facilitator and notetaker]
We are gathering information about mental health and substance use crisis response in the City of Berkeley, including by contacting (211, 911, BMH crisis triage line, etc.) and who responded (if at all): social workers, medics/EMT, fire and/or police in our city. We are interested in hearing specifically about your experiences, and/or your perceptions of, mental health and substance use crisis response in the City of Berkeley. We are gathering this information to inform the development of a Specialized Care Unit (SCU) for the City of Berkeley as a non-police crisis response to mental health and substance use calls.
At the end of the discussion, if you feel like you didn’t get to share something, or you think of something else you want to share later, feel free to visit our website for additional ways to provide feedback. https://sites.google.com/rdaconsulting.com/city-of-berkeley-scu/
This focus group will last approximately 90 minutes. If possible, please leave your video on and keep yourself muted when you are not speaking. You may respond to our questions verbally or in the chat, whichever you prefer.
Our goal for today is to understand your experiences as providers and advocates and do not expect you to share private details of your clients’ experiences. Your own responses will be kept confidential and will be de-identified in any report back to the City of Berkeley.
We understand that some experiences with the current crisis response may have been harmful to you and/or your clients; if you would like to take a break or leave the focus group, please do so at any time.
Does anyone have any questions before we begin?
Questions
Warm-up
To get us started, we would like to do some introductions.
City of Berkeley Mental Health Crisis Response & Perspectives | 52
1. Please introduce yourself to the group by sharing your name, group or organization you are representing, your role, how long you’ve been there, and a word or phrase that comes to mind when you think about “mental health and substance use crisis services”.
Experience with and perceptions of mental health and substance use crisis response Now I would like to ask you some questions about your experience with and perceptions of the mental health and substance use crisis response options in the City of Berkeley.
2. What do you know about the existing mental health and substance use crisis response options in the City of Berkeley?
a. What kinds of crises do these services respond to?
b. What is missing?
3. How do the services your organization or program provides intersect with mental health and substance use related crisis services?
4. Are individuals referred to your program after experiencing a mental health or substance use related crisis?
a. If so, what services do you typically provide
b. How are those clients connected to your program?
5. Where would your clients go/who would they call if they were experiencing a mental health or substance use related crisis?
a. If, as a provider, a client was experiencing a mental health or substance use related crisis is there a program that you would call for support? i. If so, who would you call? How do you decide who to call? ii. How effective has the response been?
iii. Please share an example of a situation where you needed to contact someone to support a mental health or substance use related crisis for a client.
1. Do you feel that the service was helpful? If so, how?
2. If not, what could have been done differently?
6. Do you feel comfortable/safe calling for support from the existing mental health or substance use related crisis service options? Why or why not? a. Do you feel that the existing mental health or substance use related crisis response options are helpful to clients? Why or why not?
7. Are there times that you have chosen not to call for mental health or substance use related crisis response services? Why or why not?
a. What did you do instead?
b. What might have made you feel more comfortable calling for support when a client was experiencing a mental health or substance use related crisis?
8. What do you feel that your clients typically need when they are experiencing a mental health or substance use related crisis?
a. Where might you refer a client if your program or organization can’t provide the help they need during a mental health or substance use related crisis?
9. Are there local organizations or groups that you collaborate with that are maybe not considered part of the “system”?
a. If so, who are they and what kinds of support do they provide? i. Do you think they would want to talk with us? [if yes, get contact info for follow up]
Strengths and challenges of the current mental health or substance use related crisis response options
City of Berkeley Mental Health Crisis Response & Perspectives | 53
In this section we will be discussing what the system is doing well and what the system is not doing so well.
10. In your opinion, what are some of the strengths of the current mental health or substance use related crisis response options?
a. If your clients have experienced a mental health or substance use related crisis, were they able to get help? How so?
11. In your opinion, what are some of the weaknesses of the current mental health or substance use related crisis response options?
a. Why do you think things aren’t working?
b. Do you think mental health or substance use related crisis response services are difficult for your clients to access? How so?
c. What are some of the gaps related to mental health or substance use related crisis response options?
12. Do you feel that some people are served better than others by the current crisis system? a. If so, who is left out?
b. Are people treated differently based on their race, gender, culture, sexuality, or disability? If so, how?
Ideas for alternative model
In this section I’m now going to ask you for your ideas for an ideal response for someone experiencing a mental health or substance use related crisis.
13. What would an ideal mental health or substance use related crisis response look like for you and the people you serve?
a. What kind of response would best meet the needs of your clients? b. What would make it more likely for you to reach out to a crisis team for support? c. What would make it less likely for you to reach out? d. Who should, and should not, be involved in a mental health or substance use related crisis response? (i.e., Police, EMT, clinicians, peers, social workers, others?) e. What do you consider to be essential features of an effective mental health or substance use related crisis response that is responsive to, and respectful of, the clients you serve?
14. What do you feel needs to be included in a new mental health or substance use related crisis response for you to feel safe calling for or providing those services?
Wrap up
We are hoping to talk to people one on one who are less likely to attend a focus group, but who have lived experience and would like to provide feedback on the development of a Specialized Care Unit. We are asking you to think about the people your program serves and consider if there are individuals who might want to share their experience with us in an interview either in person or over the phone.
15. What do you think are the best ways to engage your clients in this process? a. How can we make sure that everyone’s voice is heard? b. Who is the best person to interview them?
City of Berkeley Mental Health Crisis Response & Perspectives | 54
c. Would they be comfortable talking with someone from RDA or is there another person who might be more suited to talk with them?
d. [Note contact information for follow up if applicable]
16. Is there anything else that you didn’t get to share today that is important for us to know?
Closing
Thank you for your participation. We genuinely appreciate the time you took to speak with us today. We will be conducting interviews with other organizations and community members over the next few months and compiling a report based on the feedback, which will be shared with you and the community. If you would like to share any additional information with the City of Berkeley, feel free to visit https://sites.google.com/rda consulting.com/city-of-berkeley-scu/.
City of Berkeley Mental Health Crisis Response & Perspectives | 55
Appendix B. Demographics of Community
Engagement Participants
As a reference point, it is important to understand the demographics of the Berkeley population.
Table 1 below shows the demographics of Berkeley’s overall city population (in July 2019) and the Medi-Cal recipient population (FY 2019-2020). Medi-Cal population demographics are included because the majority of City of Berkeley ongoing funded mental health services are restricted to this population, due to funding requirements. Relative to Berkeley’s overall population, Black or African American residents are overrepresented in the City’s Medi-Cal population, while Whites and Asians are underrepresented.
Table 1. Berkeley Population and Medi-Cal Recipient Demographics (2019) City Population
(July 2019)29
Medi-Cal
Recipients
(FY 2019-2020)
Population Size 121,363 18,548
Race Ethnicity (%)
White 53.3% 26%
Black/African American 7.9% 22%
Hispanic/Latino 11.4% 12%
Asian/Pacific Islander 21.5% 10%
American Indian/Alaska Native 0.5% 0%
Other (including 2+ races) 7.5% 33%
Gender (%)
Female 50.5% 51%
Male 49.5% 49%
In the charts shown below, “provider participants” are those who were interviewed by RDA as part of CBO interviews and focus groups. “Service utilizer participants” are clients of CBOs or encampment residents who were interviewed by RDA. And “survey participants” are individuals who responded to RDA’s online survey; these respondents could be a mix of providers, servicer utilizers, and/or other Berkeley residents or stakeholders.
29 United States Census Bureau. (2019). QuickFacts – Berkeley city, California. https://www.census.gov/quickfacts/berkeleycitycalifornia
City of Berkeley Mental Health Crisis Response & Perspectives | 56
Figure 1 below shows the age distribution of the individuals that participated in this process.
Overall, RDA received information from more people in the 30-44 range (39%) than any other age range.
Figure 1. Participants by age (n = 122 individuals)
Figure 2 below shows the racial and ethnic distribution of participants in RDA’s data collection.30 Participants were asked to note all races/ethnicities that they identified with, so these are duplicated counts; for this reason, specific percentages should not be interpreted from this data.
A large proportion of participants were white, especially among the survey respondents who participated. Most of the Black or African American participants contributed their perspectives via RDA’s in-person focus groups or interviews. As compared to Berkeley’s overall population, service utilizers and providers who identified as Black or African American were overrepres ented in RDA’s data collection efforts, (see Table 1).
30 13 participants selected more than one racial or ethnic identity, so these numbers are duplicated. For example, if a participant selected White and Black or African American, they are counted in both the White and African American categories.
City of Berkeley Mental Health Crisis Response & Perspectives | 57
Figure 2. Participants by race/ethnicity (n = 122 individuals)
Figure 3 below shows the number of transgender and cisgender participants of RDA’s data collection. Overall, there were far more cisgender participants than transgender participants.
However, a higher proportion of service utilizer respondents (13%) were transgender, while less than 4% of survey respondents and 3% of provider respondents were transgender.
Figure 3. Participants by transgender/cisgender (n = 122 individuals)
City of Berkeley Mental Health Crisis Response & Perspectives | 58
Figure 4 below shows the gender identity distribution of participants to RDA’s data collection.
RDA collected feedback from more than double the number of female-identifying participants (72) than male identifying participants (31). There was an even distribution among service utilizer respondents (41% female and 41% male) compared to survey respondents (67% female vs. 20% male) and provider respondents (69% female, 16% male). Overall, there were very few genderqueer or nonbinary participants (<1% and 6% respectively).
Figure 4. Participants by gender identity (n = 122 individuals)
Figure 5 below shows the sexual orientation of participants of RDA’s collection. Over one third (35%) of participants identified as heterosexual or straight, while over one fourth (28%) identified as LGBTQ+. The remaining participants did not share their sexual orientation or it was not asked of them. Over half of survey respondents (57%) identified as straight, while only 31% of provider respondents and 10% of service utilizer respondents identified as straight.
Figure 5. Participants by gender identity (n = 122 individuals)
City of Berkeley Mental Health Crisis Response & Perspectives | 59
Figure 6 below shows the geographical distribution of participants of RDA’s data collection. The most common zip code of participants was 94710 (25%), in large part due to the number of Seabreeze encampment residents that participated in this process. Closely following were the Berkeley ZIP codes of 94702, 94703, and 94704 with 11%, 12%, and 18% of participants, respectively.
Figure 6. Participants by ZIP code (n = 122 individuals)
City of Berkeley Mental Health Crisis Response & Perspectives | 60
Appendix C. Process of a Mental Health Call
City of Berkeley Mental Health Crisis Response & Perspectives | 61
Appendix D. Mental Health Call Responses –
Call Volume and Demographics
Data Collection Methods and Challenges
Early on in this project, RDA submitted requests to Berkeley Mental Health’s Mobile Crisis Team (MCT) and the Berkeley Fire Department (BFD) to receive data on responses to all mental health related calls. MCT shared basic service-level data of their responses for FYs 2015-2020. BFD shared data from BFD and Falck (the city’s contracted ambulance services provider for mental health crises) that was limited to responses to 5150 calls in Berkeley between calendar years 2019-2021.
RDA did not submit a data request to the Berkeley Police Department (BPD) for two reasons. First, from another evaluation project that RDA currently has with the Berkeley Mental Health Division, RDA already had basic service-level data from BPD regarding their responses to calls originating for 5150s, for the period of CYs 2014-2020. Second, in April 2021, the Berkeley City Auditor released a comprehensive report on its extremely in-depth data analysis of BPD’s responses. For the purposes of RDA’s project regarding the Specialized Care Unit (SCU), there was no need to replicate any of the work and findings that came from the Berkeley City Auditor. Please see the Berkeley City Auditor’s report for a detailed description of its methods, findings, data limitations, and data recommendations for BPD.
31 The findings that are shared in this report from the Berkeley City Auditor’s study are extrapolated directly from the data about BPD calls (from CYs 2015-2019) that was included in the Auditor’s report.
In general, RDA’s analysis of MCT, BFD, Falck, and BPD call data yielded high-level summary plots about subject/patient demographics and call volume. The general limitations of all available data prevented a more in-depth analysis of the data. More detailed tabular findings are not shared in this report for two reasons: 1) given that all of the quantitative data are under representations of the true volume of crisis responses and callers in Berkeley, only the trends about the volume of mental health related calls and caller demographics should be interpreted from this data, not the specific numbers; and 2) in order to protect the privacy of the few individuals who populated some of the specific categorizations of this data, RDA cannot disclose data which includes small sample sizes.
There were limitations to the quantitative datasets that RDA received. Of greatest impact is that the data entry practices across each agency were not consistent with each othe r, thus limiting which data could be pulled for analysis as well as which findings could be compared between agencies. For example, due to data limitations, RDA was unable to present a total call volume across agencies or the unmet need for mental health intervention during 5150 transport. Though estimates on call volume and unmet need are relevant to understanding crisis response options, inconsistent data collection and reporting across agencies would make this calculation inaccurate and misleading.
31 Berkeley City Auditor. (2021, July 2). Data Analysis of the City of Berkeley’s Police Response. https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20Police%20Response.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 62
The data challenges that RDA encountered were very similar to those faced by the Berkeley City Auditor; please refer to the Berkeley City Auditor’s report of its findings of Berkeley’s Police Response for a thorough description of their data challenges. 32 Mental Health Call Volume
Mobile Crisis Team: From the call data that MCT shared with RDA, findings are limited to only showing the total volume of calls that MCT responded to during 2015-2020. Due to missing data and data elements across the various years, there were not any consistent elements for which findings could be determined over the full five-year period. Figure 7 below shows the volume of MCT’s total incidents and which of those incidents resulted in a 5150 for each year between 2015-2020.
Figure 7. Mobile Crisis Team (MCT) Incidents in 2015-2020 - Total Total Incidents 5150s Only
Sin
ce 2015, there has been a gradual decline in the nu
mber of total and 5150 incidents that
MCT responded to in Berkeley due to staff vacancies as well as the COVID -19 pandemic.
Berkeley Police Department: For the period of 2014-2020, RDA received data from BPD that included all calls initially coded by BPD as needing a 5150 response. This was the only type of designation that could be queried in BPD’s data for mental health related calls. From this dataset, RDA identified the variety of other types of incidents that were coded alongside “5150” for each call.
Figure 8 below shows the top ten incident types for all the 5150 calls that BPD responded to in 2014-2020.
Figure 8. Top 10 Berkeley Police Department (BPD) 5150 Incident Call Types, 2014-2020
32 Berkeley City Auditor. (2021, July 2). Data Analysis of the City of Berkeley’s Police Response. https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20Police%20Response.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 63
Disturbance, welfare check, mentally ill, and suicide were the most frequent incident types of all 5150 calls to BPD.
The Berkeley City Auditor conducted a qualitative analysis of its BPD call response d ata to explore the differences between calls that were or were not mental health related. Because BPD’s data does not have an explicit variable that denotes whether each call is mental health related or not, the Berkeley City Auditor did a keyword search for mental health related terms in the open narrative fields of BPD’s call entries. Figure 9 below shows the differences in mental health related and non-mental health related calls that BPD responded to between 2015-2019, stratified by call type.
Figure 9. Berkeley Police Department (BPD) Call Types, 2015-2019
City of Berkeley Mental Health Crisis Response & Perspectives | 64
Around 40% of BPD’s welfare check calls included a mental health related facet to the response, followed by around 20% of disturbance calls, and around 10% of calls regarding suspicious circumstances.
Berkeley Fire Department: The data that BFD shared with RDA (which included data from BFD and Falck) included information on the facilities that BFD and Falck transported 5150 cases to between 2019-2021. Falck conducted the large majority of 5150 transports in Berkeley. Most 5150 transports were to Alta Bates Medical Center and John George Psychiatric Emergency Services.
BFD only transported 5150 cases to Alta Bates, Oakland Children’s Hospital, and Kaiser. As contracted, Falck conducted 5150 transports to all the agencies noted below.
Figure 10. BFD and Falck 5150 Transports by Destination, 2019-2021
BFD also shared data regarding their and Falck’s time on task for each 5150 response and transport. Time on task represents the time from which BFD or Falck arrive at the scene to the point in which they complete the transport of the patient to the destination. Of the 95 5150 transports that BFD conducted between 2019-2021, BFD’s average time on task was 20 minutes.
Of the 1,523 5150 transports that Falck conducted between 2019-2021, Falck’s average time on task was 115 minutes. This is because Falck is the designated ambulance provider who is transporting 5150 cases around Alameda County. These calls can take more time and can be to farther locations. Figure 11 below shows the average time on tasks for BFD and Falck.
Figure 11. BFD and Falck Time on Task for 5150 Transports, 2019-2021
City of Berkeley Mental Health Crisis Response & Perspectives | 65
BFD, Paramedics Plus (or PPlus, the contracted ambulance provider prior to Falck), and Falck’s data on their 5150 call responses also included information on the day of the week and time that each 5150 call was initiated. RDA analyzed this data to search for any notable trends regarding when 5150 calls originate. Figure 12 below shows when each agency’s 5150 call responses occurred; this data spans the years 2018-2021. From this data, it appears that 5150s are least frequent during the very late-night and early-morning hours (2:00-8:00am), and the most frequent between 10:00am – midnight. There is no noticeable difference in the frequency of 5150s across the seven days of the week.
Figure 12. BFD, PPlus, Falck 5150 Transports by Time of Day and Day of Week, 2018-2021
City of Berkeley Mental Health Crisis Response & Perspectives | 66
Demographics of Mental Health Call Responses
Mobile Crisis Team: For the five-year period of FY 15/16 through FY 19/20, the Berkeley Mental Health Division’s Mobile Crisis Team (MCT) shared data about both their overall volume of responses as well as those pertaining specifically to 5150 calls. Figure 13 below includes four figures that show MCT’s incidents by gender (first row), and then incidents by race/ethnicity (second row) by each fiscal year.
Figure 13. Mobile Crisis Team (MCT) Incidents in 2015-2020 - Gender, Race/Ethnicity Total Incidents 5150s Only
City of Berkeley Mental Health Crisis Response & Perspectives | 67
MCT incidents were with slightly more males than females, and very few trans individuals. And, regarding race/ethnicity, MCT cases were most often White, followed by African American, other/unknown, Asian Pacific Islander, and Hispanic or Latino. Given that African Americans comprise only 7.9% of Berkeley’s population (see Table 1), they are very overrepresented in MCT’s service utilizer population.
Berkeley Police Department: For the six-year period of CY 2014 through CY 2020, the Berkeley Police Department (BPD) shared data regarding demographics (age, race, and sex) for each of its calls that were originated as designated 5150 responses. Since 2019, the majority of 5150 responses were conducted by Falck - an ambulance services provider contracted by BFD - because Falck is the designated entity (between the two agencies) to conduct 5150 transports in Berkeley.
Figure 14 below includes six figures that show: 1) the summative demographics of BFD’s 5150 subjects, and 2) the incident types stratified by subject demographics.
Figure 14. Berkeley Police Department (BPD) 5150 Subjects in 2014-2020 - Demographics and Incident Types33
Subjects by Demographics Incident Types by Demographics
33 Data noted as (blank) represent data points where data were missing.
City of Berkeley Mental Health Crisis Response & Perspectives | 68
Of the BPD 5150 calls that had demographic variables coded, most responses were with individuals between ages 26-59, White, or male. Liked noted above with MCT’s service utilizer population, given that African Americans comprise only 7.9% of Berkeley’s population (see Table 1), they are also very overrepresented amongst BPD’s 5150 population. Most BPD 5150 calls were also coded as disturbance calls, welfare checks, mentally ill individuals, and suicide. Each incident type is not mutually exclusive, so any particular incident could have one or multiple more incident type logged towards it in addition to being a 5150.
The Berkeley City Auditor’s report (released in April 2021) on BPD call responses included a variety of tables with data on the demographics of the subjects of their officer -initiated stops by race and age; please refer to the Berkeley City Auditor’s Report in Figure 19: Officer-Initiated Stops by Race and Age, 2015-2019.
34 RDA took the data shared in that figure to produce
different visual representations of all subjects that BPD responded to between 2015 -2019; this data includes responses to non-mental health related calls, as well.
34 Berkeley City Auditor. (2021, July 2). Data Analysis of the City of Berkeley’s Police Response. https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20Police%20Response.pdf
City of Berkeley Mental Health Crisis Response & Perspectives | 69
Figure 15. Berkeley Police Department (BPD) Officer-Initiated Calls in 2015-2020 - Race and Gender (via Berkeley City Auditor’s Report on BPD Calls)
Berkeley Fire Department: For the three-year period of CY 2019 through CY 2021, the Berkeley Fire Department (BFD) shared data regarding demographics (age, race, and gender) and incident type for each of its calls that were originated as designated 5150 responses. Figure 16 below includes six figures that show: 1) the summative and combined demographics of BFD and Falck’s 5150 patients, and 2) the differences in volume of BFD and Falck 5150 responses stratified by patient demographics. Figure 17 below shows the total combined 5150 responses by BFD and Falck, first grouped by gender by race, then by race by gender.
Figure 16. Berkeley Fire Department (BFD) and Falck 5150 Patients in 2019-2021 - Demographics
Patients by Demographics Transport Agency by Demographics
City of Berkeley Mental Health Crisis Response & Perspectives | 70
Figure 17. Berkeley Fire Department (BFD) and Falck 5150 Patients in 2019-2021 - By Gender and Race
City of Berkeley Mental Health Crisis Response & Perspectives | 71
Similar to the incidents that MCT responded to, the 5150 patients that BFD and Falck responded to are mostly between ages 26-59, White, or male. Falck also conducted a large majority of the 5150 transports in Berkeley, as compared to BFD.
Specialized Care Unit
Crisis Response Recommendations
City of Berkeley
City of Berkeley
Specialized Care Unit (SCU)
Crisis Response
Recommendations
Sarah Ferrell
Caroline de Bie
Sasha Gayle-Schneider
Amalia Egri Freedman
Nicole Gamache-Kocol
Jamie Dorsey
Kevin Wu
This report was developed by Resource
Development Associates under contract with
the City of Berkeley.
Resource Development Associates, 2021
Table of Contents
Executive Summary 1
Introduction 3
The SCU Model 8
Recommendations 10
System-Level Recommendations 57
Conclusion 60
Appendix 64
SCU Crisis Response Recommendations | 1
Executive Summary
As part of the larger effort to Reimagine Public Safety, the City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study for a Specialized Care Unit (SCU), an alternative mental health and substance use crisis response model that does not involve law enforcement.
This is the third of three distinct reports for this effort. The first report (“Crisis Response Models Report”) presents a summary of crisis response programs in the United States and internationally. The second report (“Mental Health Crisis Response Services and Stakeholder Perspectives Report”) is the result of engagement with stakeholders of the crisis system, including City of Berkeley and Alameda County agencies, local community-based organizations (CBOs), local community leaders, and utilizers of Berkeley’s crisis response services, and presents a summary of key themes to inform the SCU model.
This third report is intended to guide implementation of the SCU model and includes:
• Core components and guiding aims of the SCU model;
• Stakeholder and best practice-driven design recommendations; • Considerations for planning and implementation;
• A phased implementation approach;
• System-level recommendations; and
• Future design considerations.
Each recommendation put forth in this report is deeply rooted in the stakeholder feedback included in the two previous reports. This report presents RDA’s recommendations based on this year-long project, which the City of Berkeley may adapt and adjust as necessary.
SCU Crisis Response Recommendations | 2
Key Recommendations
1. The SCU should respond to mental health crises and substance use emergencies without a po
lice co-response.
2. The SCU should operate 24/7.
3. Staff a three-person SCU mobile team to respond to mental hea lth and substance use
emergencies.
4. Equip the SCU mobile team with vans.
5. The SCU mobile team should provide transport to a variety of locations.
6. Equip the SCU mobile team with supplies to meet the array of clients’ needs.
7. Clearly distinguish the SCU from MCT.
8. Participate in the Dispatch assessment and planning process to prepare for future integration.
9. Ensure the community has a 24/7 live phone line to access the SCU.
10. Plan for embedding a mental health or behavioral health clinician into Dispatch to support triage and SCU deployment.
11. Fully staff a comprehensive model to ensure the success of the SCU mobile team, including supervisory and administrative support.
12. Operate one SCU mobile team per shift for three 10-hour shifts.
13. SCU staff and Dispatch personnel should travel to alternative crisis programs for in- person observation and training.
14. Prepare the SCU mobile team with training.
15. Contract the SCU model to a CBO.
16. Integrate the SCU into existing data systems.
17. Collect and publish mental health crisis response data publicly on Berkeley’s Open Data Portal.
18. Implement care coordination case management meetings for crisis service providers.
19. Implement centralized coordination and leadership across city agencies to support the success of mental health crisis response.
20. Continue the existing SCU Steering Committee as an advisory body.
21. Solicit ongoing community input and feedback.
22. Adopt a rapid monitoring, assessment, and learning process.
23. Conduct a formal annual evaluation.
24. Launch a public awareness campaign to promote community awareness and education about the SCU.
25. The SCU mobile team should conduct outreach and build relationships with potential service utilizers.
SCU Crisis Response Recommendations | 3
Introduction
Project Background
In response to the killing of George Floyd by Minneapolis police in May 2020 and the ensuing protests across the nation for this and many other similar tragedies, a national conversation emerged about how policing can be done differently in local communiti es.
The Berkeley City Council initiated a wide-reaching process to reimagine safety in the City of Berkeley. As part of that process, in July 2020, the Council directed the City Manager to pursue reforms to limit the Berkeley Police Department’s (BPD) scope of work to “primarily violent and criminal matters.” These reforms included, in part, the development of a Specialized Care Unit (SCU) to respond to mental health crises without the involvement of law enforcement.
In order to inform the development of an SCU, the City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study that includes community-informed program design recommendations, a phased implementation plan, and funding considerations.
The Need for Specialized Mental Health Crisis Response
Just as a physical health crisis requires treatment from a medical professional, a mental health crisis requires response from a mental health professional. Unfortunately, across the country and in Berkeley, police are typically deployed to respond to mental health and substance use crises.
Without the proper infrastructure and resources in place, cities are unable to adequately meet the needs of people experiencing a mental health and/or substance use crisis.
Relying on police officers to respond to the majority of mental health 911 calls endangers the safety and well-being of community members. Tragically, police are 16 times more likely to kill someone with a mental illness compared to those without a mental illness. 1 A
November 2016 study published in the American Journal of Preventative Medicine estimated that 20% to 50% of fatal encounters with law enforcement involved an individual with a mental illness.
2 As a result, communities have begun to consider the
urgent need for crisis response models that deploy mental health professionals rather than police. An analysis found that the 10 largest police departments in the U.S. paid out nearly 250 billion dollars in settlements in 2014, much of which were related to wrongful-
1 Szabo, L. (2015). People with mental illness 16 times more likely to be killed by police. USA Today. https://www.usatoday.com/story/news/2015/12/10/people-mentalillness-16-times-more-likely-killed- police/77059710/
2 DeGue, S., Fowler, K.A., & Calkins, C. (2016). Deaths due to use of lethal force by law enforcement. American Journal of Preventive Medicine, 51(5), S173-S187. https://www.ajpmonline.org/article/S0749- 3797(16)30384-1/fulltext
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death lawsuits of people in a mental health crisis. 3 Law enforcement should not be the primary responders to mental health crises.
A 2012 Department of Justice report outlines that policing in the U.S. does not necessarily keep people safer but instead, militaristic policing causes more harm than good and disproportionately impacts communities of color. The report further assessed that over- policing requires more resources without producing benefits to public safety, draining resources that could otherwise be used for more effective public safety strategies. 4 Nationally, the negative impacts of policing and police violence have been declared a public health issue.
5 Extensive data shows that aggressive policing is a threat to physical and mental health: inappropriate stops are associated with increased anxiety, depression, PTSD, or long-term health conditions like diabetes. In 2016, at least 76,440 nonfatal injuries due to law enforcement were reported and at least 1,091 death s were reported. However, due to insufficient monitoring and surveillance of law enforcement violence, these statistics are underestimated.6
The impacts of policing disproportionately harm people of color, especially Black Americans, making policing an issue of racial justice. Police disproportionately stop, arrest, shoot, and kill Black Americans. Other marginalized populations, such as people with mental illness, people who identify as transgender, people experiencing homelessness, and people who use drugs, are also subjected to increased police stops, verbal and sexual harassment, and death.7
In California, Alameda County has the highest rate of 5150 psychiatric holds in the entire state,8 which may indicate inadequate provision of mental health crisis services. Of those individuals placed on a 5150 psychiatric hold in Alameda County and transferred to a psychiatric emergency services unit, 75-85% of the cases did not meet medical necessity criteria to be placed in inpatient acute psychiatric care. This demonstrates an overuse of emergency psychiatric services in Alameda County. Such overuse creates challenges in local communities such as lengthy wait times for ambulance services which are bu sy
3 Elinson, Z. & Frosch, D. (2015). Cost of police-misconduct cases soars in big U.S. cities. Wall Street Journal. https://www.wsj.com/articles/cost-of-police-misconduct-cases-soars-in-big-u-s-cities-1437013834 4 Ashton, P., Petteruti, A., & Walsh, N. (2012). Rethinking the blues: How we police in the U.S. and at what cost.
Justice Policy Institute, U.S. Department of Justice. https://www.ojp.gov/ncjrs/virtual- library/abstracts/rethinking-blues-how-we-police-us-and-what-cost 5 American Public Health Association. Addressing law enforcement violence as a public health issue. Policy number: 201811. 2018. https://www.apha.org/policies-and-advocacy/public-health-policy- statements/policy-database/2019/01/29/law-enforcement-violence. 6 Ibid.
7 Ibid.
8 INN Plan – Alameda County: Community Assessment and Transport Team (CATT) (2018, October 25). California Mental Health Services Oversight and Accountability Commission. https://mhsoac.ca.gov/sites/default/files/documents/2018- 10/Alameda_INN%20Project%20Plan_Community%20Assessment%20and%20Transport%20Team_8.6.2018 _Final.pdf
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transporting and discharging individuals on 5150 holds. The overuse of involuntary psychiatric holds can be traumatizing for people experiencing crisis, as well as for their friends and family.
The overuse of involuntary psychiatric holds is also an issue of racial justice. Police and ambulance workers have been found to bring Black patients with psychoses to psychiatric emergency service more frequently than non-Black patients with psychoses. 9 For example, in San Francisco, Black adults are overrepresented in psychiatric emergency services, relative to overall population size. 10
Based on 911 call data from 2001 to 2003 in San Francisco, a study found that neighborhoods with higher proportions of Black residents generate relatively fewer mental health-related 911 calls. The authors suggest that underutilization of 911 by the Black community can result in delayed treatment, therefore increasing the risk posed to the health and safety of people in crisis and their communities. The study highlights the common distrust of law enforcement among communities of color. Such distrust and fear of law enforcement may mean that people of color do not trust that mental health - related calls will be handled appropriately if they seek support for a mental health crisis through 911. The study reinforced that “law enforcement officers’ role in the disposition of calls makes them de facto gatekeepers to safety net services for persons with mental disorders.”
11 It is within this context that many Berkeley community members are calling for a more just, equitable, and health-focused crisis response system, in part due to the distrust of institutions of policing or those closely intertwined with police. A variety of stakeholder groups, including the Berkeley Mental Health Commission and the Berkeley Community Safety Coalition, have long advocated for a community-designed 24/7 crisis care model and to reduce the role of law enforcement in crisis response.
9 Kessell, E.R., Alvidrez, J., McConnell, W.A. & Shumway, M. (2009). Effect of racial and ethnic composition of neighborhoods in San Francisco on rates of mental health-related 911 calls. Psychiatric Services, 60(10), 1376- 1378. https://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2009.60.10.1376 10 Ibid.
11 Kessell, E.R., Alvidrez, J., McConnell, W.A. & Shumway, M. (2009). Effect of racial and ethnic composition of neighborhoods in San Francisco on rates of mental health-related 911 calls. Psychiatric Services, 60(10), 1376- 1378. https://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2009.60.10.1376
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In a concurrent project for the City of Berkeley’s Reimagining Public Safety initiative, the National Institute for Criminal Justice Reform found that among many Berkeley residents, there is a lack of trust in and satisfaction with the Berkeley Police Department. They found that:
12 • Non-White respondents were more likely to indicate that the Berkeley Police Department is not effective at all compared to White respondents; • 17.1% of Black respondents and 7.6% of Latinx respondents reported that police had harassed them personally in comparison to only 4.3% of White respon dents; • Respondents are less likely to call 911 during emergencies related to mental health or substance use crisis (57.9%) in comparison to an emergency not involving mental health or substance use (86.2%); and
• Substantially more Black respondents indicated extreme reluctance to call 911 as compared with other groups.
Additionally, the report shared that across all respondents, 65.9% indicated a preference for trained mental health providers to respond to mental health and substance use emergencies “with support from police when needed” and 14.9% indicated a preference “with no police involvement at all.” In total, 80.8% of respondents indicated a preference for trained mental health providers to respond to calls related to mental health and substance use.
13 Clearly, there is an urgent need for a more racially just, equitable, and health-focused mental health crisis response system. The SCU could be well poised to address these inequities by providing specialized mental health crisis intervention, de-escalation, and stabilization without the presence of law enforcement.
Inputs to the Recommendations
This report includes core components and guiding aims of the SCU model, considerations for planning and implementing the SCU model, a phased implementation approach, stakeholder-driven design recommendations, system-level recommendations, and next steps and future design considerations. Each recommendation that RDA puts forth in this report is deeply rooted in the following sources of input:
• Crisis Response Models Report (Report 1 of this series of 3) • Mental Health Crisis Response Services and Stakeholder Perspectives Report (Report 2 of this series of 3)
• Ongoing engagement with the SCU Steering Committee and the City’s Health, Housing & Community Services Department (HHCS)
12 National Institute for Criminal Justice Reform (2021). Reimagining public safety: Draft final report and implementation plan. https://www.cityofberkeley.info/uploadedFiles/Clerk/Level_3_- _Commissions/Draft%20Final%20Report%20and%20Implementation%20Plan%20FNL%20DRFT%2010.30.21.pdf 13 Ibid.
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• Learnings from the simultaneous Reimagining Public Safety initiative • Best practices research
The recommendations presented in this report are directly informed from the strengths, challenges, gaps in services, and lessons learned from crisis response programs around the country. Those considerations, however, must be uniquely tailored to the Berkeley community based on the existing crisis response system and the needs and perspectives of Berkeley residents. Together, the recommendations and implementation approaches presented here are informed by findings from the robust community engagement and citywide processes of the past year.
Crisis Response Models Report
As part of this feasibility study, RDA reviewed the components of nearly 40 crisis response programs in the United States and internationally, including virtually meeting with 10 programs between June and July 2021. A synthesized summary of RDA’s findings, including common themes that emerged across the programs, how they were implemented, considerations and rationale for design components, and overall key lessons learned can be found in the Crisis Response Models Report .
Mental Health Crisis Response Services and Stakeholder Perspectives Report With the guidance and support of the SCU Steering Committee, facilitated by the Director of City of Berkeley’s Health, Housing and Community Services Department (HHCS), RDA conducted a large volume of community and agency outreach and qualitative data collection activities in June and July 2021. Because BIPOC, LGBTQ+, unhoused, and other communities are disproportionately represented in public mental health and incarceration systems— particularly ones designed for punishment and sentencing to prisons— their input was sought to advance the goal of achieving health equity and community safety.
Crisis response service users described their routes through these systems, provid ing their perspectives about their experiences and how these experiences impact their lives in a way that other stakeholders are not able or qualified to do. The goal of the immense amount of outreach and qualitative data collection was to understand the variety of perspectives in the local community regarding how mental health crises are currently being responded to as well as the community’s desire for a different crisis response system that would better serve its population and needs. Such perspectives are necessary to improve the quality of service delivery and, moreover, to inform structural changes across the crisis response system.
The synthesis of the City of Berkeley’s current mental health crisis system and themes from qualitative data collection can be found in the
Mental Health Crisis Response
Services and Stakeholder Perspectives Report
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The SCU Model: Planning & Implementation
Core Components
The recommendations presented in this report represent a model that is responsive to community needs, but as planning continues throughout 2021 and into 2022, new considerations and constraints may arise. As dynamics evolve and more information is obtained and assessed, the model must be flexible and adaptable. There are several components that should, however, remain core to the SCU model:
• The SCU responds to mental health and substance use crises. • The SCU responds with providers specialized in mental health and substance use. • The SCU model does not include police as a part of the crisis response. • The SCU is not an adjunct to nor overseen by a policing entity (e.g., Police, Fire, or CERN
14).
With these core components in mind, the SCU model and phased appr oach were designed to address the challenges, gaps in services, and community aspirations shared by numerous stakeholders throughout Berkeley. The SCU model seeks to:
• Address the urgent need for a non-police crisis response. • Disrupt the processes of criminalization that harm Black residents and other residents of color, substance users, people experiencing homelessness, and others who experience structural marginalization.
• Increase the availability, accessibility, and quality of mental health crisis servi ces. • Provide quality harm reduction services for substance use emergencies. • Strengthen collaboration and system integration across the crisis and wraparound service network.
• Be responsive to ongoing community feedback and experiences. • Build and repair trust with community members and increase public awareness of newly available services.
A System-wide Change Initiative
The development of a mental health crisis response model as a component of the City of Berkeley’s emergency services should be understood as a systemwide change initiative of great magnitude. Developing a shared narrative around community health and well - being while reducing harm, trauma, and unnecessary use of force may build collective support for the SCU model across City of Berkeley agencies and departments. Other cities implementing non-police crisis response models found that garnering buy-in from other
14 Community Emergency Response Network (CERN) is a model recommended by the National Institute for Criminal Justice Reform through the Reimagining Public Safety process.
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city or county departments requires collaboration from the earliest planning stages. Cities shared that when they focused these conversations about shared objectives between the crisis response program and the police, police began to see the program as a resource to them, as mental health professionals could often better handle mental health crises because of their training and backgrounds. Alignment on shared goals and values may support leadership across the City of Berkeley to identify and advance the best resource(s) for responding to mental health needs and substance use crises. An effective systemwide change initiative will also require all involved leaders to communicate and champion the shared vision.
The SCU model requires not only collaboration, but also structural changes and integration across other entities. For one, the SCU’s ability to respond to crises relies in large part on the 911 Communications Center (“Dispatch”). However, in 2019, a Berkeley City Auditor’s report
15 elevated that the understaffing of Dispatch has led to staffing levels that cannot meet the call volume of residents and has increased call wait times .
Increased wait times for 911 callers have negative implications for the safety and well - being of service utilizers and community members. Increased wait times also have negative implications for service providers and crisis responders that are responding to a potentially more advanced state of crisis. Additionally, inadequate staffing levels rely on overtime spending to fund Dispatch, which increases the cost of the entity.
The Auditor’s report also recommended increased training for Dispatchers to manage and respond to mental and behavioral health crisis calls, including the management of suicidal callers and persons with mental illness. The well-being and stress of call takers are also of concern. In all, if they are not addressed, such resource shortages and unmet training needs could have a significant impact on the SCU’s success.
Other entities that will be affected by the implementation of the SCU model include Berkeley Fire, who responds to crises through Dispatch, and the Mobile Crisis Team (MCT), who provide mental health crisis services in partnership with the Berkeley Police Department. These entities, in addition to Dispatch and the SCU, will have to establish new working relationships and protocols to effectively serve the community together.
Dispatch is an immensely complex system. Integrating the SCU into such a system, while addressing staff capacity and training needs, will take significant planning and coordination, as well as funding. For these reasons, the recommendat ions for the planning and implementation of the SCU model are laid out in a phased implementation approach to allow for sufficient preparation of Dispatch while providing urgently needed mental health crisis response to community members.
15 Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads to Excessive Overtime and Low Morale. https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
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Recommendations
Overview
This report presents recommendations that address what is required for SCU model. Figure 1, below, provides an overview of the specialized care unit’s response. Figure 2 shows the many components required for a comprehensive 24/7 SCU model.
The Specialized Care Unit: Crisis Response
Community members experiencing or witnessing a mental health or substance use crisis will be able to call the SCU through a 24/7 live phone line, from which the SCU mobile team will be deployed to the crisis. The SCU mobile team will include specialists who support a person in crisis with intervention, de-escalation, and stabilization techniques. If necessary, the SCU will also be able to transport a person in crisis to locations that promote the person’s safety and care.
Figure 1: An overview of the SCU crisis response.
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The SCU Model: A Comprehensive 24/7 Crisis Response
The SCU is not solely a mobile team that delivers specialized care during mental health and substance use crises, but rather requires a comprehensive model. This model includes clinical and administrative staff to ensure 24/7 live access to the phone line and SCU mobile team. The model also requires centralized leadership and system integration to realize systemwide changes. As this new model is implemented, it will require ongoing data collection, assessment, and iteration to ensure it is meeting the needs of the community. And, the model requires that community members know that they can call a non-police, specialized mental health and substance use crisis team.
Figure 2: An Overview of the comprehensive 24/7 SCU model.
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Phased Implementation
A phased approach will support a successful rollout of the SCU model while planning for integration across city agencies. These timelines may be ambitious given the magnitude of this systems -change initiative and the dependencies of the various model components. While the phased implementation approach represents an ideal timeline and is responsive to the urgent need for specialized mental health and substance use crisis response in Berkeley, it may need to be adjusted to realize the success of the S CU.
Refer to Appendix A for a complete phased implementation roadmap.
Figure 3: An overview of the phased implementation approach.
PHASE 0 PHASE 1 PHASE 2
Nov 2021 - Aug 2022 Sept 2022 - Aug 2023 Sept 2023 - Feb 2024 Feb 2024+
• Engage SCU
Steering
Committee &
community
stakeholders on
RFP; launch RFP
• SCU
staff:
Contracting,
hiring, training
• Dispatch:
Planning &
assessment
• Establish
preliminary
triage criteria,
workflows and
pr
otocols
• Launch public
awareness
campaign
• SCU implements crisis
response services
• Dis
patch implements
integration or
c
omponents based on
Phase 0 planning
• Conduct rapid
assessment, monitoring,
and iteration
• Engage centralized
leadership in
coordination
• Review annual
evaluation and
rapid
assessments
• Pr
epare for
Phase 2
• Implement
changes
based on
evaluation and
community
need
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SCU Mobile Team
The goal of the SCU is to provide specialized care during mental health crises and substance use emergencies, including crisis intervention, de-escalation, and stabilization. This specialized care does not require a police response but instead should be a three-person team of medical and behavioral health specialists. The SCU will need to be equipped to address the nuanced variety of crisis needs across mental health and substance use emergencies.
By providing 24/7 SCU services, the City of Berkeley asserts that mental health crisis response is of the same importance as other crisis services and limits the need to use the police to respond to such crises. Overall, the SCU model aims to disrupt the criminalization of substance use and mental illness and advance racial justice in the City of Berkeley. There are several considerations for how to most effectively promote the safety of crisis responders, persons in crisis, and general community members.
The following recommendations are aligned to best practices and emerging alternative models, while being rooted in community-driven recommendations. Each recommendation is tailored to the City of Berkeley and provides key considerations to support planning and implementation:
Key Recommendations
1. The SCU should respond to mental health crises and substance use emergencies without a police co-response.
2. The SCU should operate 24/7.
3. Staff a three-person SCU mobile team to respond to mental health and substance use emergencies.
4. Equip the SCU mobile team with vans.
5. The SCU mobile team should provide transport to a variety of locations.
6. Equip the SCU mobile team with supplies to meet the array of clients’ needs.
7. Clearly distinguish the SCU from MCT.
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Recommendation #1
The SCU should respond to mental health crises and substance use emergencies without a police co-response.
The goal of the SCU is to provide specialized care during mental health crises and substance use emergencies. Below are suggested guidelines of when the SCU should and should not respond to a call.
Types of calls SCU should respond to:
• Suicide
• Drug overdose
• W
elfare check
• Suspicious circumstance
• Complaint of an intoxicated person
• Social disorder
• Indecent exposure
• Trespassing
• Disturbance
Location of calls SCU should respond to:
• Public settings (e.g., parks, sidewalks,
vehicles)
• Commercial settings (e.g.,
pharmacies, restaurants)
• Private settings (e.g., homes)
Types of calls SCU should not respond to:
• Confirmed presence of firearm, knife,
or other serious weapon
• Social monitoring and enforcement
(
e.g., of unsheltered residents in
public spaces)
• Calls that Dispatch already deems
do not need an in-person response
(e.g., argument with a neighbor,
minor noise violation)
Note: These guidelines and types of calls will need to be further explored to develop triage criteria that adequately reflect all t
he considerations for when the SCU will respond to crises.
Why isn’t the SCU responding with police?
Stakeholders consistently emphasized the need to provide non-police mental health crisis response options, noting that police are primarily trained in issues of imminent public safety threats, not mental health care. Rather than duplicating the MCT's model, the SCU model provides a new option for those better served by a non-police response. A dedicated response unit for mental health, behavioral health, and substance use emergencies will also help to build community trust and increase the likelihood that someone will call for help when they are in a crisis.
Why is the SCU responding to calls at public and private locations? Is that safe? A mental health crisis can happen anywhere, so the SCU must be able to respond to mental health and substance use crises in both public and private settings. Any variables around the safety of responding to a crisis in a private setting should be assessed before deploying the SCU team (e.g., the presence of a serious weapon).
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How were the types of calls decided?
Research from alternative models in other cities, community stakeholders ’ perceptions of existing needs in Berkeley, and input from crisis responders in the City of Berkeley all indicate that these call types may be well suited for behavioral health and mental health specialists instead of police. The nuance s within any of these call types will be further planned for throughout Phase 0.
Considerations for Implementation
Safety & Weapons:
● Not all weapons pose the same risk to crisis responders, so triage and deployment protocols should be aligned to best practices and standards of practice. The SCU may be able to respond to some calls where a weapon is present. The criteria for this safety precaution should be evaluated and planned for during Phase 0.
● If there is a mental health or substance use emergency where a weapon is present, then MCT-Police co-response should be deployed rather than the SCU.
● If the SCU mobile team is on scene but feels their safety is in imminent danger, they should have the ability to call in the MCT-Police co-response as backup support.
Coordinating with Other Entities
● Mobile Crisis Team: The types of calls, triage criteria, and workflows will need to be differentiated for deploying MCT versus SCU.
● Berkeley Police Department: When BPD is on scene and MCT is not available, BPD and SCU will need clear processes for whether police can bring the SCU to support. Similarly, BPD and SCU will need clear processes for when/how SCU leaves if they call the BPD to a scene.
University of California Police Department: Plan for differentiation or ongoing collaboration between UC’s new mobile crisis unit and the SCU, such as for crises on the UC campus or for students in crisis.
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Recommendation #2
The SCU should operate 24/7.
The SCU mobile team should be available to respond to a crisis in person 24 hours per day, 7 days per week.
Not having services available 24/7 was the most common challenge expressed by stakeholders about the current mental health crisis response system. In contrast, other crisis services like Fire and Police are available 24/7. By operating the SCU 24/7, the City of Berkeley asserts that mental health crisis response is of the same importance as other crisis services and negates the need to use police to respond to such crises. The need for 24/7 service is supported by national trends, as although some cities have implemented alternative crisis models with limited hours, many of them shared that they plan to expand to 24/7 to meet community needs.
Why does the SCU need to be available 24/7? Why can’t it operate only during peak hours? A mental health or substance use crisis can happen at any time. Stakeholders stressed the importance of having mental health crisis response services available 24 hours per day and 7 days per week. If community members are to trust in the SCU as an ongoing and authentic alternative to police involvement, services need to be available whenever someone calls.
Considerations for Implementation
All other supporting elements described throughout this report will need to accommodate 24/7 availability, such as:
● Phone access to the SCU
● Certain personnel roles, like a Clinical Supervisor
● Staffing structure that allows redundancy of personnel to cover each shift ● Equipment and infrastructure including the number of vans for the mobile team
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Recommendation #3
Staff a three-person SCU mobile team to respond to mental health and substance use emergencies.
The array of mental health, behavioral health, and substance use services offered by the SCU requi re staff with varying professional specialties. The following roles are necessary to adequately provide these services:
1. A Mental Health Specialist
This role will be the primary provider of mental health services with the ability to conduct 5150 assessments, and therefore need to be licensed. They should have significant training in mental health and behavioral health conditions and disorders, crisis de-escalation, and counseling. • Recommended position: Licensed Behavioral Health Clinician • Possible positions: Licensed Clinical Social Worker (LCSW), Associate Clinical Social Worker (ASW), SUD or AOD Counselor, psychologist
2. A Peer Specialist
This role should have lived experience with mental health crises and systems, substance use crises or addiction, and be equipped to support system navigation for a person in crisis. • Recommended position: Peer Specialist
• Other possible positions: Community Health Worker, Case Manager
3. A Medical Professional
This role should be able to identify physical health issues that may be contributing to or exacerbating a mental health crisis, including psychosomatic drug interactions . They should be able to administer single-dose psychiatric medicines and have training in harm reduction theory and approaches. They can also assess and triage for higher levels of medical care as needed. • Recommended position: Psychiatric Nurse Practitioner (Psych-NP) • Other possible positions: Nurse Practitioner (NP), EMT, Paramedic
Why a three-person team?
These three distinct roles create a team that can effectively provide the necessary range of specialized services and can engage in organic collaboration to address each crisis. Cities who have implemented similar models spoke to the advantage of team members taking different roles in each scenario based on each client’s needs and preferences.
Why is the mental health specialist conducting 5150 assessments? The SCU’s aim is to reduce the overall number of involuntary holds through effective crisis intervention, de- escalation, and stabilization. However, ensuring the SCU has the ability to conduct 5150 assessments and involuntary holds rather than calling in the police to do the assessment can reduc e interactions between people experiencing mental health crisis and police. Additionally, enabling th e SCU to conduct the 5150
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assessment is a more trauma-informed model because it eliminates the need for a person in crisis to interact with multiple teams and reduces the time it takes to respond to a crisis from start to finish.
Why is there a peer on the team?
The peer is a critical member of the crisis team. Other systems shared that a person in crisis may be most responsive to a peer who has gone through a similar experience and th at, at times, peers’ unique training and skills allow them to engage that person more effectively than other specialties. Berkeley stakeholder participants emphasized the invaluable contributions of peer specialist s, noting that they may be best equipped to lead the de-escalation before the mental health specialist or medical professional steps in to administer care because a person in crisis may be most responsive to someone that has similar lived experience.
Why is there a medical professional on the team? Why a Psych -NP? Mental health and physical health needs often co-present, with physical needs ranging from basic first aid (e.g., wound care, dehydration) to reactions to substances, such as overdoses or drug interactions. A medical professional, such as a Psych-NP, brings the clinical expertise to understand how physical ailments, chronic medical conditions, and psychiatric conditions affect a service utilizer (e.g., someone with hypertension and schizophrenia using methamphetamines). Other medical prof essionals, such as NPs, may also have sufficient training to meet the mental health and substance use needs of service utilizers. These situations do not require the expertise of a paramedic or doctor who are trained to respond to emergencies and deliver life-saving care.
Considerations for Implementation:
● The number of mobile teams required will be based on multiple variables including community needs, call volume, and budget (for a more in-depth description, refer to recommendation #12). ● There may be challenges in staffing the SCU mobile team with these specific roles, such as the Psych-NP. The SCU model may need to allow for a variety of specialists to fill each of the three main roles.
● Across these roles, the SCU mobile team should have the following co mpetencies:
○ Lived experience of behavioral health or mental health needs, homelessness, addiction or substance use, and/or incarceration
○ Emphasis on dual diagnosis (mental health and substance use) training, psychosomatic interactions, substance use management, and harm reduction ○ Identities reflective of those most harmed by the current system of care and/or those who are most likely to use or benefit from the SCU services ○ Multilingual
● Across these roles, the SCU mobile team will need to be trained on a variety of topics (for a full list, refer to recommendation #14). These may be desirable prerequisite skills, such as:
○ Disarming without the use of weapon
○ Motivational interviewing
○ Naloxone administration
○ Harm reduction
○ Trauma-informed care
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Recommendation #4
Equip the SCU mobile team with vans.
Based on the scope of services, the SCU mobile team will need a vehicle to arrive at each call, carry equipment and supplies, and transport clients to another location. A well -equipped van should be both welcoming and physically accessible to clients and easily maneuverable by staff.
SCU vans should include:
• Wheelchair accessible features
• Lights affixed to the top of the van,
allowing for sidewalk parking
• Locked supply cabinets
• Rear tinted windows for client privacy
• Rear doors not operable from the inside
• Power ports to charge laptops, tablets,
and phones
• Comfortable seating
• SCU logo on the side of the van so the
community can easily identify the team
SCU vans should not include:
• Sirens
• A plexiglass barrier between the front
and back seats
Why not use an ambulance?
There are a several reasons why an ambulance is not the appropriate vehicle for the SCU:
• Ambulances must transport to a receiving emergency department when transporting from th e field (a call for service from a community member), which may not always be the most appropriate end point for the level of care required (refer to recommendation #5). • Ambulances require a special license to drive and would require the inclusion of an EM T or paramedic on staff and would therefore increase the expense of the SCU. • Ambulances are more expensive to purchase and maintain than a van. • A van is potentially less stigmatizing and traumatizing for a person in crisis.
Why were these specific features chosen?
All van specifications are based on lessons learned from alternative crisis response programs in other cities and experiences and insight shared by the Berkeley Fire Department. Many van features, such as locked supply cabinets and locked rear doors, are designed to increase the safety of both crisis responders and a person in crisis. Other van features support the SCU mobile teams to provide a variety of services.
Why shouldn’t the van have sirens or a plexiglass barrier? Sirens can draw unnecessary public attention, thereby reducing privacy for a person in crisis , while both sirens and plexiglass barriers can exacerbate the stigmatization, traumatization, and criminalization of mental health and substance use crises.
Considerations for Implementation
The number of vans required will be based on the number of SCU mobile teams and shift structure/overlap (refer to recommendation #12).
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Recommendation #5
The SCU mobile team should provide transport to a variety of locations.
The SCU should provide a level of care appropriate to each specific crisis with the aim of de -escalating crises, preventing emergencies, and promoting well-being. The SCU will transport service utilizers in the SCU van (refer to recommendation #4) unless there is a medical need that requires the SCU to request an ambulance for transport.
The SCU will transport service utilizers to:
• Inpatient units of psychiatric emergency
departments
• Primary care providers, psychiatric facilities, or
u
rgent care
• Crisis stabilization units, detox centers, or
sobering centers
• Drop-in centers and other CBOs
• Shelter or housing sites
• Domestic violence service sites
• Long-term programs including residential
rehabilitation sites
• Requested public locations (e.g., parks)
• Requested private locations (e.g., home)
Considerations when deciding transport location:
• Transport can be voluntary or involuntary,
based on a 5150 assessment
• The SCU should be able to deny the request of
a pe
rson in crisis for transportation based on
their assessment of the appropriate level of
care
• The SCU will need to assess safety or liability
concerns for the service utilizer or other
bystanders based on transport location (e.g.,
not transporting an intoxicated person home
where another person is present at the home)
Why should the SCU transport service utilizers to so many different locations? The SCU model aims to support diversion of people experiencing crises away from jails and hospitals and into the appropriate community-based care and resources. Some crises can be resolved on scene, while others will require transport to another location. Even if a crisis is de-escalated on scene, service utilizers may benefit from being transported to another location for additional care or resources. Throughout this project, stakeholder participants emphasized that the level of need outweighs the available resources and providers in Berkeley and Alameda County. Providing transport to a variety of locations and resources allows the SCU to provide the level of care appropriate to each specific crisis and increases the possibility of providing care in an overwhelmed service network. Refer to Section V for long-term recommendations for addressing the needs of the service network.
Considerations for Implementation
• Established, trust-based relationships with community partners and warm handoff procedures will improve overall quality of care and can reduce the amount of time required when dropping off a client.
• Staff at emergency facilities will need to be familiar with the SCU, includi ng the van, logo, and uniforms, to be prepared to receive transported clients in a timely and responsive manner, reducing “wall time.”
• Triage criteria and workflows should support the SCU in assessing where and how to transport a person in crisis.
• Triage criteria and workflows for transport should address the safety implications for both the person in crisis and other community members.
SCU Crisis Response Recommendations | 21
Recommendation #6
Equip the SCU mobile team with supplies to meet the array of clients’ needs.
The SCU will be responding to a variety of calls, each with their own specific needs. The supplies needed will vary depending on the call. Below is a suggested list of supplies the SCU should carry , generated from the input of stakeholders and other alternative crisis response programs. These supplies will facilitate a harm reduction approach and directly contribute to the health and well-being of the person in crisis.
Medical supplies
• First aid kit
• Personal protective equipment
• Wound care supplies
• Stethoscope
• Blood pressure armband
• Oxygen
• Intravenous bags
• Single-dose psychiatric medications
Client
engagement
items
• Food and water
• Clothing, blankets, and socks
• Transportation vouchers
• “Mercy beers” and cigarettes
• Tampons and hygiene packs
Community
health supplies
• Safe sex supplies and pregnancy tests
• N
aloxone
• Clean needles and glassware
• Sharps disposal supplies
Technology
• Cel
l phones
• Da
ta-enabled tablets
• Computer Aided Dispatch (CAD)
• Police radio
Uniforms • Casual dress: polo or sweatshirt with the SCU logo
SCU Crisis Response Recommendations | 22
Why does the SCU need to carry client engagement items? These items can help initiate an interaction while also meeting the basic needs of clients while they are experiencing a crisis.
Why does the SCU need to carry community health supplies? These supplies can help address an underlying physical health need or provide harm reduction for substance use crises.
Why does the SCU need technology and uniforms?
The team needs cell phones and data-enabled tablets for mobile data entry. The tablets should be preloaded with an electronic health record (EHR) application so staff can access client history to provide more effective, tailored care. Wearing a casual uniform can help the team appear more approachable to clients and be easily identifiable. Uniforms that look more like traditional emergency response uniforms c an be triggering for clients who have had traumatic experiences with emergency responders.
Considerations for Implementation
• The need for basic provisions among service utilizers is often significant and therefore affects the model’s budget. To effectively plan for the program budget, San Francisco’s Street Crisis Response Team shared that they budgeted for $20 in supplies per client contact but quickly exceeded their $10,000 annual budget. Denver’s STAR program noted that these supplies were in high demand and the budget was supplemented with donations.
• Staff should track which supplies are used most often and which supplies are requested by clients that the SCU does not carry.
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Recommendation #7
Clearly distinguish the SCU from MCT.
Once the SCU model is implemented, there will be two teams responding to mental health crisis calls in the City of Berkeley: the Specialized Care Unit and the Mobile Crisis Team. It will be necessary to clearly distinguish the role of these two teams so that the proper response is deployed for each situation. The general public will also need to be informed regarding the two teams, how to access them, and why .
Suggested scenarios when MCT and Police should be deployed instead of the SCU:
• If there is a confirmed presence of a serious weapon during a mental health crisis, the police and MCT would be deployed.
• If the police request mental health support during a crisis, MCT will be deployed as a co-response. • If the SCU is on a call and needs backup or cannot successfully intervene, they would call for an MCT-police co-response.
If there’s an SCU, why should the MCT still exist?
When the police respond due to the presence of a weapon or other element outlined above , a joint response that includes clinical staff to support the intervention is a best practice and community asset, delivering a trauma-informed response focused on de-escalation. This is especially true for a person in crisis with past traumatic experiences with the police. The MCT remains an important resource that can reduce the negative impacts of police presence during situations where a mental health crisis intersects with issues of imminent public safety.
Why is it important to distinguish MCT from the SCU?
Trust & Acceptability of SCU: MCT responds to the majority of their calls with police backup. Because SCU is a non-police crisis response option, clearly distinguishing the two models will be essential in establishing and maintaining community trust to increase utilization of the SCU, particularly among groups most at risk of harm from police violence.
Logistics for Deploying the Right Team: Dispatch will need tools and training to clearly differentiate the teams’ roles to effectively deploy the right team for each mental health crisis call.
Considerations for Implementation
• All triage criteria and workflows need to be reflective of the differentiation between SCU and MCT.
This includes the triage criteria and workflows for Dispatch and/or the alternative phone line and Alameda County’s Crisis Support Services (CSS) (refer to recommendation #9). • The distinction between MCT and the SCU, particularly around availability and police involvement, should be emphasized in the public awareness campaign (refer to recommendation #24). • Tracking the acuity levels of calls, as well as whether MCT and police were called in for backup, can help refine the Dispatch process and ensure that the right team is deployed .
SCU Crisis Response Recommendations | 24
Accessing the SCU Crisis Response: Dispatch &
Alternative Phone Number
Implementing the SCU as a 24/7 mental health and substance use crisis model requires that community members have reliable and equitable access to the team. By integrating the SCU crisis response into 911 and Dispatch’s processes, mental health crisis services will be elevated to the same level of importance as Fire and Police when calling for emergency services, thus promoting community access to specialized crisis care. To reach this goal, the SCU model, City of Berkeley leadership, and Dispatch will need to work together during assessment and planning processes.
The need to develop and implement the SCU model is urgent. Yet Dispatch is a complex, under-resourced, and overburdened system. To achieve structural change that ensures sustainability, significant planning and coordination is essential.
There are several possibilities for how to advance the SCU-911 integration aligned to the phased implementation approach. The following recommendations are aligned to best practices and emerging alternative models and responsive to the needs and concerns expressed by community stakeholder participants. Each recommendation should be further explored, assessed, and discussed across City of Berkeley leadership:
Key Recommendations
8. Participate in the Dispatch assessment and planning process to prepare for future integration.
9. Ensure the community has a 24/7 live phone line to access the SCU.
10. Plan for embedding a mental health or behavioral health clinician into Dispatch to support triage and SCU deployment.
SCU Crisis Response Recommendations | 25
Recommendation #8
Participate in the Dispatch assessment and planning process to prepare for future integration.
Ultimately, the SCU should be integrated into 911 and Dispatch protocols. To reach this goal, the SCU model, City of Berkeley leadership, and Dispatch will need to work together during assessment and planning.
Dispatch, through the Berkeley Fire Department, has conducted a Request for Proposal process and selected a consulting firm to support enhancements to the deployment of Fire and EMS/Ambulance services. That assessment and planning process should integrate SCU implementation, preparing for the SCU to be a mental health emergency response on par with police and fire emergency calls.
If this is a non-police response model, why is Dispatch involved? An effective mental health crisis response that increases community safety, well -being, and health outcomes relies on the SCU actually being deployed to community members in cr isis. Dispatch has established infrastructure and technology that could effectively and safely deploy the SCU mobile team.
Moreover, 911 is a well-known resource to the general public, which many people do seek during crises. In 2017, Dispatch received 256,000 calls.
16 For these reasons, integration of the SCU into 911 and Dispatch’s processes is an important method for deploying the SCU team to people experiencing a mental health or substance use crisis.
Will another assessment and planning process delay the launch of the SCU? Dispatch’s expertise and experience are a critical asset to lead the assessment, planning, and implementation of revised 911 procedures that include the SCU. The Dispatch assessment and planning project is slated to begin in 2022; by incorporating assessment and planning for the SCU into an existing project, it will initiate the process several months sooner than if a separate and new project were to be initiated. Additionally, integrating both projects will ensure consistent and simu ltaneous efforts rather than disjointed efforts that require backtracking or undoing of work and decisions.
Considerations for Implementation
• A systems-change initiative of this magnitude will need identified shared aims and goals. • A systems-change initiative of this magnitude will need Dispatch leadership to champion the effort and communicate early, often, and positively about the upcoming changes. • By participating in Dispatch’s assessment and planning processes, the SCU model can identify opportunities early on that support the integration, such as using aligned terminology and data collection processes.
• A Dispatch representative should join the SCU Steering Committee (refer to recommendation #20).
• Dispatch leadership should join the model’s centralized coordinating body (refer to recommendation #19).
16 Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads to Excessive Overtime and Low Morale. https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_-_General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
SCU Crisis Response Recommendations | 26
Recommendation #9
Ensure the community has a 24/7 live phone line to access the SCU.
Implementing the SCU as a 24/7 mental health and substance use crisis model requires a 24/7 live phone line to ensure community members have reliable and equitable access to mental health crisis response.
The 24/7 availability is essential for community members to feel confident in the availability of the mental health crisis response, as stakeholders reported that MCT’s alternative phone number— which is not live and relies on voicemail and callbacks— does not feel like a reliable resource during crises.
The need to develop and implement the SCU model is urgent and at the same time must achieve structural change to ensure sustainability. Implementing a process for the short-term that must be undone would be an inefficient use of funds and may confuse the public and exacerbate distrust. For these reasons, the following three options should be further considered and assessed for how to most effectively ensure 24/7 live access to the SCU crisis response:
1. Option A: Use the existing 911 Communications Center (“Dispatch”) to deploy the SCU.
2. Option B: Contract to a CBO that can staff and implement an alternative number phone line as part of the SCU model.
3. Option C: Use the 988 National Suicide Prevention Lifeline to receive, triage, and assess all mental health crisis calls.
Table 1 below highlights several factors to consider related to timeline and staff capacity, funding, safety, system integration, and public awareness. Based on these factors, it appears that Option A (using the existing 911 Communications Center to deploy the SCU) would be the best option for the City of Berkeley.
However, these factors should be further discussed by City of Berkeley leadership across HHCS and Dispatch with careful consideration of the phased implementation approach and timeline .
SCU Crisis Response Recommendations | 27
Table 1: Options and factors to assess when planning for the community to have 24/7 live phone line access to the SCU .
Option A *Recommended Option*
Use 911 and existing Communications
Center (“Dispatch”) to deploy the SCU.
Option B
Contract to a CBO that can staff and
implement an alternative number
phone line as part of the SCU model.
Option C
Use the 988 national phone line to
receive, triage, and assess all
mental health crisis calls.17
Timeline & Staff
Capacity
Assess Dispatch’s ability to recruit, hire,
and train new staff on a timeline aligned
to the phased implementation
approach.
Consider the amount of resources and
time required for Dispatch to train
existing staff on new protocols.
Consider Dispatch’s capacity to support
the SCU adoption and integration in
addition to the current accreditation
process.
Assess whether a CBO can realistically
implement both the SCU model and an
alternative phone number (i.e., call
center), including recruiting, hiring, and
training all new personnel.
Monitor the alignment of national,
state, and county timelines for 988
implementation.
Assess whether the 988 call center
will be staffed appropriately for
the additional call volume brought
in by requests for SCU.
Funding
Es
timate the additional funds required
for Dispatch to recruit new personnel
(i.e., a recruitment team) and manage
the Human Resource capacity to
support additional sta
ff.
Estimate the cost to create and operate
an independent 24/7 live alternative
phone line.
Explore the amount of funding and
resourcing available for 988 to
assess whether the funds
sufficiently support the 24/7 SCU.
17 Gold, J. (2021). How will California’s new 988 mental health line actually work? U.S. News. https://www.usnews.com/news/health-news/articles/2021-10-12/how-will-californias- new-mental-health-hotline-actually-work
SCU Crisis Response Recommendations | 28
Safety
Promotes
Safety
Evaluate and compare each option’s ability to establish protocols or infrastructure to support the safety of crisis responders and community members.
Dispatch already has established
protocols and technology to track the
crisis responder’s location/position
through CAD.
Dispatch already has established
protocols and technology to maintain
radio communication between
Dispatch and crisis responders,
especially during rapid changes in a
situation.
Dispatch already has established
protocols and technology to streamline
the handling and transfer of calls so
that a person in crisis does not have to
repeat their story multiple times,
thereby reducing the number of
dropped calls.
Assess the resources and timing
required for a CBO to ensure sufficient
training on the use of the CAD system
and radio communication.
Assess workflows and processes that
would affect the number of times a
caller must repeat triage/assessment;
estimate whether there will be an
increase in dropped calls.
Consider if a non-911 entity will more
effectively reduce police-community
interactions during mental health and
substance use crises.
Assess the ability for existing
Alameda CSS and 988 technology
to integrate with Dispatch’s CAD
system and radio communication.
Evaluate the effectiveness of
existing processes to transfer calls
between Alameda CSS and
Dispatch.
Consider if the 988 entity will more
effectively reduce police-
community interactions during
mental health and substance use
crises.
Risks to
Sa
fety
Evaluate and compare the potential risks to the safety of crisis responders and community members across each option.
Consider whether Dispatch will be more
likely to deploy the police than the SCU
during initial model implementation.
Evaluate whether community members’
fear of a police response, will reduce the
utility, acceptability, and accessibility of
the SCU.
Consider whether alternative phone line
personnel will be more likely to deploy
the SCU than transferring calls to 911.
Evaluate whether community members
will be more likely to call an alternative
phone number than 911 if they are
experiencing a mental health or
substance use crisis.
Consider whether community
members will be confused about
988 and may believe it is only for
suicide prevention rather than the
full spectrum of mental health and
substance use crises, and therefore
be less likely to call 988.
Option A (Recommended) Option B Option C
SCU Crisis Response Recommendations | 29
System
Integration
N/A
(911 is already integrated with Berkeley
Fire, Falck, and Alameda County CSS)
Explore the process for a CBO to assess
and prepare callers if they need to
transfer the call to 911, such as if the
presence of weap
ons is confirmed.
Evaluate the effects, such as a slowed
response time or increased risk of a
dropped call.
Consider whether the transfer of calls to
911 (i.e., calls ineligible for SCU) will
undermine community trust in the
alternative phone line.
Determine the feasibility of integrating a
CBO’s technology to allow for the
transfer of calls between Alameda CSS
and Dispatch.
Determine the feasibility of a CBO’s
technology to receive calls from Fire
and Falck if they request the SCU.
Determine whether Alameda
County will be able to deploy a
Berkeley-specific team (the SCU)
for only Berkeley residents as a
component within the larger 988
model.
Assess what will be required for a
county system to deploy a model
administered by a CBO, such as
additional contracts, MOUs, or staff
licensure requirements.
Public Awareness
Consider what will be required of a
public awareness campaign to build
community trust in 911 to deploy the SCU
as a non-police response.
Consider what will be required of a
public awareness campaign to inform
Berkeley residents both about the SCU
as a non-police crisis response and
promote an alternative phone number
to access the SCU.
Assess the public awareness and
education planned for 988.
Assess whether the Alameda
County 988 public awareness
campaign can be adjusted for
Berkeley to communicate the
availability of the SCU through 988.
Option A (Recommended) Option B Option C
SCU Crisis Response Recommendations | 30
Why consider different options for phone access to the SCU? The numerous factors that should be assessed to determine the best option for phone access to the SCU will require a significant amount of collaboration and detailed planning across city leadership , which requires time throughout Phase 0. The general public is familiar with 911 as a crisis response resource. As a result, 911 could be an important method of ensuring mental health and substance use crises are routed to the SCU mobile team. However, stakeholders, especially residents of color and Black residents, consistently shared that the fear of physical violence, criminalization, or retaliation by police in response to mental health and substance use emergencies is a barrier to calling 911. Therefore, a non-911 option may support community members to feel confident in the SCU as a non-police mental health crisis response.
Considering and assessing the full array of options will ensure the best approach for a reliable and equitable access to 24/7 mental health crisis response.
Why is Option A elevated as the recommended option?
Overall, Option A is recommended because it appears to be a better fit for the SCU model. It will most likely be the more cost-effective option, will allow for the SCU mobile team to be launched soonest, and will align to the phased implementation approach and the future integration of the SCU into 911.
By pursuing Option A, preparation with Dispatch can begin sooner than the other options, thus allowing for additional time to plan and prepare. This additional planning time can be used to address concerns regarding safety, community trust, and public awareness. Integrating the SCU into 911 from the initial phases of implementation may also support a streamlined and efficient integration. In contrast, Option B will likely require significantly more funding to create an entirely new call center, which may become obsolete once 988 is implemented, nationally. The feasibility and expense of standing up an entirely new call center (option B) may be prohibitive. Option C will require significant coordination with Alameda County and has many implications that are outside of the control of the City of Berkeley, which could cause delays or challenges to the implementation of the SCU model.
Additionally, 911 has established technology and infrastructure for receiving and triaging phone calls, deploying crisis responders, tracking the crisis response to promote responder safety, and collecting data that is essential for monitoring, evaluation, and follow-up. Moreover, for the public awareness campaign, it may be easier to communicate the SCU as a non-police response through 911 than it is to both communicate the SCU as a non-police response and to publicize an alternative phone number.
Why might the model implement an alternative phone number? (Option B or Option C) First, due to existing community distrust of policing systems, it is important to establish the SCU response as a non-police response. By implementing the alternative phone number first, community members may be encouraged to utilize the SCU. Second, the existing Dispatch system is complex, overburdened, and underfunded. In order to have a successful integration of the SCU within 911, it may require more time for planning for a sustainable integration that ensures community safety. Third, lessons learned from other cities implementing alternative models may indicate this order would support SCU success. For example, the Portland Street Response team can be accessed through both 911 and a non- emergency phone number connected to Dispatch. However, they found that calls from 911 were prioritized rather than calls from the alternative line when deploying the team. Berkeley will need to establish clear prioritization and triage protocols so that the highest-acuity calls receive adequate responses, rather than the response being determined by the source of the call.
SCU Crisis Response Recommendations | 31
Do other cities use multiple phone numbers?
From the reviewed models, at least seven use two or more lines for emergency crisis calls:
• Olympia, WA: Crisis Response Unit
• Sacramento, CA: Department of Community Response
• Austin, TX: Expanded Mobile Crisis Outreach Team (EMCOT) • Oakland, CA: Mobile Evaluation Team (MET)
• Portland, OR: Portland Street Response
• Eugene, OR: Crisis Assistance Helping Out on the Streets (CAHOOTS) • Denver, CO: Supported Team Assisted Response (STAR)
If the model uses an alternative phone line, what happens if people still call 911 when they are having a mental health crisis?
Dispatch should have the option to forward calls to the SCU alternative phone line, where those staff can triage the call and deploy the SCU. Establishing these protocols will be part of the assessment and planning process. It is also important that a public awareness campaign promotes access to the SCU team (refer to recommendation #24).
Additional Considerations for Implementation:
• The phone line will require dedicated office space and equipment to process calls and deploy the SCU.
• The phone line will need technology and protocols to ensure data collection and integrity to support monitoring and evaluation (refer to recommendations #22 and #23). • The phone line will require enough staff to maintain a 24/7 live response including staff to receive calls and supervisory staff. This team will need to be sufficiently staffed to account for shift overlap, sick leave, and vacation time.
• Additional data collection and planning will be required to determine the adequate number of call takers and fully implement the phone line.
• Option A may require that Dispatch makes more gradual changes to triage criteria, deploying the SCU to a more limited scope of call types with a gradual increase in SCU deployment through Phase 1 implementation.
• Either option B or option C would still require the phone line entity to collaborate with Dispatch to develop types of calls, triage criteria, and workflows to allow for future integration of SCU into Dispatch.
• The future structure of the 911 Communications Center within Berkeley Police Department should be evaluated (refer to Section V).
*Please note: Dispatch uses specific terminology that may not be accurately represented here. The language in these recommendations should be understood from a lay perspective rather than rigid technical language (e.g., call takers versus dispatchers, assessment versus triage versus decision-trees).
SCU Crisis Response Recommendations | 32
Recommendation #10
Plan for embedding a mental health or behavioral health clinician into Dispatch to support triage and SCU deployment.
Embedding a mental or behavioral health clinician within the Dispatch represents a new process for Berkeley’s Dispatch and broadens Dispatch’s lens from being solely a Police entity to an entity that includes clinical specialists. Dispatch must be involved in planning for this additional team member.
Why should Dispatch have a clinician in the call center? Embedding a mental health clinician in emergency call centers is an emerging best practice, though only a few cities nationally report staffing their call centers with clinicians. The few cities that have included mental health clinicians in their call centers have found them to be a useful resource. Where implemented, clinicians provide specialized training for call takers to handle behavioral health crisis calls, receive transferred behavioral health crisis calls, and provide guidance.
18 How does having a clinician in Dispatch promote community or crisis responder safety? Berkeley Dispatch is deeply committed to the safety of crisis responders. In interviews for this project, Austin’s EMCOT program19 shared that embedding a clinician within their call center increased communication around safety and risk assessment during triage, including increased deployment of the crisis response team. They also shared that this integration improved handoffs for telehealth conducted by the clinician. Berkeley should plan for embedding a clinician in Dispatch to support with de-escalation and determinations because it could promote safety.
Why does the clinician need to be part of planning in Phase 0 if implementation is in Phase 1? This change represents a structural shift for Dispatch, incorporates new roles for a specialized skillset, and changes several workflows. As a result, having a clinician participate in planning in Phase 0 will support successful implementation in future phases. Additionally, given the current significant understaffing and under-resourcing of Dispatch, the clinician can augment staff capacity without Dispatch having to acquire a new, specialized skillset.
Considerations for Implementation:
● Calls that do not require an in-person response should continue to be sent to Alameda County CSS for phone support.
● Staffing structures will need to be adapted, such as determining which roles supervise the clinician and which roles the clinician supervises.
● The clinician may be able to provide training and ongoing professional development to support call takers to identify and address mental health calls.
● There may be a need for multiple clinicians depending on their role and the call volume. ● This recommendation will need to be adapted based on how recommendations #8 and #9 are implemented.
18 Velazquez, T & Clark-Moorman, K. (2021). New research suggests 911 call centers lack resources to handle behavioral health crises.
ResearchGate.
https://www.researchgate.net/publication/355684339_New_Research_Suggests_911_Call_Centers_Lack_Resources_to_Handl e_Behavioral_Health_Crises
19 Read more about the EMCOT program here: http://www.austintexas.gov/edims/pio/document.cfm?id=348966
SCU Crisis Response Recommendations | 33
Implement a Comprehensive 24/7 Mental Health
Crisis Response Model
There are many considerations for realizing the full implementation of a 24/7 model including hiring personnel, establishing clear roles, and providing office space and required materials. Staffing a comprehensive model should seek to address the perceived challenges of existing crisis response systems throughout Berkeley, such as not having 24/7 availability or sufficient staff capacity.
The following recommendations are designed to leverage the lessons learned from other cities implementing non-police crisis response models and be responsive to the needs and concerns expressed by community stakeholder participants. Each recommendation should be further explored as launch and implementation progresses:
Key Recommendations
11. Fully staff a comprehensive model to ensure the success of the SCU mobile team, including supervisory and administrative support.
12. Operate one SCU mobile team per shift for three 10-hour shifts.
13. SCU staff and Dispatch personnel travel to alternative crisis programs for in -person observation and training.
14. Prepare the SCU mobile team with training.
SCU Crisis Response Recommendations | 34
Recommendation #11
Fully staff a comprehensive model to ensure the success of the SCU mobile team, including supervisory and administrative support.
In addition to the three-person SCU mobile team (recommendation #3), the 24/7 live phone line (recommendation #9), and the clinician in Dispatch (recommendation #10), the SCU will require supervisory and administrative support roles. These roles will support the day -to-day services and operations of the SCU mobile team. They also will participate in case management meetings (recommendation #18), rapid assessment and monitoring (recommendation #22), and model evaluation (recommendation #23).
Recommended Personnel Roles & Types of Responsibilities20:
Program Manager
• Review data from implementation, lead rapid assessment process, support changes and iteration to model
• Liaise with city, Dispatch, and central leadership around implementation, rapid assessment, and coordination
• Manage contract and budget
• Manage scheduling and shifts
Clinical Supervisors
• Oversee and support SCU mobile team, provide consultation for medical and mental health services
• Plan and lead training and professional development for SCU mobile team • Collaborate with peer specialist supervisor on how to best support SCU mobile team • Share client and staff feedback to program manager for rapid assessment and monitoring Peer Specialist Supervisor
• Oversee and support peer specialists on SCU mobile team with an emphasis on emotional support for peers
• Plan and lead training and professional development for SCU mobile team, with an emphasis on utilizing peer specialists and other forms of team communication and support (e.g., advocacy, equal value, communication)
• Collaborate with clinical supervisor
Call Takers / Call Center (pending implementation of recommendations #8-10) • Receive calls from the 24/7 live phone line; triage calls and deploy SCU mobile team, as required • Receive calls from Dispatch
• Transfer calls that do not require in-person services to Alameda County CSS • Participate in case management care coordination meetings, as relevant
20 Refer to Appendix B for the number of personnel, availability, shifts, and a sample shift structure
SCU Crisis Response Recommendations | 35
Considerations for Implementation
Availability or shift structure for roles:
• The program manager and peer specialist supervisor roles should be available during traditional business hours.
• The clinical supervisor role should be available 24/7 and will require redundancy in hiring. • The call center will need to be staffed to ensure a 24/7 live phone line. I f Option B is pursued (refer to recommendation #9), the call center should be situated within the SCU model rather than a separate CBO. This could promote morale and team identity and will increase the quality and efficiency of communication.
Office & Equipment Needs:
• The SCU model will need an office space that accommodates all personnel and their roles, such as daily huddles, desks, and equipment.21
• Stakeholders suggested that the SCU would benefit from developing relationships with service utilizers and their families. If these opportunities are pursued as part of the SCU’s function, then office space could also accommodate service utilizer and family consultations and/or open “office hours” for relationship building.
21 Refer to Appendix C for the budget and additional office equipment needs, such as computers, phones, printers, etc.
SCU Crisis Response Recommendations | 36
Recommendation #12
Operate one SCU mobile team per shift for three 10-hour shifts.
In order to staff a crisis response model that operates 24/7, the SCU should staff one mobile team per shift for three 10-hour shifts. We estimate that the SCU would respond to three to six incidents per 10-hour shift, with each incident requiring 20 to 120 minutes for response and closure. This should generally be manageable by one SCU mobile team.22
Why 10-hour shifts?
Based on feedback from those operating similar models as well as from community stakeholders, 10-hour shifts are common in residential settings and tend to work well for clinical and mental health staff. There are often labor union protections for shifts longer than 10 hours. Three 10-hour shifts would provide 24/7 coverage while allowing for some overlap before and after each shift.
Why should shifts overlap?
The SCU mobile team shifts should overlap so that the team can conclude engagement with a person in crisis before their shift ends. The next shift would be able to respond to a crisis call that comes in towards the end of the preceding team’s shift. The overlap also supports team huddles for care coordination. The shift structure and overlap should include time for the required paperwork at the end of the shift so that there is not an expectation that paperwork is completed during off hours.
Will one SCU mobile team be sufficient?
This estimate is comparable to the call and incident volume reported by Denver’s STAR pilot, Portland’s Street Response pilot, and Eugene’s CAHOOTS program. Though the city population of Denver and Portland are 5.8 and 5.3 times larger than Berkeley’s population, respectively, their pilots are restricted to smaller geographic units of the city; Denver and Portland both operate only 1 mobile crisis response team per shift.
Eugene’s city population is 1.4 times the population of Berkeley, and Eugene operates 1 crisis team per shift, with an additional team during peak hours of 10am-12pm and 5pm-10pm. 23 Considerations for Implementation
● Staffing structure will require redundancy to allow for personnel to take vacation and sick days, and in anticipation of periodic vacancies.24
● Staffing structure may need to plan for on-call or floater shifts.
22 Estimates for SCU call volume are based on analysis of call and service volume by MCT from 2015 to 2019, the Auditor’s Report and analysis of Berkeley Police Department’s call and service volume from 2015 to 2019, and analysis of Berkeley Fire’s and Falck’s transport volume and time on task from 2019 to 2021. Please refer to Appendix D for more specific analysis and estimates. 23 The City of Eugene (2019-03240). https://www.eugene-or.gov/DocumentCenter/View/56579/2019-03240-White-Bird-CAHOOTS- Services---SIGNED
24 Refer to Appendix B for the number of personnel, availability, and a sample shift structure.
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Recommendation #13
SCU staff and Dispatch personnel should travel to alternative crisis programs for in-person observation and training.
Although Berkeley’s SCU model will be uniquely designed and tailored for the Berkeley community, there are many opportunities to learn from successes and challenges of other models that have implemented non - police mental health crisis response programs. For example, the Denver STAR team shared that their Dispatch team benefited greatly from traveling to Eugene, OR to observe and learn about the CAHOOTS model and plan their deployment protocols.
Options for city programs to visit:
• CAHOOTS: Eugene, OR
• STAR: Denver, CO
• EMCOT: Austin, TX
Recommended personnel to attend:
• Dispatch: Supervisor
• SCU: Clinical Supervisor and Program Manager
• Phone line staff, as relevant (refer to recommendation #9) Potential program components to observe during site visit:
• Triage criteria and workflows
• Assessing for risk and safety
• Working with the mental health clinicians embedded in Dispatch • Coordinating and prioritizing calls between 911 and an alternative phone number • SCU mobile team services and team coordination
• Role clarification
Why should Dispatch and SCU staff travel to these sites together? This training opportunity would support the collaboration between the SCU and Dispatch in planning for the phased integration. By traveling to the sites together, SCU and Dispatch will not only hear the same questions and answers but can ideate and collaborate on adaptations for the Berkeley SCU model. F inally, this is an important opportunity for relationship building between SCU staff and Dispatch, which is essential to this systems-change initiative.
Considerations for Implementation
● Travel costs will need to be included in the initial budget; estimates for consulting fees from the sites are already included.25
25 Refer to Appendix C for the estimated SCU model budget.
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Recommendation #14
Prepare the SCU mobile team with training.
The SCU will require training in a set of specific skill areas to be best equipped to provide mental health crisis response. The personnel hired should already have demonstrated their specialized skill set in previous employment settings; training will therefore support the team to align on how to implement their skills.
Training also supports teams to work together and with other entities effectively, such as Dispatch, which is essential in crisis response.
The SCU mobile team should be trained in the following topics:
• General de-escalation techniques
• Disarming without use of weapon
• Substance use management
• Naloxone administration
• Harm reduction theory and practice
• First aid
• Situational awareness and self-defense
• Radio communication
• Motivational interviewing
• Implicit bias, cultural competency, and racial equity • Trauma-informed care
• Training on data collection protocols and data integrity (refer to recommendations #17 and #18) • Compliance with confidentiality and HIPAA when interacting with Police and/or Dispatch How long will it take to train staff?
Eugene’s CAHOOTS program includes at least 40 hours of classroom training and 500 to 600 hours of field training for all new staff.26 This equates to 12.5 to 15 weeks of training when calculated on a full-time basis.
What informed these suggested training topics?
These training topics were generated from a variety of alternative model program recommendations and input from Berkeley service providers and community stakeholders.
Considerations for Implementation:
● The phased approach timeline incorporates an estimate aligned to CAHOOTS’ model, with room for adaptation.
● Training should be provided to all new SCU staff as they are added to the team, regardless of start date.
● Additional training topics may be identified by the SCU team.
26 Beck, J., Reuland, M., & Pope L. (2020). Case Study: CAHOOTS. Vera. https://www.vera.org/behavioral-health-crisis- alternatives/cahoots
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Administration and Evaluation
There are many considerations for effectively administering and monitoring implementation of a new, 24/7 mental health crisis response model. Effective implementation includes ongoing collaboration and decision-making at both the structural and provider levels.
At a structural level, the SCU model will require cross-system coordination for implementing new processes and therefore will require leadership across the City of Berkeley and SCU to collaborate around ongoing program monitoring, data review and transparency, and system integration. At a provider level, the SCU model will require collaboration and communication to support care coordination and case management for people that have experienced crisis as well as to elevate emerging challenges and successes.
Moreover, the community can— and must— provide essential advisory capacities. The community should be actively engaged to provide input and feedback throughout the planning and implementation of the SCU, including through the SCU Steering Committee and ongoing opportunities for the general public.
The following recommendations were informed by the lessons learned from other cities implementing alternative crisis models and aim to be reflective of the perspectives shared by the project’s stakeholder participants. Each recommendation should be a starting point to promote cross -sector collaboration, adjusting to accommodate the evolution of the SCU:
Key Recommendations
15. Contract the SCU model to a CBO.
16. Integrate the SCU into existing data systems.
17. Collect and publish mental health crisis response data publicly on Berkeley’s Open Data Portal.
18. Implement care coordination case management meetings for crisis service providers.
19. Implement centralized coordination and leadership across city agencies to support the success of mental health crisis response.
20. Continue the existing SCU Steering Committee as an advisory body.
21. Solicit ongoing community input and feedback.
22. Adopt a Rapid Monitoring, Assessment, and Learning process.
23. Conduct a formal annual evaluation.
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Recommendation #15
Contract the SCU model to a CBO.
The administrative structure of crisis response systems across the country varies significantly. Some are administered by government agencies, some are run in collaboration between a government agency and CBO, and some are entirely operated by CBOs. There are several reasons why the SCU model should be contracted to a CBO, at least through Phase 2 of the phased implementation approach.
The SCU crisis response model would benefit from being contracted to a CBO for several reasons:
• Supports a quick launch: CBOs are often able to move more nimbly than government agencies, especially as it relates to hiring; adequately staffing the SCU mobile crisis team is a critical element in timely implementation.
Given the urgent need, the ability to launch the SCU quickly and provide non-police mental health crisis response services is critical.
• Established relationships with community members: Stakeholders made it clear that CBOs have developed strong relationships with service utilizers accessing mental health support, homelessness resources, street medicine, and system navigation and referrals. CBOs in Berkeley have expertise in the community that can be leveraged
to advance the SCU’s crisis response efforts.
• Referral networks and partnerships: A CBO with established networks and partnerships would be well positioned to support service utilizers with referrals as well as transport to community-based resources.
Additionally, these relationships can support warm handoffs at transport locations.
Considerations for Implementation
● To contract with a CBO, the City of Berkeley will have to issue a Request for Proposals (RFP). The RFP process will need to evaluate a CBO’s capacity to develop and implement a model of this size on this timeline. ● The City should identify a backup plan if no qualified CBOs respond to the RFP. ● The CBO’s practices should align to the values and principles of the SCU. The City may need to use contracts and MOU specifications to require:
○ Adequate and equitable wages for all SCU staff and crisis responders, especially peer specialists and peer specialist supervisors.
○ A representative and equitable hiring process that prioritizes staff who are reflective of those most marginalized and harmed by existing crisis response options and the criminal legal system. ○ Necessary data and metrics to collect and report as well as ensuring sufficient technological systems to meet these needs.
● CBOs may face challenges inherent in the contract structure, which should be evaluated and protected against as these challenges can undermine sustainability and longevity. ○ Short-term funding: only funding the SCU in one-year increments can reduce staff retention and inhibit investments in operations (refer to Section V).
○ Overhead costs: allocate enough funds for overhead costs (e.g., salary, training, and office equipment), which are critical to SCU success.
○ Contract monitoring: data collection, monitoring, and evaluation are essential to the success and iteration of the SCU but should not be prohibitive to the work. ● There may be additional needs or considerations around data and system integration (refer to recommendation #16) and the collaboration across administration and leadership if a CBO implements the SCU; these may need to be included in the contract.
● All recommendations are written with a contracted CBO in mind; additional implications may arise during planning and Phase 0.
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Recommendation #16
Integrate the SCU into existing data systems.
Having access to patient data will support the SCU to provide tailored, informed, and equitable services for those experiencing mental health and substance use crises. Access to existing data systems, such as an EHR, will not only ensure that the SCU has access to relevant patient information, but also that other providers are aware when, how, and why their client might be interacting with crisis response. Finally, integrating the SCU into existing data systems will ensure aligned and consistent data collection, which is essential for the rapid assessment monitoring (refer to recommendation #22) and evaluation (refer to recommendation #23).
There are many factors outside of the purview of the SCU, HHCS, or even that City of Berke ley that affect whether data and system integration can be achieved. These factors include patient privacy and legal protections (i.e., HIPAA), technological capabilities, available funding, logistics across private and government entities, and more. As a result, this recommendation is included as an aspiration that should be planned for in future phases and may not be realized during Phase 1 of implementation. • Bidirectional, live data feeds should be integrated between the SCU and other data sources, including but not limited to:
o EHRs used by major medical systems and Federally Qualified Health Centers (FQHC) o Alameda County’s Community Health Record (CHR)
o Alameda County’s YellowFin
Why does the SCU need to access service utilizers’ records, such as EHRs? Access to an EHR allows crisis responders to make informed decisions based on a service utilizer’s health history. This access also enables crisis responders to communicate directly with a service utilizer’s existing support team, such as psychiatrists or case managers, when providing crisis response or referring the service utilizer for follow-up care.
Is it common for crisis responders and clinicians to have access to service utilizer records? Many other crisis response programs enable access to these sources of data. For example, the Alameda County Community Assessment and Transport Team (CATT) has access to the county’s CHR. Providers at FQHCs, including programs like Lifelong’s Street Medicine Team, have access to an integrated EHR. Berkeley Mental Health (BMH) is already integrated with the county’s YellowFin reporting system. Other city models, such as Denver STAR, enable their crisis responders to access existing data systems.
Why should the data feeds be bidirectional?
Not only do crisis responders need to access service utilizer medical history, but the data they collect during a crisis response should be entered into the centralized data systems so that a service utilizer’s existing support team has an updated and complete case history. The county’s CHR has live data feeds from many providers and so the SCU’s data should also have bidirectional capabilities when possible.
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Considerations for Implementation
● The Berkeley City Attorney and IT have signed onto the county’s CHR, and many CBOs and medical providers have also already signed onto the CHR, which could facilitate the SCU’s integration into this system.
● The SCU will need access to EHRs and the CHR to participate in client case management meetings (refer to recommendation #18).
● SCU team members will need training and support to accurately enter data into these platforms, which is essential to data integrity.
● Legal protections for confidentiality and consent will have to be carefully assessed to determine the feasibility of this recommendation and implementation approach. ● Many health conditions can be criminalized and prosecuted. The SCU data must be separate from Dispatch and CAD data because Dispatch is situated within Berkeley Police Department . Presently, Dispatch does not have access to EHRs or the CHR, and in the future, this separation should continue.
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Recommendation #17
Collect and publish mental health crisis response data publicly on Berkeley’s Open Data Portal
Data collection is essential to monitoring and evaluation and spans across the SCU mobile team and supporting personnel, Dispatch and/or the alternative phone line, and central leadership. Given how many different personnel and agencies will be collecting and reviewing data, it is essential that data collection be planned for early in Phase 0 to ensure alignment, accuracy, and data integrity. • Types of data that should be collected and published:
o Call volume
o Time of calls received
o Service areas
o Response times
o Speed of deployment
o Determinations and dispositions of Dispatch (including specific coding for violence , weapons, and emergency)
o All determinations and deployed teams from Dispatch
o Percentage of calls responded to by SCU of all calls sent to SCU o Type or level of service needed compared to the initial determination at the point of Dispatch o Service utilizer outcomes
o Number of 5150 assessments conducted
o Number of 5150s confirmed and involuntary holds placed o Number of transports conducted
o Location of transport destinations
o Type of referrals made
o Priority needs of clients served (housing, mental health) o Number of requests for police involvement
o Racial demographics of service utilizers
o Other relevant characteristics of service utilizers, such as homelessness status or dementia Note: not an exhaustive list.
• Examples of public data dashboards from alternative crisis models:
o Portland’s Street Response data dashboards
o NYC’s B-HEARD monthly data reports