District Attorney Chesa Boudin hosts a panel discussion at Manny's on July 28, 2021. Photo by Eleni Balakrishnan

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.” 

Photo by Eleni Balakrishnan on July 28, 2021.

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. 

Eleni Balakrishnan

Eleni is our reporter focused on policing in San Francisco. She first moved to the city on a whim over eight years ago, and the Mission has become her home. Follow her on Twitter @miss_elenius.

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13 Comments

  1. Thanks for a great article. It is pretty revealing of the type of characters recalling Boudin! DARK MONEY trying to wipe out diversity , and reflects the THUGGISH mentality of thugendorf et al.

  2. Wow the keeper of the cookie jar and all it’s crumbs and wanning odors of false hope, thinks snack time is going well. What children, marveling over their wonderful backyard creation before dinner time.
    This is sad. Of the 2,000 calls how many should have been prosecuted? Of all those reverted hotel rooms is causing a degradation of tourism which provides real long term funding? How many hotels converted into mental illness dorms destroy’s the fabric of our city – permanently ? This is pure enabling and Chesa needs to be running a Co-dependency workshop not dancing in his own Fire of contrived fantasy. Upon my recent travels aboard, not one regular traveler was motivated or committed to EVER vacationing in San Francisco, again. ( oh you do gooders say “f… ‘em, well they pay the rent FYI! Not u ! ) I used to receive accolades for being a native. This trip I received true pity and sorrow about the death of my birth place.
    You are all dreaming and living on junky/pimp Bindens ill gotten money. When it runs out the city is permanently screwed! We will have nothing but mentally ill addicts and disabused drug dealers living under Chesa’s umbrella!
    Time to really get awake.

  3. Why should we trust these people anymore than Mohammad Nuru or Harlan Kelly or Tom Hui or Sandra Zuniga? I DON’T…

  4. Among the police alternatives being discussed, I want to give a shout out to the plan for CART (Compassionate Alternative Response Team), a street response team focused on the needs of the unhoused. CART now has initial funding. While CART compassionate responders can also handle overflow crisis calls that the SCRT (Street Crisis Response Team) is not available to handle, it can do a lot more. This includes responding to 911 and 311 complaints about encampments, sit/lie violations, aggressive panhandling, blocked doorways, homeless trespassing and similar. The design of CART was heavily influenced by the successful 30 year CAHOOTS program in Eugene Oregon. Everything we can do to get police out of the field of social work and mental health crisis calls, the better.

  5. It’s frustrating that they are still not removing tents and the associated garbage, needles etc. Calls and reports to 311 about encampments are basically ignored.

  6. Chesa should be holding a co-dependency group rather than crowing about naive assortments conducted in the backyard prior to dinner being called. It’s childish to think enabling is going to save the city and even tacitly approach any sort of remedy.
    I recently travelled and polled fellow travelers, previously committed to including a stay in SF, felt nothing but pity and sorrow for SF. I know a lot of you will say “f.., ‘em” but they pay the bills not you.
    How many of the 2,000 calls should have been prosecuted ?What happens when they turn tourist hotels into mental health asylums ? What happens when people not a junkie or sick are unable to
    engage in the city they are
    attempting to enjoy?
    The City is in deep trouble and those who actually live here ( not just arrive and inflict their diatribe of weak and immature ideologies )
    Better get awake.

  7. The woman whose son has been hospitalized in the ER 181 times, her issue was not addressed at the meeting. Whether it’s things like an actual good faith implementation of Laura’s Law or LPS conservatorship, the city is failing. Ideologues like Boudin ignore the medicine and evidence around these interventions because it doesn’t fit with their ideology. And they just push more of the same.

    Also pretty disingenuous of him to assert that the 2000 calls to the Crisis Response Team averted 2000 prosecutions. Many of those calls to police in the past would also not have lead to an arrest, or would lead instead to a 5150. I support the Street Crisis Response team idea, but am tired of the Boudin bs.

    1. Were you there? I was & they did address her. In fact, much time was spent on her difficult situation. It seems she was interested in some kind of conservatorship so that her son would be forced to take his medication, not have access to alcohol & get other needed support, but it’s not a simple process & there are many laws that make it difficult to do this. Not all public health professionals are in favor of this as well. The DA is not in charge of the Public Health Dept. in SF so your statement, “Ideologues like Boudin ignore the medicine and evidence around these interventions because it doesn’t fit with their ideology” doesn’t make sense. Ideologue is an insult often leveled at the DA from the right and it’s just not true. He’s a thinker, a learner, a person with empathy, visionary. Millions of people in this country want us to address our intractable problems differently than we have in the past. Collaborating–the DA, Health Department folks, Fire Dept. EMTs, other community based orgs–this is IMPORTANT work.

  8. I want to say that although I am an older white woman, I’m system impacted (have an incarcerated loved one), a survivor of sexual assault & have had CLOSE family members with SUD, two who committed suicide. I know that my white, middle class privilege makes it easier for me to navigate these hardships, but I am, in some ways, very representative of the issues.

    1. Those who cannot be vaccinated should follow the public health orders and remain masked indoors or isolate to avoid infection.

      Those who will not be vaccinated should be left to their chosen fate, having declined the lowest bar of adaptation to avoid the penalties of natural selection in history..

  9. Pearl Harbor will be attacked on December 10th!

    Damn, registration date for being candidate to replace Newsom expired 10 days before I warned it would.

    Pay attention much, h.?

    Well, I’ll double my mileage with my ‘Save Chesa’ sign.

    Go Giants!

    h.

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