What works for San Franciscans in a crisis?

Compassionate, non-punitive approaches to behavioral health are showing recent success in San Francisco. In places where these alternatives have been in effect longer, they’ve been successful, too. 

Here, for example, the few months of a Street Crisis Response team replacing the police as first responders to non-violent mental health crisis calls has seen “wild success,” said Dr. Angelica Almeida, a psychologist with the Department of Public Health who oversees the team.

Of 2,000 calls, none has led to an arrest or contact with the criminal justice system, Almeida said. “That’s 2,000 fewer cases for my assistant district attorney to consider prosecuting,” said San Francisco District Attorney Chesa Boudin, who moderated a recent discussion at Manny’s, a civic gathering space at 16th and Valencia streets. 

The four-hour event, “Public Health is Public Safety,” brought together 12 experts from various backgrounds like homelessness services, policy and research, and even the city’s jail health services. It was sponsored by the DA’s Office and offered residents the opportunity to hear first-hand about the alternatives to successfully dealing with behavioral health issues. 

Many of the featured speakers also had a history of substance abuse or had experienced homelessness themselves, or had family members who did — and offered many had ideas on how to start chipping away at the colossal and complex issue that plagues San Francisco and other California cities. 

UCSF professor Dr. Margot Kushel discussed a successful “housing-first” study she conducted in Santa Clara, with which DA Boudin admitted he’s “obsessed.” The study found that simply providing housing to people who most needed it helped reduce emergency room visits and allowed people the chance to get mental health services. 

“So this idea that people don’t want to be housed is BS,” Kushel, a practicing doctor at San Francisco General Hospital said. 

Seeking out people with the “most chaotic” use of emergency services, hospitalizations, and jail, Kushel said that only one in about 400 people refused the opportunity to possibly get housing through the study. By the end, 86 percent of the subjects were housed, and stayed housed for 93 percent of the days for the next seven years, Kushel said. 

“Let’s do it! What do you guys say?” Boudin said, turning to the clapping crowd. After a brief introduction in the morning, Boudin primarily let his guests do the talking, while he introduced and asked questions of the panelists on the stage or rotating through on Zoom. An audience of about 40 sat on plush velvet couches and plastic folding chairs, drinking coffee and eating snacks. 

Panelist Philip Jones said stable housing was crucial in his journey to successfully exiting the cycle of addiction, homelessness, and recidivism. Today, he works as a peer case manager with the Department of Public Health. 

“I want to really be very clear that I wasn’t able to be successful until I wasn’t afraid of losing housing, … I had the resources to address my mental health and my substance use, and I had income that allowed me to live in this world as a contributing member to society and my own life,” Jones said. “So, at any point along the journey where those things were in jeopardy, it became very scary for me.” 

Beyond California, compassion-based methods that avoid resorting to criminalization have also proven to be effective in longer-term practice. 

Boudin said the program in Eugene, Oregon called CAHOOTS, launched in 1989, has inspired him. There, he said, 911 triage includes a third option beyond the police or fire departments, of “folks who can de-escalate, who can help in housing, who can help get someone who has overdosed the medical help that they need and do it in a way that actually saves those really specialized policing resources for the situations that uniquely call for arrest and an armed response.” 

CAHOOTS reports saving the Eugene police department millions of dollars each year. 

In San Francisco, the Street Crisis Response Team is currently scaling out to be available 24/7, Almeida said. Also in the works is the Compassionate Alternative Response Team, which panelist Vinny Eng said would help allow community members, instead of police, respond to mental health crises.   

Part of changing the approach to behavioral health involves not only the reaction to those in crisis, but a cultural shift, too. 

Via Zoom, Tanya Mera, of the Department of Public Health’s Jail Health Services program, said there are many predictors for who will end up entangled in the criminal justice system. Addressing more systemic issues, like poverty and poor education is difficult, she said, but this approach might help people who need mental health and other types of support earlier on. 

“Someone should not have to commit a felony to get into treatment they need,” said Mera, the director of Jail Behavioral Health and Reentry Services. Her team conducts early assessments when people come into the San Francisco jail, and helps coordinate care for those getting out. 

Mera said that 233 of the people in jail currently are on psychotropic medication, which DA Boudin noted is about 30 percent of the total jail population. The DA’s office pamphlet distributed at the event highlighted that more than 30 percent of the jail population is homeless, and the Black community is disproportionately homeless and jailed.  

And even more fundamentally, the keynote speaker State Senator Sydney Kamlager of Los Angeles said the public mindset has to change. “We have a very parochial understanding of people with disabilities, we have a very stigmatized approach and view of folks with behavioral health challenges.” Kamlager, who has an autistic stepson, has authored legislation in criminal justice reform, health care equity, and affordable housing. 

Through a culture shift, eventually, laws can be changed to allow larger scale shifts in policy. 

But for now, “legally, we are stuck,” Mera said. “… I would really like to see advocacy on the state level to change some of our antiquated laws that really leave families helpless, leave treatment providers helpless.” 

Boudin mentioned the CRISES Act, which Kamlager is still advocating for even though it was vetoed by Governor Gavin Newsom in 2020. The act would have the state fund alternative community-based organizations and first responses to 911 calls. Kamlager said 70 percent of 911 calls are nonviolent and noncriminal, and therefore don’t need a police response. 

For the most part, the panelists were in agreement and built upon each others’ points, but occasional disagreements came up. 

While the event was touted as a space to make connections in the community, the generally older, whiter audience eating smoked salmon bagels wasn’t quite as representative of the city’s demographics as it could have been. Further, the speakers talked about including those impacted by homelessness, addiction, or mental health challenges, but how to do that seemed still uncertain. 

Boudin asked Kristen Marshall, associate director of San Francisco Programs at the National Harm Reduction Coalition, about why people who use substances are often excluded from conversations about policy and effective interventions, and how to ensure they are at the table. 

“Make it safe for them to be at that table — or you go to their table,” Marshall replied. Even as a speaker virtually attending the event, she said she “probably would not bring anybody that I represent in this community to a space like this.” Marshall grew up around drug users, and now she works with them every day. 

“It’s really crucial to keep the folks most impacted centered because at the end of the day, it’s the folks most impacted who are doing the most work to keep each other and themselves safe,” Marshall said. 

At the start of the panel, Boudin read an email aloud from a member of the community who had planned to attend the event. The night before, her son, who has mental illnesses that have landed him in the ER 181 times, was arrested during an episode. 

“It remains the policy of the DPH to use the jail as a cheaper overflow facility for those with serious mental illness, rather than give them the comprehensive care that they need,” the email read. “So now he will spend some time in jail, when what he really needs is a hospital.”

A few hours into the panel, a woman in the audience stood and revealed herself as the emailer. Just providing housing isn’t a solution for people like her son who have severe mental health issues, she said, and each individual has a different level of need. 

As both Dr. Almeida and Sen. Kamlager emphasized, flexibility to apply resources differently in different places is paramount in a state like California, or even within a diverse city like San Francisco. That could mean breaking down the four walls of the clinic and bringing services to those in need, or even providing funding that can be used as each community sees fit. 

Thanks to the state budget surplus, Kamlager said funds have been diverted to areas she hopes can start to help, like nearly $3 billion to Project Homekey, which buys hotels and converts them into housing, and $2 billion in the state budget that will be distributed to local jurisdictions for flexible use to address homelessness.