Police violence and lack of access to essential care services have emerged as twin hallmarks of American life. In a nation where people with unmet mental health needs are sixteen times more likely to be killed by police, about a quarter of all people killed by US police since 2015 were suffering — or were perceived to be suffering — from a mental health crisis. In Chicago, a series of killings by police since former mayor Rahm Emmanuel closed over half the city’s public mental health centers has galvanized a movement to confront this by transforming the city’s mental health and policing systems.
Born out of the occupation of the Woodlawn Mental Health Center by community organizers after Emmanuel announced its closure in 2012, the movement has coalesced around a policy demand called Treatment Not Trauma (TNT). Chicago’s new progressive mayor, Brandon Johnson, has embraced TNT as a central policy for rebuilding the city’s public health infrastructure and addressing deep-rooted abuse and corruption in the Chicago Police Department. With a TNT working group tasked with delivering recommendations to the mayor in advance of next year’s budget proposal, the degree to which the Johnson administration is truly committed to building TNT at scale— and not just as a symbolic gesture without serious financial investment — will soon become clear.
TNT begins from the recognition that the most important part of addressing mental health and behavioral crises is to prevent them from ever arising. It therefore calls for neither a psychiatric nor police model of response, but instead for a public health model.
This community mental health approach, which I have contributed to designing with the Collaborative for Community Wellness, consists of three interdependent parts. First, to relieve police of their responsibility to function as mental health workers, it calls for the Chicago Department of Public Health (CDPH) to build out a nonpolice mobile crisis response system for the entire city. Second, it entails reopening the network of nineteen public mental health centers that CDPH operated until the 1990s to now function as crisis reception and stabilization centers, as well as community hubs for everyday preventative outreach and supportive services.
Third, TNT revolves around hiring a large-scale community care worker corps comprised of lay residents from Chicago’s most dispossessed neighborhoods who are then trained and employed by CDPH in dignified, career positions (i.e. with compensation, benefits, and protections parallel to those currently given to police officers). These workers will collaborate and share tasks with supporting mental health professionals in communities with greatest unmet social, medical, and economic needs. It’s this last part — a bottom-up human infrastructure for community care that seeks “mental health for all by involving all” — that’s the most essential, transformational, and currently widely overlooked element of the TNT agenda.
If TNT succeeds in garnering sufficient financial support in ongoing city budget negotiations, Chicago will become one of the few US cities to attempt to buck the lucrative American medical industry’s disastrous domination over the nation’s care systems. Instead it will put 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. Programs like TNT would 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.
TNT is, in short, exactly the kind of revamped model of demedicalized public health that this country — which is suffering from what is now without question the worst public health, safety, and health care among all wealthy nations — desperately needs. TNT is also the kind of bold social program required to foster trust in government and between neighbors during a historical period characterized by worsening social isolation and the profoundly fragile state of US democracy. By building systems to support people in caring for one another, we are in effect also building systems with which to care for the future of democratic possibility in a world prone to self-destructive violence and authoritarianism.
The Programmed Failure of Community Mental Health
TNT may now seem like a radical departure from the history of American health and social policy, but it is in reality a return to an earlier moment before the country’s profit-driven medical industry and mass incarceration asserted their grip over the nation.
Although police today function as de facto mental health workers across nearly all American cities, a half century ago it seemed that community mental health was moving toward a dramatically different destination. In conjunction with the closure of infamously cruel asylums in the 1950s and ’60s, mental health professionals, patients, and lawmakers called for the creation of a new model for community-based mental health systems. Led by the field of social psychiatry, many demonstration projects focused on both treatment and prevention ensued. These included several effective initiatives that prioritized nonprofessional community care workers, neighborhood mental health service centers, and supplemental support from mental health professionals as needed, with a focus on urban neighborhoods with highest levels of unmet economic and social needs. Among them were a community mental health program at Lincoln Hospital in the South Bronx and the first CDPH community mental health center, the Mid-South Center in Bronzeville, which opened in 1959 and was followed by the opening of eighteen more CDPH-run centers over the subsequent years.
By the late 1960s, however, public investment in such programs — via, for example, the Economic Opportunity Act of 1964 as part of the short-lived War on Poverty — began to dry up. With the establishment of the Centers for Medicare and Medicaid in 1965, new federal grants crafted around medical treatment rather than preventive social care, such as the Mental Health Center Staffing Grant, required conformity to traditional medical models of care delivery. They prioritized professional services for which health insurers, now including Medicare and Medicaid, could be billed. Federal qualified health centers (FQHCs), private nonprofit centers meant to provide care to underserved populations, were also rolled out during this period. They were subject to similar funding pressures, often leading to exclusion of individuals without insurance or other means of payment or whose needs exceeded the ability of available psychiatric treatments to address.
This severely limited the development of community mental health infrastructures equipped to go beyond reductive medical models in order to focus on community-based peer support, mobile crisis response, housing, employment and financial support, conflict resolution, elder care, and additional key social determinants of mental health. As a result, particularly as pharmaceutical companies began producing more and more powerfully sedating and profitable psychiatric medications, reactive psychiatric treatment — after mental health needs had already worsened to the point of crisis — rather than continuous social support and crisis prevention were prioritized. The shift short-circuited the promise of community mental health before it even had a chance to be built, leading to its “programmed failure.”
In the years that followed, matters became considerably worse as the War on Poverty was replaced by the “war on crime” and “war on drugs.” This has led to an ongoing national practice of responding to overlapping problems of poverty, addiction, serious mental illness, and homelessness primarily through criminalization rather than support. Given that evidence shows incarceration can actually increase crime at state and local levels, this reality contributes to remarkably poor both public health and public safety outcomes relative to peer wealthy nations by fueling the United States’ globally unparalleled incarceration rate — now approximately seven times that of other wealthy countries.
Today, jails and prisons are the largest providers of mental health services in the United States, and police function as the main mental health crisis responders. Rather than improving mental health, this leads to a feedback loop that worsens it and exacerbates racial inequalities — all in a historical context in which people of color are already subjected to disproportionate rates of poverty and policing. This is partly because health care in jails and prisons, which feature widespread abuse and violence, is of notoriously poor quality, severely under-regulated, and often altogether unavailable. Moreover, medical treatment alone, no matter how good its quality, can’t address the root causes of most mental health afflictions that leave individuals vulnerable to arrest and repeated incarceration.
A National Shift Toward Nonpolice Crisis Response
In the wake of George Floyd’s murder and the national movement against structural racism and police brutality that it provoked, most major US cities — from New York City and Atlanta to San Francisco, Albuquerque, and Denver — have launched or expanded programs to send mental health responders rather than police to address emergency calls related to mental health.
With over one hundred US municipalities launching such programs, almost all have been remarkably successful. Denver’s STAR program may be the most rigorously studied. After expanding citywide, the Denver program responded to 48 percent of welfare check, trespassing, and unwanted persons calls flagged by dispatchers. One hundred percent of responses did not lead to police involvement. According to a 2022 study, during its first six months in operation, STAR reduced low-level crimes (e.g. trespassing and public disorder) by 34 percent and prevented almost 1,400 criminal offenses. Furthermore, shifting to a civilian responder model did not increase more serious crime. The study also found that “the direct costs of having police as the first responders to individuals in mental health and substance abuse crises are over four times as large as those associated with a community response model.” And, notably, those savings do not include additional savings from reduced health care utilization associated with diverting individuals from costly emergency room visits and hospitalizations.
Chicago, where violence and police brutality routinely make national headlines, has only a tiny pilot program for alternative crisis response and has continued to rely on a police model of “co-response” in it. The city is well behind the national curve. The obstacles to building an effective and scalable nonpolice crisis response system in Chicago are much the same as what has held back other cities from realizing their full potential.
Alongside lack of public funds to scale up such programs in cities where current policing costs already vacuum up a large proportion of municipal budgets, three major obstacles exist to moving away from police-based crisis response to more effective public health models for crisis response and prevention: staff, space, and support systems. In Chicago and across the United States, there does not currently exist a workforce adequate to staff necessary crisis response and prevention infrastructures. Most cities also do not currently have a remotely adequate number of physical spaces designed for twenty-four/seven mental health emergency response, de-escalation, stabilization, and subsequent ongoing community care provision. Last, many US cities lack systems to support the operation of nonpolice crisis response, such as an option upon calling 911 for callers to request mental health teams without police presence and a 988 system capable of dispatching nonpolice mobile crisis teams.
With its integrated focus on nonpolice crisis response, mental health centers, and a robust community care worker corps, Chicago’s TNT campaign addresses each of these necessarily interwoven parts of an effective community mental health infrastructure equipped both for crisis response and for crisis prevention.
TNT’s goals and methods are common sense, even if they seem ambitious in a national context in which police and expensive professional mental health services have crowded out more obvious solutions. The economic case for TNT is also clear: a nonpolice crisis response program like TNT is estimated to yield about $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 disastrously shortsighted privatization schemes have decimated Chicago’s care infrastructure.
Treatment Not Trauma and the Future of Public Health
Public health is at a pivotal historical juncture after COVID has proven the current technocratic, privatized model of US public health to be an unequivocal failure in need of substantial reorganization and increased funding. Trust in government in general and public health in particular are at historic lows. Simply continuing with the status quo in public health will further weaken health and safety, deepen racial inequalities, and undermine democratic participation.
TNT appears to have the potential to revitalize public health systems in Chicago by shifting CDPH away from impersonal technocracy and biosurveillance toward a relationship-based model of public health focused on direct service delivery, public jobs, and trust-building community care systems based in everyday supportive relationships. It also promises a coordinated response to the overlapping public health crises of gun violence, mass incarceration, mental illness, homelessness, overdose, distrust, and growing racial health inequalities in Chicago, where the black-white gap in life expectancy has widened to ten years.
But public health must be refunded to make revitalization of CDPH possible. At present, CDPH — where city-funded positions have been slashed by 60 percent over the last two decades — receives the vast majority of its funding from federal grants restricted to specific uses, with almost no funding from the state and less than 10 percent of its budget ensured by the city of Chicago. Among large city public health departments in the United States, this reliance on federal grants is unusual. In New York City, for example, over half of health department funding is supplied by city taxes, 31 percent comes from the state, and less than 17 percent from federal grants. Chicago’s reliance on federal funding as a substitute for city and state funding is irresponsible, in direct contradiction to recommended funding practices in public health, and harmful to Chicago’s residents. It undercuts CDPH’s capacity to build necessary, innovative, sustainable programs responsive to shifting community needs.
After a three-decade-long defunding process, CDPH is now the most understaffed and underfunded big-city public health department in the country. As Chicago’s notably poor health and safety outcomes reflect, residents are paying the price for divesting from one of the city’s most essential responsibilities — a situation set to soon dramatically worsen as COVID-related federal grants expire over the coming year.
In contrast to Chicago’s defunding of public health, and in a closely related process, the city has rapidly increased police funding over the last several decades. Chicago is now home to the highest number of officers per capita, and the second-highest per capita police budget among large US cities. To improve both public health and safety for Chicagoans, TNT advocates argue that this lopsided city budget that prioritizes reactive punishment over preventative care must be confronted and changed.
It’s clear that for CDPH — like the vast majority of municipal public health systems across the country — to be effective, it must secure a major increase in its guaranteed annual budget from the city and substantially increase its staffing levels with a focus on direct care services. In order to motivate such changes, CDPH will also have to design, promote, and implement programs to justify such funding in the public eye and before the Chicago City Council. TNT is ideally poised to do just that, provided it can overcome entrenched political proclivities for reaction rather than prevention.