Moving from crisis response to crisis prevention in U.S. mental health systems

Despite widespread promises of reform after the murder of George Floyd in 2020, in 2023, police killed at least 1,246 people — the most in more than a decade. This police violence is intertwined with a parallel public policy disaster: America’s abysmal mental health systems that force police officers to function as de facto mental health workers. People with unmet mental health needs are 16 times more likely to be killed by police, and a quarter of all those killed by police since 2015 were perceived to be suffering from a mental health crisis.

Meanwhile, there is now an historic amount of money flowing through the mental health industry, and the U.S. spends more on mental health services than almost any other nation. Yet mental health has only been worsening. In 2023, more than 50,000 Americans died by suicide — the highest number on record, even as the proportion of people taking antidepressants has more than doubled over the past two decades and nearly a quarter of adults are now taking at least one prescribed psychiatric medication. Nearly half of all adults recently reported that they believe they have needed mental health treatment over the past year but have not received it. But what few recognize is that the currently dominant framework for addressing mental health, which focuses on reactive medical treatment while neglecting preventive social support, is itself a root cause of our collective disease.

Neither mental health nor policing can be fixed by simply pouring more money into business as usual. To improve either will require building non-police crisis response systems while also reconceptualizing community-based systems for mental health.

Several major U.S. cities, including New York City, Atlanta, San Francisco, Albuquerque, and Denver, have been engaging in the first part of this work by launching or expanding programs to send mental health responders rather than police to address emergency calls related to mental health. These programs have been remarkably effective at deescalating crises while preventing violence, crime, needless arrests, and wasteful police and health care spending. But they remain profoundly limited by a narrow orientation around crisis response rather than prevention.

In Chicago, a coalition of community organizers is trying to take the national movement toward non-police crisis response systems a step further by refusing to take crises for granted. If it succeeds, it will, in the process, provide a new foundation for both community mental health and public health writ large.

This effort has coalesced around a policy demand called Treatment Not Trauma, which recently elected Mayor Brandon Johnson has endorsed as a central policy for rebuilding the City’s public infrastructure. Treatment Not Trauma begins from the recognition that the most important part of addressing mental health crises is to prevent them from ever arising. It therefore calls for neither a psychiatric nor police model of mental health response — both of which are dominated by reaction rather than prevention — but instead for a public health model of community wellness.

This approach, which I have worked with the Collaborative for Community Wellness to design, consists of three interdependent parts. First, to relieve police of inappropriate responsibilities to function as mental health workers, it calls for the Chicago Department of Public Health (CDPH) to build out a non-police mobile crisis response system for the entire city. Second, it entails reopening the network of 19 public mental health centers that CDPH operated until, beginning in the 1990s, it incrementally closed all but five as part of an agenda to privatize care services by providing grants to nonprofit organizations operating on the basis of charity rather than funding public systems built on rights. These centers — including the five that never closed and two more slated to be opened by the end of 2024 — are now to function as crisis reception and stabilization centers as well as community hubs for everyday preventative outreach and supportive services.

The third component of Treatment Not Trauma is its most transformational: It revolves around hiring a large-scale community care worker corps comprised of lay residents from Chicago’s neighborhoods with greatest unmet social, medical, and economic needs. These care workers are to be trained and employed by CDPH in dignified, career positions (i.e., with compensation, benefits, and protections parallel to those currently given to police officers) as peer support specialists working in task-sharing collaboration with supporting mental health professionals to serve their own neighbors. Over time, the goal is to hire, train, and stably employ thousands of such workers.

Treatment Not Trauma is thus meant to supply a relational infrastructure for community care that seeks “mental health for all by involving all.” To do so, it embraces what underpins the most successful community health worker initiatives both in the U.S. and internationally: the principle of accompaniment. This participatory model of community-building care rejects paternalistic, salvific fantasies of caring for those who our society has most excluded — that is, self-affirming missions that often reproduce the very inequalities they ostensibly address. Accompaniment-based systems are instead about caring with one another and restoring to dispossessed communities the resources required to care for themselves. Such systems therefore prioritize local knowledge and lived experience in program design and leadership, and the training and stable employment of residents of marginalized communities to care for their own neighbors.

With this approach, the goal of Treatment Not Trauma’s community worker corps is not only to generate benefit through the services that care workers deliver but also to foster individual and collective wellness by providing meaningful, empowering public jobs that nurture community cohesion, individual capabilities, and economic stability.

Treatment Not Trauma puts into practice a model of preventive social care that has been shown in numerous examples around the world to be more effective, efficient, and equitable than top-down professional medical approaches to mental health. To succeed, it will have to upend the medical industry’s narrow, self-serving vision of who can provide care that has for so long over-prioritized expensive (and often ineffective) professional mental health services while marginalizing and divesting from nonprofessional care workers and systems for everyday social support.

Treatment Not Trauma represents the kind of bottom-up model of demedicalized public health that this country — which is suffering from the worst public health, safety, and health care among all wealthy nations — desperately needs to build functional health and safety systems. It is also the kind of bold public jobs program required to foster trust in government and between neighbors during a historical period characterized by worsening social isolation, declining trust in state and civic institutions, and the profoundly fragile state of U.S. democracy. By investing in public systems that support people in reciprocally caring for one another, we are in effect also building systems with which to care for the future of democratic possibility in a world inclined toward self-destructive violence, ever-growing policing, and authoritarianism. Democratizing care is essential to caring for democracy.

There is also an economic case for Treatment Not Trauma. RI International’s Crisis Resource Need Calculator estimates that a non-police crisis response program could yield $537 million in savings per year if implemented across Cook County, or $279 million when restricted to the City of Chicago alone. But the road to implementation starts from deep within a pit of public disinvestment after a series of short-sighted privatization schemes have decimated Chicago’s care infrastructure.

After a three-decade-long defunding process, CDPH is the most understaffed and underfunded big-city public health department in the country, with the number of positions at CDPH cut by 60% since 2000. By contrast, the city has rapidly increased police funding. Chicago is now home to the highest number of officers per capita and the second-highest per capita police budget among large U.S. cities. Direct spending on police consumes 35% of the total city budget; indirect spending on police (such as maintenance of police assets) brings that figure closer to 50%.

To improve health and safety, Mayor Johnson and the Chicago City Council must confront a city budget that has repeatedly prioritized reactive punishment over preventative care. To date, Johnson has shied away from doing so. His recently passed first city budget features substantial increases in police funding alongside — as federal grants expire — a shrinking overall budget for public health with minimal increases to city-ensured funds. This reflects what appears to be a growing tendency in the Johnson administration to compromise with, continue, and even expand the very same failed police-first paradigms that Johnson campaigned against, leaving local organizers alarmed and increasingly concerned about the strength of his commitment to Treatment Not Trauma.

Covid has proven the current technocratic, privatized model of U.S. public health to be deficient and ill-equipped to earn the public’s trust — without which it cannot succeed. To rebuild our public health systems, we must shift them toward a relationship-based model of care focused on direct service delivery, public jobs, and trust-building community care systems. Given profound inertia and resistance to such changes at the federal level, states and cities must now find the courage to lead the way forward.

Eric Reinhart, M.D., is a political anthropologist of law, psychiatry, and public health.