San Francisco Chronicle - (Sunday)
Street crisis team is in crisis
When Diana Valentine, a licensed social worker, first heard about San Francisco’s plan to launch an emergency response team that didn’t include cops, she was amazed. After two decades of working with unhoused people in San Francisco and seeing the negative effects of policing on their lives, the idea seemed radical.
“Creating a community rather than a police response — I never thought I’d see that in my career,” she told me.Inspired, she left her job and joined the city’s Street Crisis Response Team as one of its first employees. As a clinical supervisor, she supported mental health clinicians as they navigated the streets in a van, accompanied by a San Francisco Fire Department paramedic and a peer mentor with lived experience of homelessness.
Then last month, with no warning, the city announced that all mental health clinicians would be removed from the vans and replaced with emergency medical technicians. The clinicians could keep their jobs, but they would no longer respond to immediate crises. Instead, they would do case-by-case follow-ups with people after the team saw them. In other words, San Francisco’s only mental-healthfirst crisis response team will have no mental health professional on board. That means there is no one on the van who can issue a 5150 — state code for an involuntary psychiatric hold — if someone is in extreme crisis.
Karey Fenderson, a crisis response clinician who worked on a street team in 2021 and 2022, told me that while some calls he responded to were minor, others were fraught — like the time he helped someone threatening to jump off a bridge. Once, he got a call about a person driving in the pedestrian area of Golden Gate Park who seemed to be trying to run people over.
The benefits of having a mental health clinician available to respond to these types of emergencies seem obvious.
I have talked to six clinicians who worked for the Street Crisis Response Team, five of whom have quit. Some left successful careers, such as working for crisis response teams in other cities, for a chance to help San Francisco create its own. They have different backgrounds and skill sets, but the recurring narrative from all of them was the same: San Francisco has taken a nonsensical step backward by removing mental health clinicians from the city’s only crisis response team that’s an alternative to police.
Mayor London Breed announced the creation of the Street Crisis Response Team in November 2020, months after the George Floyd protests spread across the nation.
“When the Street Crisis Response Team responds to a call for someone in crisis, they’ll be able to help with compassion and clinical skills to get people the care and support they need,” Breed said in a statement when the pilot program launched.
According to data released in November, the street teams had responded to an impressive 14,000 calls in an average of 17 minutes. Of those, 64% involved someone experiencing homelessness. It received national accolades and was featured in Mother Jones, Psychiatric News, NPR and the Guardian.
So, the sudden 180 in the Street Crisis Response Team’s operational structure took its staff by surprise. Vitka Eisen, CEO of HealthRIGHT 360, which employed the clinicians, told me she was stunned by the city’s decision to remove them from the vans.
“We never sat down and had a conversation (with the city) about it. The people we have are very dedicated to doing street crisis response. For our workers … it’s not the job they signed up for, and it may not be the job that they want.”
The Department of Emergency Management, which coordinates the various city departments involved with the street teams, said the shift is necessary to provide follow-up care to people after the crisis team responds. And that makes sense: If a team responds to someone who is, say, naked and upset in traffic, its members can calm that person down, give them clothes and make sure they’re OK. But leaving them on the street isn’t a long-term solution. Repeated follow-up care is an effective and essential way to help people get indoors and sober.
But providing an urgent mental health response and follow-up care shouldn’t be an either/or situation.
This was echoed by the clinicians I spoke to — none of whom disputed that follow-up care is important.
“This in no way negates the value and need for mental health clinicians on the Street Crisis Response Teams,” said Suzanne Gothard, who worked on the team as a clinical supervisor and program manager. By her account, clinicians were involved in every call in a critical way. “It’s a nuanced process of joining with a person to foster safety and seek to understand the person’s experiences, needs and preferences.”
Shuffling people from one job description to another is a risky move — particularly without their input or consent.
“The city made statements about wanting to redistribute efforts of clinicians elsewhere due to difficulty with staffing,” Cat, a former crisis response clinician, told me. (Cat, like other former and current street team clinicians I spoke to, didn’t want their last name or full names used over concerns it would affect their job hunt or job situations. The Chronicle agreed not to name them in accordance with its anonymous sources policy.) “Qualified, passionate clinicians are moving to other counties because of this decision.”
There isn’t a huge pool of these clinicians to begin with. HealthRIGHT had 14 mental health clinicians on staff, five on-call, two clinical supervisors and one program manager. In reporting this story, it was hard to find anyone who wasn’t considering quitting or already had done so.
Subsequently, the city’s plan to reroute clinicians to do follow-up care may fall flat.
What we’re left with is an unbalanced team, where two people — a community paramedic and an EMT — work for one department, which also provides the vans. Peer mentors I spoke to are also unhappy with this shift, worried that their skills will be overlooked by professionals whose job is to resolve crises quickly.
“This seems dangerous and reckless,” one peer mentor, who asked to remain anonymous, told me. “The clinicians went to school to specifically handle high-stress situations in people’s lives. We talk about de-escalation training, but that’s literally their job. They’re a vital part of handling those calls.”
The decision not to have anyone on board authorized to issue a 5150 is also mystifying. City data shows that they were only issued in approximately 5% of all street team calls — a statistic that has come under fire from some who think it should be higher. On-board clinicians think it should be lower; those I talked to said it’s a sign of success when a situation can be de-escalated and a person is routed to care that’s not psychiatric emergency services.
Amid this debate, responsibility for determining what is or isn’t the correct number of mental health holds will now rest on the shoulders of on-call fire captains. Madi, another former crisis response clinician, rightly questioned what sense this makes.
“Why would a fire captain be the person making mental health evaluation decisions for San Francisco?” she asked.
As San Francisco navigates crises on its streets and struggles to earn the trust of its constituents, transparency in its decision-making is vital. Requiring people to call 911 for the Street Crisis Response Team is a hard enough hurdle to clear; people in certain communities are reluctant to call because it could result in a police response.
Fenderson rode the Bayview van for a while, where calls to 911 for mental health crises were scarce. His team didn’t get dispatched often, despite knowing there were people in that neighborhood who could have used their help.
Without the guarantee that trained mental health workers are responding to a crisis, building and retaining that trust may be a bigger struggle than the city realizes.
And for many who worked on the team, like Valentine, this is a deeply disappointing failure.
“This essentially is going to be policing in red rather than blue,” she said. “We’re right back to where we started.”