Clevelanders share their views about emergency response for people in crisis

Elaine Schleiffer | Piet van Lier

People experiencing crises related to behavioral health, homelessness or substance use do best when they are treated with compassion and care. That’s why advocates, policymakers and service providers in Cleveland are increasingly recognizing the value of embracing non-police care response.

Care response provides a health-first approach that, rather than sending police, sends emergency medical technicians, paramedics, mental health clinicians, social workers or trained peers with lived experience on emergency calls. Such initiatives are already in use in cities around the country and are being piloted in other Ohio cities. The goal is to prioritize support and compassion for people experiencing a range of health-related crises.

Care response is a new idea in Cuyahoga County. Both Cleveland and Shaker Heights have limited “co-response” programs that send social workers on certain emergency calls with police; care response eliminates the police presence for appropriate calls. With the goal of helping move the local conversation in a new direction, in August Policy Matters Ohio collaborated with the Center for Community Solutions and the Mental Health & Addiction Advocacy Coalition on a policy brief describing care response and ways to sustainably fund such initiatives in the short and long term.[1]

The current local exploration of care response provides an opportunity to ask those most impacted — and most likely to need the services of such a program — about their experiences, perspectives and hopes for what an expanded crisis services continuum can provide. Policy Matters Ohio and REACH NEO, (Responding with Empathy, Access and Community Healing) teamed up to better understand experiences in the community with first responders (including police, emergency medical technicians/paramedics, and firefighters) through a survey. REACH is a grassroots coalition that is pushing communities to offer more appropriate and effective resources to people experiencing crises, conflict or poor health. REACH aims to establish a care response program across Northeast Ohio.

We worked with the Northeast Ohio Coalition for the Homeless (NEOCH) on the first phase of the survey. Over the summer of 2022, members of NEOCH’s Homeless Congress interviewed 177 people, many of whom may not know where they will sleep at night or have experienced this kind of housing insecurity. The Homeless Congress is an organizing group of community members, advocates, and local leaders with lived experience of homelessness. The interviewers spoke to people in homeless shelters, social service agencies, bus and Rapid stops, libraries, and other locations across the city.[2]

The survey reveals a complex snapshot of directly impacted Clevelanders’ views of first response for people experiencing behavioral health crises or struggling with issues including homelessness and substance use. On the one hand, nearly half of survey participants said their interactions with first responders over the past year have been mostly positive, with 30% reporting them as negative. Nevertheless, participants’ responses to open-ended survey questions show much room for improvement in how people are treated when they are experiencing crisis and need help, and the services that are available to them.

Our methodology, explained in more detail in Appendix A, includes a mix of quantitative and qualitative questions; the qualitative portion is based on a survey by Portland Street Response.[3] The survey tool is in Appendix B. Of the 177 survey participants, 57% were male and 42% female, while 88% identified as heterosexual and 6% as homosexual or bisexual. The majority (68%) were Black, 17% were white, 6% Hispanic/Latinx, and 2% Indigenous. Most (83%) were aged 26 to 64, 10% were 65 or older, and 6% were 18 to 25.

Figure 1: Demographics of survey participants

Figure 1a: Race/ethnicity

Figure 1b: Age

Source: Policy Matters Ohio/REACH survey, June and July 2022, available online at https://bit.ly/3rYG9EW.

Most participants (91%) reported that they live or stay most of the time in the city of Cleveland. Nearly half (46%) said they had permanent or stable housing, while 27% said they were in a shelter, 19% in temporary or unstable housing, 14% reported that they stay outdoors, including streets, parks, transit stations or shelters, or other outdoor locations. Just 2% reported that they stay in the home of a family or friend.

Summary

All but a handful of people interviewed for the survey reported having at least one interaction with first responders over the past year.[4] When asked about how positive or negative they felt about different types of first responders, survey participants expressed a clear desire for different responders for different needs.

Overall, participants felt more positive and safer when they received a police response for a threat against their safety, a firefighter response for a fire, and a health care response for a health care need. A majority of participants reported that their calls to 911 were driven by health needs — either physical or behavioral health.

When asked specifically about non-police first responders such as EMTs/paramedics, social workers, mental health clinicians, or peers with similar lived experience, respondents had the most positive assessment of EMTs/paramedics, but a majority of participants had favorable views of all these options. Of these options, only EMTs/paramedics are currently deployed as emergency responders in Northeast Ohio communities. Small co-response pilots in Cleveland and Shaker Heights include social workers who ride with police, but for the most part police officers are required to clear the scene before social workers are able to approach people requesting assistance.[5]

The survey included several open-ended questions inviting participants to share specific experiences and their thoughts on interactions with first responders.

The survey asked about the kinds of services they need and would like first responders to provide, and their responses included food and water and access to medical care and resources for people struggling with housing insecurity. We also asked what kind of training non-police first responders should have; mental health topped the list, along with things like active listening, anti-internal bias training and other interpersonal skills.

The survey also asked the question: “What was your interaction with a first responder like? Was there anything positive about any of your experiences that you’d like to see more of?” Prompts connected to the question included issues of safety and what about the interaction made the participant safe or unsafe.

Responses ranged from positive to negative, with nuanced answers being allowed in long-form answers, prompting honest storytelling and touching on issues such as physical safety, mental health, homelessness and life on the streets.

A selection of comments from survey participants is featured throughout the report, and others are included in a section at the end. Survey responses are available online as well, at https://bit.ly/3rYG9EW.

Who called, who responded and why

In the survey questions about past interactions, the term “first responder” was defined to include law enforcement, firefighters and emergency medical technicians or paramedics. Law enforcement entities named repeatedly by survey participants were the Greater Cleveland Regional Transit Authority police and the Cleveland Division of Police. A few mentions included suburban police departments.

Over half of participants reported having more than one interaction with first responders over the past year, with 42% reporting between two and five interactions and 18% reporting more than five; one-third said they had just one interaction.[6]

The largest share of participants (30%) said that in the interaction they were asked to discuss for the survey, they called for help, while 20% said a staff member or representative of an organization called, 14% said a friend or family member did and 6% said the interaction was initiated by a first responder. Seventeen percent said they did not know who called 911 during their most recent crisis.

When asked to discuss their most recent interaction, 48% of participants said they were responded to by law enforcement, 37% by EMTs or paramedics, 10% by firefighters and 5% by all three.

A majority of survey participants (59%) reported that their calls for help were driven by health needs — 37% related to physical health and 22% related to a mental or behavioral health crisis. In addition, 23% said their crisis was caused by a threat to someone's safety, 14% reported it was related to lack of stable housing or homelessness, and 4% reported the cause to be substance use or withdrawal.

Interactions with first responders

Survey participants’ assessments were similar regardless of whether they were describing multiple interactions over the past year or their most recent interaction.

Assessing multiple interactions, 49% of participants described them as positive or mostly positive, 27% described them as negative or mostly negative, and 20% as neutral. Assessing their most recent interactions, 47% described them as very positive or positive, 29% described them as negative or very negative, and 24% as neutral.

Figure 2: Survey question: How would you describe your most recent interaction with a first responder?

Figure 3: Survey question: If you’ve had more than one interaction with a first responder in the past year, how would you describe them?

Source: Policy Matters Ohio/REACH survey, June and July 2022. Responses available online at https://bit.ly/3rYG9EW.

At first glance, this would seem to reflect well on most interactions participants have had with first responders. But closer examination that connects this quantitative assessment with responses to open-ended suggestions about interactions results in a less clear appraisal, particularly of police. Of the 87 participants (47% of all survey participants) who rated their most recent interactions as positive or very positive, the open-ended responses of 12 reported a negative interaction with law enforcement that contradicted the positive quantitative assessment that participant had provided. As evidenced by the survey participant quotes on this page, one analysis of this discrepancy is that the participants’ willingness to rate the interactions as positive resulted from an interaction that ended without injury or damaging outcomes, even if they reported it as a negative encounter in their open responses.[7]

Preferred responders for crisis intervention

Overall, participants expressed a clear desire for responders with the right training and skills to help people depending on their needs. They felt more positive and safer when they received a police response to a threat against their safety, a firefighter response to a fire, and a health care response to a health care need.

Survey participants were asked the question: “If you call an emergency line for help and someone who’s not a police officer responds, who should that be?” They were given the opportunity to indicate whether they would feel safe with four different types of non-police response. They expressed largely positive views of all options, with 78% reporting that paramedics make them feel safe, 67% saying the same for mental health professionals, 60% for peers with similar lived experience and 58% for social workers.

Figure 4: Survey Question: If you call an emergency line for help and someone who’s not a police officer responds, who should that be? (Choose all that apply.)

Source: Policy Matters Ohio/REACH survey, June and July 2022, available online at https://bit.ly/3rYG9EW.

The survey did not delve into these views, but some of the differences may be that survey participants have had more experience with EMTs and paramedics than with the other responders listed as options, since crisis response programs involving mental health clinicians, social workers or peers are limited or non-existent in the Cleveland area.

For example, participants may not have interacted with mental health workers outside of a hospital or being pink-slipped.[8] And while they likely have interacted with social workers through hospitals or services focused on housing or shelter, reentry, veterans’ support, domestic violence or rape, those interactions are not generally in the context of an acute crisis or emergency response. Similarly, unless they are part of the substance use recovery community, participants are unlikely to have had any experience with peers as service providers in the context of a crisis.

Conversations with community members, and broader public safety dialogues, suggest that social workers can be seen negatively for their role in enforcing laws and agency rules, especially those that impact families enmeshed in social services systems in marginalized communities.[9]

In response to an open-ended question about the types of situations in which they would want police to be present, survey participants commonly mentioned situations where there was physical danger, a threat or a crime being committed. The vast majority gave at least one example of when police presence is wanted; only 8% said they never wanted police to be present because of fear, distrust or dislike.

Figure 5: Participant responses to questions about first responders and sense of safety

Needed services, skills and approaches

Survey participants were asked what services or supplies they would like a non-police care response team to be able to provide. These are the most common answers, in order of most mentions to fewest:

• Access to medical care — mentioned by about half of respondents.
• Access to homelessness resources — mentioned by about half of respondents.
• Food, with diabetic-friendly options — mentioned by about a third of respondents.
• Water.
• Transportation.
• Blankets.
• Hygiene supplies.
• First-aid supplies.
• Narcan, Naloxone, test strips for drugs, etc.

Participants were also asked what kinds of training they would like a non-police care response team to have. The most common answers, also in order of most mentions to fewest:

• Wide range of skills — Nearly half agreed that first responders need a wide range of training, including in mental health, interpersonal skills and trauma-informed care, and youth-, LGBTQ+, and homeless-specific competencies.
• Mental health — specifically mentioned by just under a third of participants.
• Active listening, anti-internal bias, relationship building, or other interpersonal skills — mentioned by nearly 15%.
• Conflict resolution or mediation.
• Trauma-informed competency.
• Racial equity competency.
• Physical health care/medical skills.
• Homeless community competency.
• Knowledge of social services, local resources, or wraparound care options.

We asked participants how they want to be approached by crisis responders. Common answers included:

• I want to be shown your badge or ID.
• I want you to say your name and your intentions up front.
• I don’t want to get in a plainclothes car or vehicle for transport.
• I want a responder who is calm, respectful, clear and kind.

Feeling safe

The survey asked participants to “talk more about what kind of response makes you feel safer and why.”

The most common responses (41) included words like compassion, calm, friendly and positive, while many participants (25) said that what makes them feel safer depends largely on the situation they are confronted with. EMS was included in the response 28 times, social workers or mental health workers 10 times. Fourteen responses included police and an equal number included some version of “not police.” Twelve participants emphasized the need for a quick response.

Sample responses on what makes people feel safe:

"Anyone who can stabilize the situation & deescalate & solve it."

"Come and talk to me in a friendly manner."

"Familiar face I get along with."

"Police presence makes me feel safe, also EMTs."

"Talk to me like a regular person, not a criminal."

“EMS and firefighters because they don't mess with nobody. They not trying to write you no ticket or trying to take you to jail. They show up ready to help.”

“For myself it definitely needs to be someone who has an understanding of long-term trauma and mental health. I feel safer if there is someone present who knows what they are dealing with. I'm not violent.”

“I feel safe anytime I don't have to talk to the police.”

“Mental health professionals and my case worker makes me feel safer. My case worker knows what to do for me and my psych doctor knows how to treat my Schizophrenia.”

Commentary on first responders

Quotes from survey participants as they described their experiences with first responders.

Homelessness and life on the street

“Usually it will be a white person who calls the police on me because they think I'm doing something wrong. Then the police show up and ask me what I’m doing. Usually I'm helping someone or doing yard work for people. When the police find out I'm not trespassing on the homeowner's property or breaking into their house or garage, we cool. The police apologize.”

“I don't feel safe around the police because they always coming up on me. They ask me if I'm okay, they ask me where I'm going. They ask me a bunch of questions. I don't even be calling them. What make me feel unsafe is that I'm their target. They don't stop the police car and bother nobody else.”

“I was standing outside of McDonalds asking people for change. They told me I couldn't do that because it was outside of a business. They just told me that I had to go or they would have to arrest me. So I left. They didn't help.”

“I was released from the hospital. I was tired because I couldn't sleep at all while I was in the psych unit. So I slept on the bench at the bus stop. Three transit cops woke me up and told me I couldn't sleep there. I told them what happened. They didn't help at all. They never do. They just tell you to go. I had nowhere to go to sleep.”

“There is nothing positive about my experience with the transit police. The bus driver be calling the transit police on me because I don't have no bus fare. How am I going to pay bus fare? I just got out of the joint. I'm homeless. I don't have nothing. I'm starting all over again. I tell the police this but they don't be listening. I tell them I'm hungry. They don't do nothing. All they do is tell me to get off the bus. They don't give me no bus pass, no food, no nothing.”

“I was walking in Lorain County and the North Ridgeville police told me I couldn't walk in their city. They took me to the #55 bus stop. I don't know why the police don't want me walking in their city…. Other polices stop me when I'm walking in their city and ask me where I'm going. I'm not a bad guy. I'm harmless. I'm not doing nothing.”

“Every time I dealt with the police it's the same things. You can't sleep here. You can't sit there. You can't ask people for money right here. I don't feel unsafe, I feel annoyed. The police just tell me what I can't do. I'm homeless I have nowhere to go.”

“I was sitting outside a public building. The police showed up and asked me what was I doing. I told him, ‘I was sitting here minding my own business.’ He said somebody called and said I seem suspicious. I think he was lying. I saw him drive by me and turn around. The one driving was doing the most talking, he just wanted to mess with me. The officer wasn't doing nothing, he was just standing there with his partner. After we had words, the police told me to leave.”

Physical health and safety

“This year the RTA bus got into an accident. The fire department came first and then the ambulance in timely fashion. They were responsive, courteous and helpful.”

“My friend had a seizure. I called 911 and the police and EMS showed up. It turned out positive.”

“Being sick is never a good feeling and you do get scared while you waiting for help because there is a chance you can die. I feel better when the fire department show up because they are paramedics too. They can help me until the EMS get there. The EMS show up and their job is to drive you to the hospital because they got the right truck. Seeing these people make me feel safe. Knowing that they taking me to the hospital makes me feel safer.”

“I was being physically and verbally assaulted. The police came out first and then the EMS to check me out. The police took my harasser to jail.”

“People like to mess with me because I'm homosexual, homosexual, homosexual. There has been plenty of times where groups of guys try to jump me or beat me up because of my sexual orientation and I call the police for protection. When the police show up they do their job but they are not that nice to me. Sometimes I feel like the police believe it is okay for people to harass me because I'm homosexual but they can't really say it.”

“I called the police for a domestic dispute because I felt unsafe. I called the police for help. They were supposed to make me feel safe but they didn't. They acted like I was the one who was wrong when I really wasn't. Then the police told me to leave my home.”

Mental health

“When the police or EMS show up, a friendly one will make me feel safe. Who don't feel safe when someone is being nice to them?”

“Because they were police officers I was immediately hostile and uncooperative. Eventually after an hour-long standoff they were able to initiate transport to a hospital.”

“There was a lack of communication between me and the police and a lack of understanding. I was trying to talk to them and they wasn't listening to me. It was like they didn't care what I was saying. Like I was the ‘crazy’ one with no sense. I didn't feel safe. I felt like they were not taking me seriously.”

“I didn't call 911 for me, I called it for a guy in the park who was having a mental health crisis. I was calling for EMS but the police showed up first. They wanted to arrest the guy because they thought he was high on drugs. I told them they guy had a mental illness. Then the fire truck showed up and the ambulance. The paramedics were nice but the police were nasty. Their attitudes needed to be adjusted.”

“First of all, I wasn't feeling good and even though I didn't want to do it, I called for the EMS. But what happen was they sent the EMS and the police. The police accused me of being high and I don't do drugs. I was already not feeling good then the police want to come out and mess with me. I never called the police, I called the EMS for help.”

Other comments

“The interaction with first responders wasn't negative, the situations itself was negative. In less than one year I've dealt with family issues, death and a suicide. It wasn't the first responders who made me feel unsafe, it was the situations I was in that made me feel unsafe. There was nothing first responders could do to make me feel safe.”

“I was alone in my apartment. Staff called the EMS. They came out along with the fire department and the police. The police found out they wasn't needed so they left. The EMS took me to the hospital. They were all nice and made me feel safe. Knowing that I was in good hands made me feel safe.”

“The interactions itself wasn't so bad but I didn't feel safe because I was dealing with the police. It's not easy dealing with people you don't trust and don't like.”

"They were rude, felt unsafe: had guns/tasers drawn for no reason."

Policymakers, service providers and advocates have an opportunity to improve public safety in Cleveland and Cuyahoga County by implementing a mobile care response pilot based on the non-police crisis response programs with a long track record of success and others being developed across the country.

Our August 2022 paper outlined ideas to fund this new approach that send people who are trained to provide compassion and support for people who are experiencing behavioral health crises, including housing insecurity.[10] This report begins to provide the perspective of people who are most directly impacted by emergency responders.

We recommend that policymakers, service providers and agency staff seeking to implement care response use the perspectives shared in this report and of other directly impacted people to plan what care response will look like in our communities. This survey provides guidance, for example, on what makes people feel safe when they are interacting with first responders and the kind of training community members think responders should have.

For non-police response to effectively address the needs of our communities in Cleveland and Cuyahoga County, the people like those who participated in this survey must help inform any program established here.

Policymakers and service providers working to establish care response in Cleveland must also:

Study well-established, successful programs in cities like Denver, Portland, Phoenix, and St. Petersburg, Florida, to understand how they built toward success by understanding the particular needs of their communities. Examine the best practices they used or developed in hiring, training, retention, operations, and data collection.

Investigate care response pilot programs in Cincinnati, Columbus and Dayton to further inform program building for Cleveland.

Identify intersections with the existing work and service populations of local care providers and others working in public safety.

Begin working to ensure that policymakers and service providers develop a deeper understanding and a trusting relationship with the communities they serve.

Expand the peer and behavioral health workforce in Cuyahoga County to ensure the long-term success of any care response program our communities choose to implement.

Reach out to the authors of this paper to be connected to contacts in the above-named cities and other resources on non-police care response.

Our goal with this survey is to understand the experiences of people who have frequent contact with crisis response programming or first responders who serve in Cuyahoga County, and how those experiences shape their opinions about the kind of crisis response that would best meet their needs in future interactions.

Survey administrators in active relationship with a segment of the community solicited feedback from individuals at locations across the county, providing small incentives for participants’ time.

This, the first phase of the survey, began in partnership with the Northeast Ohio Coalition for the Homeless in June 2022. Their Homeless Congress helped vet the content of the survey and three members of the Congress collected the survey responses.

Subsequent phases are underway, focused on people living with mental illness and/or substance use disorder, youth and people from historically marginalized neighborhoods that experience a disproportionate level of policing.

This methodology is based on a survey by Portland Street Response, the results of which are available here.[11]

This survey was designed primarily to offer open-ended questions that invite deeper responses than a survey with only multiple-choice or true/false questions could provide. Field interviewers spent 20-30 minutes on each conversation to draw out meaningful responses that would help inform changes to public safety response in Cuyahoga County. All information presented here is based on responses from 177 people, many of whom have experienced housing instability. Subsequent reporting is planned upon the completion of the next phases of our survey work.

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