From the New York Review of Books, September 20, 2020
Eugene, Oregon—Every call that is dispatched through the radio, twenty-four hours a day, to the CAHOOTS crisis responders is a tiny mystery, a staticky, incomplete assemblage of details. “White female in her thirties, brown hair, black mid-length shirt, last seen on Sixth, yelling and running into traffic,” for instance, on a recent Saturday evening in late August.
The responders in this case—Michael Williams, an emergency medical technician, and Ashley Hubbard, an EMT and mental health crisis worker—piloted their bulky white Ford Explorer van toward a likely strip of Sixth Avenue, a downtown thoroughfare, shortly before sunset. Aside from a handful of restaurants seating people outdoors, the avenue was quiet, and they soon found a woman who fit the description outside the High Priestess Tattoo Shop on Sixth and Charnelton Street. She was smoking a cigarette and crying noisily, with a crumpled bunch of papers in her other hand. When she saw the responders, she started talking.
“They won’t help me!” she wailed, over and over. “I just want my stuff!”
Hubbard sat cross-legged next to her in the parking lot and asked her what was going on. She learned that the woman had been in the county jail for two days, for disorderly conduct, and she couldn’t figure out how to get what had been seized at the time of her arrest. The papers she held included a pink “prisoner property receipt,” listing “various items in bags,” and a check for thirty-three dollars, equivalent to the cash on her person when she was arrested. Tiffany—I am using a pseudonym to respect her privacy—was very thin and had matted brown hair. She had sores on her arms and wore black track pants pushed up to her calves and gray canvas sneakers with untied laces.
“We can help you,” said Williams, calmly. They convinced her to get into the back of their van, which is fitted with two passenger seats behind a plastic partition, and drove a couple minutes to the Lane County Jail. Williams took her papers and set out for the property retrieval office. Meanwhile, Hubbard continued talking to Tiffany in soothing tones.
“Where have you been sleeping?”
“I have a house on Madison Avenue.”
“Will you go back there after this?”
“I don’t know.”
Hubbard offered some Ritz crackers and a carton of almond milk, which Tiffany accepted. Then Williams came back with Tiffany’s things—a garbage bag filled with bedsheets, clothes, and more sneakers.
“This is a very easy solution to a bureaucratic problem,” Williams said, for my benefit. “It could be blown up into a bigger thing, but it doesn’t have to be.”
Tiffany seemed momentarily placated, but then became upset again after rifling through the bag, from which she suspected some key items had been omitted, including her notebooks. Their discussion of what had been lost went on for a few minutes until Williams asked her: “Can we give you a cigarette and go for a drive? Let’s not catastrophize. We’re going to think this through, okay?” Instead, she lay prone on the sidewalk, within eyesight of the county jail, wrapped in a fleece blanket from the plastic bag.
“Where do you want to go?” asked Hubbard. She told Tiffany about a drop-in facility called the Hourglass Community Crisis Center. “I don’t want counseling, I don’t want to talk to anybody,” Tiffany moaned. She stubbed out her cigarette on the curb and curled up.
Hubbard reiterated the offer and handed Tiffany a card with the CAHOOTS phone number on it. “Can you stay safe or call us?”
Williams and Hubbard got back in the van, and Williams logged the case, including Tiffany’s name and birthday, into a Panasonic Toughbook. They drove away after dedicating a full half hour to her case.
“I think this is not a bad outcome actually,” he mused to Hubbard. “It seemed like that suicidal ideation was more out of frustration than anything.” They had just solved one pressing problem for her at the jail, and on top of that, by the time they left her, she was dozing off and thus no longer agitated in a public place.
The first time I witnessed this deliberately circumscribed approach in action, I found it to be counterintuitive, and almost callous. But over the course of several weeks, I came to see why it is integral to CAHOOTS: the program’s narrowly defined scope and its responders’ practiced lack of attachment to any particular outcome, either short- or long-term, are essential to their effectiveness.
When I asked Williams later where he thought Tiffany would end up after this, let alone how she would cash that check, he gently parried my question with one of his.
“What’s the best outcome for today?” he asked, rhetorically. CAHOOTS members can transport people to staffed services and hospitals, or counsel them, or give them food or shelter supplies, but the list is not much longer than that. “We’re an intervention team,” Williams explained, with deliberate limits, honed over decades of operation, as to the degree and duration of that intervention.
“We’re trying to meet people where they’re at,” Hubbard added, a refrain I heard from nearly a dozen other people involved with CAHOOTS.
“And that builds trust between us and our clients,” picked up Williams. “We might actually have multiple contacts with Tiffany. And each of those times, we’re not going to force her to do anything. So there will be more trust there.”
CAHOOTS emergency crisis worker Matt Eads checks his medical kit, Eugene, Oregon, October 2019
The need for trust, in place of force, has been a recurrent theme of police reforms discussed across the country over the long summer that followed George Floyd’s murder in Minneapolis on Memorial Day. The idea is that armed police officers are simply called to address too many situations, often ones in which trained mental health or social workers would be more effective and more humane. CAHOOTS has been in operation since 1989, administered by a local nonprofit, the White Bird Clinic, and publicly funded by municipal government, making it one of the oldest such organizations in the country. And the service it provides—responding to crises that would elsewhere, by default, become police matters—has lately drawn national attention.
White Bird was founded in 1969, in part to respond to the fallout of that decade’s radical upheavals, which had left a lot of runaways and unhoused young people in countercultural hubs like Eugene. The clinic was formed by an ad hoc collective of graduate students, medical workers, and concerned citizens who wanted to help people they knew would be unlikely to seek help from the police or enroll in regular treatment for their problems. It eventually evolved into a more formal, official program—at the request of the Eugene Police Department itself.
This wasn’t as radical a shift as it might sound, according to David Zeiss, one of the clinic’s earliest members, who retired in 2014 but remains on its board of directors. “Throughout the 1970s, some Eugene policemen would informally call on us for help,” he said. The police recognized the value of their unique service, and that interest only grew during the 1980s, when the concept of community policing enjoyed one of its cyclical periods of currency. But in the years leading up to the announcement of a formal collaboration between the clinic and the police department, there was a vigorous debate on both sides about how closely the crisis responders and law enforcement officers could be allies.
Zeiss himself was a holdout. “I had a cluster of concerns,” he said, including how well the police would maintain patient confidentiality, and whether the alliance would violate the public trust from the point of view of their most vulnerable client populations. What changed his mind, finally, was the promise of “relatively abundant, consistent funding for crisis intervention.”
On the other side, the decisive swing vote on the city council to approve a pilot program in 1989 came from a conservative councilman who was “not politically aligned with White Bird,” but who had had family members helped by CAHOOTS, according to the Clinic’s coordinator Ben Brubaker. One of the concessions negotiated in this early phase by Zeiss was that the police would not force CAHOOTS responders to take down anyone’s last name—so a crisis call would not trigger a warrant check and possible arrest. And Zeiss found that his initial misgivings evaporated as the decades went by. “Now, there is much less mistrust in both directions, because we have literally waited out a whole generation of Eugene police,” he said. “There’s essentially no one left in the force who doesn’t know about CAHOOTS; we have become sort of a background assumption.”
Despite the passage of time, White Bird’s radical founding ethos lives on. Its charter stipulates that no member can make more than 25 percent more than the lowest-paid employee’s wage. Today, CAHOOTS responders earn eighteen dollars an hour, though a growing number of employees are pressing to raise the hourly wage to twenty-five dollars. But it remains a consensus-based organization, which holds regular, and sometimes intense, all-hands meetings, so staff members first have to persuade all their colleagues that their jobs merit higher compensation and then have to succeed in renegotiating the organization’s contracts with the Eugene and Springfield police departments.
“I think twenty-five dollars is highly, highly feasible,” said Robert Parrish, who joined CAHOOTS in 2004 and is the currently longest-serving responder. “It reflects the fact that our jobs have elements of risk and require a degree of training that is just a little different from other programs at the center…and a higher wage would help people think of this as a long-term career, rather than a waystation.” For a CAHOOTS worker who takes four twelve-hour shifts a week, their salary works out to about $43,000 a year. The starting wage for a Eugene police officer is $64,542.40 (at an hourly wage of $31.03) and can go up to over $82,000.
“I feel like we’re presented as a low-cost model to save money,” said Williams, who is in favor of renegotiating wages sooner. “We are an alternative to the police, sure, but we’re also a mental health first-responders organization on our own. It’s not as though the police are just allowing us to use their radios for fun.”
CAHOOTS has three vans available, two constantly circulating Eugene, the other in the adjacent town of Springfield, with professional in each. These responders usually log between fifty and seventy reports such as Tiffany’s in every twenty-four-hour period.
Williams’s and Hubbard’s shift runs from 5:00 PM one day to 5:00 AM the next. Together, they encounter the full gamut of urban human distress: drug overdoses, mental health crises, potential suicides, public intoxication, and first aid emergencies. Many of their dispatches come through 911 calls, but some also come through CAHOOTS’s own crisis line.
The demand for CAHOOTS’s interventions has ballooned, with the number of calls per year doubling from 2014 to 2018. By its own reporting, the program’s statistics are impressive: last year, their staff needed to call for police backup on only 150 of about 23,000 calls. The numbers are shaping up to be roughly similar this year, though precise data has not yet been tallied, said Brubaker. And in its entire history, not a single responder has been seriously injured on a call, said Parrish, despite some intense situations.
Well before this summer’s historic protests against police brutality, CAHOOTS had been advising similar projects and pilot programs in cities such as Denver, Oakland, Portland, and Olympia, Washington, which voted to create an unarmed Crisis Response Unit in 2017. But the experiences of CAHOOTS and its spinoffs have gained a new, instructive pertinence as municipalities nationwide look to divest parts of their public safety apparatus from police departments.
In November 2017, Olympia residents voted for a “public safety levy,” a property tax to address the public safety situation in its downtown area, especially to address mental health issues. When Anne Larsen took on the task of establishing a crisis response team in Olympia, she made it her business to learn how CAHOOTS operated. Her official job title is outreach services coordinator for the Olympia police, but she had to muscle Olympia’s version of the program through the police department.
The city ended up contracting with a company called Recovery Innovations International to hire a small team of workers, now numbering six, who form its Crisis Response Unit. Last quarter, they handled 511 calls, said Larsen. Parrish came up from Portland in April 2019 to help train the team, riding along with CRU responders for three days.
The CRU has different priorities and constraints to CAHOOTS. It cannot involve EMTs, because in Washington State emergency medicine falls under the purview of the fire department, not the police department. And its staff, who are mainly trained as social workers, are not currently eligible for the police union, so they have much less liability protection. Limited funding also means the service is not round the clock.
“I thought we would have access to more calls,” Aana Sundling, a crisis responder, told me, “but it turns out, even responding to suicide attempts is sort of above our pay grade.”
Initially skeptical—CRU members were not quick studies with radio dispatch etiquette, for one thing—the Olympia police department has quickly come to see the value of their work. “When I started in policing more than twenty years ago, the approach to something like homelessness was to just arrest people constantly so that they would have no incentive to stay in the city,” said Lieutenant Sam Costello, head of Community Policing. “We’d get some callers ten times a night and did not have any solution that was not handcuffs. And now, we just call CRU… and they handle it.”
For over a year now, Tim Black, the director of consulting at White Bird Clinic, Anne Larsen in Olympia, and counterparts in Oakland, Portland, and Toronto have regularly corresponded about their initiatives through email. “For models seeking to emulate CAHOOTS,” said Parrish, “it’s probably most important to know that people might not immediately buy in, but that they should give people time to evolve.”
“I think the biggest thing that we’ve encountered this summer,” said Black, who has been fielding hundreds of consulting requests lately, “is that there’s this perception that this type of model can only occur if and when police departments are reduced. [But] we’re not trying to make decisions around public safety funding for other communities. All we’re trying to do is articulate that there’s a very distinct need for a behavioral-health-first response.”
At first sight, employing trained crisis responders instead of police to address acute emergencies seems like a pragmatic fix that could potentially command very broad community support. Setting up such programs need not, for example, hinge on defunding the police, though they could just as easily be part of a radical overhaul of a police department and its budget. To the responders in Eugene and Olympia, though, access to police radio is not simply a necessary tool for the job, but also a guarantee of last-resort security.
“It’s funny because we’re lately presented as an alternative to the police, but we couldn’t do our job without the police,” said Henry Cakebread, another CAHOOTS member. “They underscore our safety.”
Hubbard said she has called for police backup when agitated people have run into traffic, for domestic violence situations, and even, occasionally, during suicide attempts, if verbal de-escalation doesn’t do the job. “All of our actions are voluntary, but if police deem someone an imminent danger, they can force them to go to the hospital,” said Cakebread.
This kind of delicate and, again, sharply circumscribed alliance between police and crisis responders requires a degree of cooperation, comfort, and trust that is actively worked for over time. CAHOOTS interventions also depend on a value-neutral, nonjudgmental handling of manifestations of serious social problems that is counterintuitive and deeply unfamiliar to most US agencies currently involved in public safety. On top of that, these projects have thus far depended on recruiting, training, and retaining a large staff—CAHOOTS has about forty active responders—that is both comfortable with their intensive approach and willing to work in an intense environment at much lower salaries and with fewer benefits than police officers.
CAHOOTS’s headquarters is a grey-shingled one-story house on West Seventh Avenue. Inside, there are rows of metal lockers for the responders who shuffle in and out all day, a meeting room, couches, and a kitchen with a well-worn microwave. There are mountains of first-aid supplies and food donations. The responders wear T-shirts with the White Bird logo, long pants, and heavy-duty shoes like Doc Martens and Blundstones. They sling police radios on coiled cables across their chests. I accompanied pairs of them on three of their standard twelve-hour shifts, two through the night and one in the daytime.
Their vans are stocked with water bottles, tuna packets, and Ritz crackers, as well as, since the pandemic started, boxes of plastic gloves and extra masks. A cabinet attached to one side of the van holds basic medicines and first-aid supplies, and personal hygiene items like tampons.
There is no typical shift, and the calls I observed included: bringing several people to the university hospital’s emergency room, picking up used syringes whose locations were called in as tips, transporting unhoused people to shelters for the night or giving others blankets and extra shirts, dressing wounds for people living in motels and shelters, rousing a woman who had overdosed on a stranger’s doorstep in a residential complex, talking a young trans girl through her suicidal ideation, and counseling a man who had gotten too drunk to go to his scheduled detox program and had to make it through another night at home with his beleaguered wife.
CAHOOTS EMTs have a slightly different job description than a hospital EMT, said Williams. “I don’t do things like IV drips and intubation, but I do respond to chronic unmanaged conditions that traditional EMS would not.” This often includes wound care and dressing, especially for chronic drug users. One man on a shift I attended had had his leg wound dressed for several days in a row by CAHOOTS; his right calf had had an inch-deep cavity that had been eaten away by maggots.
Repeat clientele is a pervasive phenomenon. On both of the nights I was on call, the responders addressed a seventy-two-year-old woman, Andrea, with both bipolar disorder and kidney failure, living with her daughter and son-in-law. She had gotten in the habit of calling CAHOOTS herself. When Williams and Hubbard rang their townhouse’s doorbell early on Thursday morning, her daughter told them with weary resignation that Andrea had taken all her clothes off and peed everywhere.
Williams and Hubbard coaxed Andrea to put on some clothes and talked to her for an hour. They project a feeling of expansive leisure in these encounters, listening patiently to her stories about her youth and letting her flip through a photo album, but returning at regular intervals to the practical matter of whether she wanted to go to the hospital. Eventually, they asked Andrea one last time and she, in a small voice, said, “Yes.” So they brought her to the ER, where a nurse cleaned her up—she had soiled her outfit and shoes on the ride over—and set her up in a bed for the night. Andrea turned to Hubbard and said, “Can I say I’m going to die?” and started softly crying.
Three days later, I found myself at Andrea’s house again, with two other responders, watching her flip through the same photo album. It was clear this time that she just wanted to talk to someone that night and once she called CAHOOTS, they were obliged to respond. Cakebread and Simone Tessler, the responders on call, indulged her for a while. Cakebread politely but firmly asked her if they could take any practical measures.
“What can we do to make your night more enjoyable?” he asked her.
“Well, you’re doing it now,” Andrea said, in a girlish voice. “You have smiling eyes.”
When it became apparent that she didn’t want any concrete action on her behalf this time, the responders said their goodbyes and left.
The constricted time frame for interventions permitted by CAHOOTS protocol can be applied quite severely. On one daytime shift I attended with Parrish and Summer Johnson, a twenty-year-old boy facing eviction the next day was looking for a place to sleep for two nights until he could get on a bus to his hometown in Ohio. Parrish listened attentively to his plight, but they couldn’t book him a bed in any shelter that far in advance, so they told him to call the hotline back tomorrow. In fact, Parrish would be on the same shift the following day and would likely be the responder again, but CAHOOTS’s rules permit only a response to a present crisis, as opposed to something that involves plans and forward arrangements. “We meet people where they are,” said Cakebread, summoning the CAHOOTS refrain to give me another example, “so we will treat a lot of cuts and wounds arising from domestic violence in people who want to stay in their relationship.” They would not, he said, try to counsel anyone to leave such a relationship outright.
Not everyone can work within these stringent methodological constraints. Between 30 and 60 percent of new EMTS don’t complete the induction, Cakebread told me. And as dedicated as those crisis workers who complete the training are, they all made clear to me that many outcomes of their efforts are only as good as the patchwork of social services available to their clients in Eugene—for example, other staffed services like the Hourglass Community Crisis Center, a 24/7 facility with counselors on call, where people in a tough situation can stay for up to twenty-three hours. CAHOOTS’s parent organization, White Bird, also offers a broad suite of more long-term social services, from housing assistance to dentistry, at its three outposts. But the responders’ options for cases involving high or inebriated clients, for instance, have shrunk when just a single “sobering center” shuttered in March due to the Covid-19 pandemic.
Tim Black said that the pandemic also compounded the chronic health problems that often manifest as CAHOOTS emergency calls: “Many people [especially unhoused people, who often don’t have reliable access to cell phones or laptops] couldn’t figure out telemedicine, and chronic medical conditions had a chance to kind of ferment.”
On top of that, Eugene has the highest per capita homeless population in the US and, anecdotally, the number of unhoused people living there has increased even more since the pandemic started. With a chronic shortage of beds in the handful of shelters in town, there’s little prospect of a more comprehensive, longer-term solution.
It’s clear that a CAHOOTS response is more appropriate to the immediate needs of these clients than one by an armed policeman. What is less obvious is the logical next step for clients at the receiving end of multiple “emergency” visits.
“There will always be a need for a crisis response team in a given city, but it’s not really going to solve long-term problems,” said Daniel Herman, a professor at Hunter College’s Silberman School of Social Work. “I think this is comparable to some of the challenges faced in healthcare, when you think about what can be done in an emergency room…. People often see ‘regulars’ in the ER and have to treat them every time, even if the reason they’re coming is due to a chronic condition.”
Herman, who is in his sixties and has worked on mental health and crisis interventions for four decades, said that, in thinking through the structural problems underlying crisis responses, “most people in my field would probably start with adequate housing.” (This is sometimes referred to as a “housing first” approach.) “As long as the US is a place where we believe that housing isn’t a basic right, these other problems will be there, unfortunately,” he concluded.
More than a hundred people a month become “newly homeless” in Lane County, which includes Eugene, according to one 2018 report, but there are still only a handful of shelters. In March, near the beginning of the pandemic, the Oregon statehouse voted down funding for a new, seventy-five-bed shelter in Eugene. The city still intends to build one, but there is no definite timeline for that as of now. This disjunction between an escalating long-term crisis and slow-moving, limited social services has put CAHOOTS, by default, in the position of bridging this unmet demand for help.
Beyond the CAHOOTS model, “housing-first programs, peer support, supported employment and education, and easy and timely access to health services” should all be a part of a region’s “public health mandate,” said Amy Watson, a social work professor at the University of Wisconsin–Milwaukee. These are, in fact, part of the White Bird Clinic’s agenda, so the problems are ones of scale, funding, and political will. But absent this far more comprehensive mandate, these problems would exist with or without the crisis responders, as Larsen said in Olympia, “so we have a choice how to respond at every step.”
And just the first step of outreach is not the least. In Olympia, I met Larry Jefferson, a Black public defender, who lost his son Jandon, aged twenty-three, to an overdose in June. Jandon had struggled at school and was then homeless for five years. “He went through so many psych wards, but I just couldn’t help him,” Jefferson told me. In early 2020, Jefferson had been contacted by one of Olympia’s crisis responders, who asked him, very simply, what Jandon’s favorite snacks were. “Goldfish crackers,” Jefferson replied instantly. For the next six months, Jefferson knew that responders were checking in on Jandon, who stabilized to a point where he was communicating with his family again. Even though that intervention could not save him from overdosing, “we wouldn’t have had those last six months with him without this crisis team,” said Jefferson, his voice cracking. “We had our best Mother’s Day in ten years.”
In his job, Jefferson works closely with incarcerated people and is no stranger to the shortcomings of law enforcement. “I think Olympia Police Department has the same problems as every other PD—but it also has this,” he said, of the crisis responders. “Gosh, I just love that van.”