As leaders examine solutions to workforce shortages in behavioral health, many are also thinking about how to do so in an inclusive way that fits the needs of the people they serve. “Historically,” says Dr. Matthew Edwards, “we’ve created systems and asked people to be our partners.” “That’s not really how it works—we have to come up with the solutions together.” 988 gives states an opportunity to build crisis systems that involve the very people they’re meant to serve. “It begins with engaging community stakeholders in conversations at every step of system development,” he says, “and building partnerships and alliances from the outset.” Dr. Edwards is a clinical fellow in forensic psychiatry at Emory University School of Medicine. He’s also one of the foremost experts on Pittsburgh’s Freedom House Ambulance Service and has written pieces on the community-based sociomedical program, race, and policing for Oxford’s Journal of the History of Medicine and Allied Sciences and the New England Journal of Medicine.
In response to the Covid pandemic, an increased lens on racial equity, and 988, state and county leaders are developing alternatives to justice system involvement like community crisis responder programs. Though street responder programs have long existed, they’re catching traction across the United States to deflect and divert people experiencing a behavioral health or “quality of life” crisis from a law enforcement response. Communities, like Oakland, have pushed for resident-centered crisis responses, and some programs explicitly encourage people with a diversity of lived experience and backgrounds to apply to their crisis responder initiatives. Racial or ethnic concordance fosters trust and increases people’s outreach of services and support before they’re in crisis. For example, a Stanford study found that Black men randomly assigned to a Black physician were more apt to sign up for preventative services and share their health challenges than with a non-Black doctor. The potential impact is nothing to sniff at: the findings suggest that the concordance could lead to a 19% reduction in the cardiovascular mortality gap between Black and White men.
Dr. Edwards points out that diversity and concordance between a person in crisis and crisis responders is an important starting point—which can lead to more informed care—but can’t, on its own, rectify structural racism. “We have to address structural racism within education, including medical education, mental healthcare, policing, and within our communities,” he says. As with all efforts, it’s also critical to examine the potential unintended consequences of resident-centered crisis response. Crisis workers experience tremendous occupational stress, and by creating a workforce within communities that face structural racism and violence, responders are at greater risk of retraumatization. “They’re in a potentially better position to understand the system, but they’re also more likely to have been traumatized by the system.” As communities build out resident-centered crisis responder programs with increased racial or ethnic concordance, they should do so equitably and responsibly to ensure crisis workers are supported.
People within a marginalized population can experience vicarious racism and trauma. For example, researchers found that law enforcement killings of unarmed Black Americans were associated with worse mental health outcomes among other Black Americans in the general U.S. population. Furthermore, the researchers found that poor mental health days increased by 0-14 days per month for 3 months after each killing. Dr. Head-Dunham shared with us in October 2020 that racial disparities in Covid cases and deaths, the political climate, and the murder of George Floyd by four Minneapolis police officers on May 25 had taken a mental health toll on Black Americans. “It’s so palpable that it’s hard for us not to lose it emotionally,” she said. “I have to figure out the words to even engage in this conversation.”
If vicarious exposure to traumatic events has an undue burden, what’s the impact for crisis responders who are directly exposed? “People are harmed even through passive exposure,” says Dr. Edwards. “I’m in that city, I watch the news, I see this, and it affects me.” However, crisis responder teams experience a heightened level of in-person exposure to racial trauma, or race-based traumatic stress, leaving them even more at risk of being adversely impacted. The idea, he notes, isn’t to halt resident-centered initiatives but rather to ensure crisis responders receive the support they need. That includes providing responders with ample opportunities for psychosocial support, such as counseling or affinity groups. The latter—also known as employee resource groups—are organized based on life experiences, shared characteristics, or social identity. Equally important is that responders have meaningful representation in a way that avoids tokenism like “having one vote on a board.” “They need to have real veto and decision-making power,” he says.
The Freedom House ambulance service is an example of how this type of model can work and how when resident responders are insufficiently supported, they continue to be marginalized. The resident-centered response pioneered emergency medical services, becoming the national model for what EMS is today. “Freedom House was a local solution to local problems,” Dr. Edwards says. It was creative in ensuring the service could divert emergency response from funeral homes and law enforcement. When police officers wouldn’t route calls to Freedom House, Nancy Caroline, a critical care physician who helped scaffold the paramedic program, integrated the police frequency into the service’s radio. “She found a way,” notes Dr. Edwards, “to circumvent local resistance.”
Recently, stories on the ‘60s-‘70s Black-run ambulance service have spotlighted the success of the Freedom House model. What’s been far less discussed is how and why the program fell apart. The program’s success is undisputed, points out Dr. Edwards. It was nationalized and became a pilot program for the U.S. Department of Transportation. “The Freedom House model reached the level of the White House,” he says. Yet, those who benefited from the service’s achievements weren’t the community EMTs. “Rising tides supposedly lift all boats,” he points out, “but in the case of Freedom House, some boats received a huge lift while the tide merely pushed others along.” Simultaneously, mounting political pressure and obstacles placed by the city of Pittsburgh led to the service not having sufficient funding and its eventual closure. “Suddenly, many of the EMTs were in the same situation they’d been in before the program began.” In contrast, the physician leaders’ careers experienced a continued upward trajectory.
Politics and funding were key reasons Freedom House couldn’t keep its doors open. That’s another lesson, notes Dr. Edwards. As communities build resident-centered crisis responder programs, funding must be sustainable instead of a patchwork of temporary forms of “soft funding.” Not knowing where funding will come from—if a program will survive—often leads to uncertainty and profound insecurity for employees. “Sustainable funding is what’s needed to maximize 988.” The real innovation, says Dr. Edwards, is in the process, ensuring there’s built-in flexibility to create programs and processes that are iterative, have accountability for outcomes, are responsive to a community’s need for change, and appreciate a diversity of people, thoughts, and perspectives. “Throughout, we have to ask ourselves, ‘How do we equip, empower, and support our local communities?’”
Learn more: “Crisis Services: Addressing Unique Needs of Diverse Populations,” by Dr. Debra A. Pinals and Dr. Matthew L. Edwards.