How to create a non-custodial response to a mental health crisis, even in a big city

This program in Toronto takes a non-coercive, person-centred approach to mental health.

When someone is experiencing a mental health crisis, the first response is often to call the police or emergency services.but A succession of tragedies shows how this can put people at risk, especially if they belong to marginalized groups. Research from the Center for Treatment Initiatives estimates that people with mental illness are 16 times more likely to be killed in police encounters than other civilians contacted by law enforcement.

But there are alternatives to incarcerated approaches to mental health care, according to a new study Case study published jointly by Human Rights Watch and the Gerstein Crisis Center in Toronto.

As cities across North America battle homelessness and substance abuse crises, some are pursuing policies that force people with mental illness into treatment. In October, California officially launched CARE Court, a program that allows third parties to petition the courts to force individuals with schizophrenia and related disorders to receive mental health treatment. In New York City, Mayor Eric Adams has pursued a controversial policy of involuntary hospitalization of homeless people with severe mental illness.

If there is a growing movement to remove people with mental illness from public spaces, there will also be a renewed push for non-coercive solutions centered on individual rights. The Gerstein Crisis Center model provides an alternative to supporting people experiencing a mental health crisis through community-based mental health crisis response, rather than policing, involuntary hospitalization, or mandatory treatment.

A rights-based, people-centred approach

After deinstitutionalization in Canada and the United States, the promised community mental health centers never materialized, leaving police, prisons, and hospitals as the primary means of dealing with people in crisis. Founded in 1989, the Gerstein Center provides community-based services to people experiencing mental health or substance abuse crises. The organization currently has around 100 staff, most of whom have personal experience of mental illness or substance abuse.

The Gerstein Center handles approximately 30,000 crisis calls annually and provides mobile crisis teams, follow-up, referrals to other health and social services, crisis beds, and recovery and peer support programs. In 2021, Gerstein launched a pilot program to place crisis workers directly in 911 call centers. Mental health calls shift from police dispatch to mental health intervention and support.

Gerstein’s rights-based approach takes into account power dynamics where outreach workers wear normal clothing, for example, in an effort to destigmatize mental health care. Staff also assume that each client is an expert on their own life and recovery, and who a person is before and after a crisis is critical to providing the right treatment.

Executive Director Susan Davis said they have a wealth of skills, resources and knowledge gained over the years, all of which need to be recognized and seen during the crisis.

While Gerstein has been providing non-custodial solutions to Toronto’s mental health crisis for more than 30 years, there’s new interest in alternatives to police responses.

There’s a real hunger for solutions and a real willingness to think about these issues in intersectional ways, said Olivia Nsain, a senior advocate and researcher with Human Rights Watch’s U.S. Program. So it’s not just racial justice groups, it’s not just police groups, it’s not just disability rights groups, it’s people thinking in a holistic and intersectional way and coming up with solutions.

As Davis points out, Toronto, with a population of about three million, is not a small city. Large cities have the opportunity to adopt community-based models, but this paradigm shift can be a challenge.

“We have many criminal justice response systems for health issues built around mental health,” Davis said. Nurses don’t want to go out without police, and social workers don’t feel safe without police.

Davis said programs like Toronto’s were not created to address the problems of people with serious mental illness living outside. But early intervention centered on autonomy and social connectedness can help people in crisis find the stability they need to get back on their feet.

Rather than overloading already overstretched resources such as hospitals, law enforcement, and police, [these programs are] Baird said addressing personal health issues would support people in finding ways to be productive, involved in their communities and give back.

Connect people to communities

When Koala Baird sought out Gerstein’s services, she felt her life fall apart.

Have a group of people, or a place where you can be human and feel safe. For me, I always felt like I was going to be in trouble. “So even though I wasn’t feeling well, somehow it was my fault,” she said.

She is a fitness professional and currently works for their peer support program.

I know personally that they help you feel grounded and stable. Then you can slowly start doing whatever you need to do.

Gerstein offers more than just crisis hotlines and services. It can also help people find social connections and support.

Gerstein founded FRESH, or Finding Recovery Through Building Skills and Hope, after a crisis worker discovered that many people calling crisis hotlines were experiencing loneliness and social isolation.

We need ways for people to connect[s] Building a natural support network involves more than meeting your case manager, psychiatrist and nurse twice a month, Davis said.

FRESH is a peer-led program that connects people through group activities such as hiking, yoga and music.

Baird currently works with FRESH. She also learned how to play guitar through the program and formed a band with other participants, which even landed its first paid gig. FRESH has even expanded to the Toronto Public Library’s four downtown locations.

This is just one case study of how mental health crisis programs are rooted in community needs. But it helps illustrate the impact and scalability of this model.

Baird says that in times of crisis, it’s powerful to treat it like a person with a past, present and future that’s more than just a diagnosis. Even today, years later, talking about it still brings her to tears.

This story was made through us Equitable Urban Social Impact Design Fellowship, made possible with a grant from the National Endowment for the Arts.

Maylin Tu is a researcher for Next City’s Equitable Urban Social Impact Design Report. She is a Los Angeles-based freelance journalist who writes about transportation and public infrastructure, especially bus shelters and bathrooms, and has bylines in The Guardian, KCET, Next City, LAist, LA Public Press and JoySauce . She graduated from William Jewell College in Missouri with a BA in English.

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