In March 2021 “The American Rescue Plan Act of 2021” was signed into law. It contained an amendment to Title XIX of the Social Security Act to include federal Medicaid dollars for states to opt in to “Provide Qualifying Community-Based Mobile Crisis Intervention Services” (SEC. 1947) funding allocations specifically to increase or create community based multi-disciplinary mobile crisis intervention services. The original Bill proposed in 2019 was called the CAHOOTS Bill, named after Crisis Assistance Helping Out On The Streets, a long-standing program in Eugene Oregon and used as a model in numerous cities across the country in recent years. Simultaneously, Vermont organizations and residents had begun our own deeper reflections and advocacy regarding policies, practices and behaviors in line with the racial reckoning building momentum through the 2000’s and erupting into a more collective activism effort in the summer of 2020 following the murder of George Floyd, and the call to abolish or defund police (Greater Burlington BLM Movement, Burlington City Council approves reduction though attrition). Organizations and state agencies as well as the legislature increased its rigorous review and action to address systemic issues related to access and delivery practices across healthcare, including Substance Use Disorder and Mental Health, criminal justice practices, incarceration and policing. In 2017, the state legislature had called on national, and local, advocates, scholars, persons with lived experience and administrators to coalesce their collective wisdom to identify a path forward (Vision 2030) that includes respect for the inherent dignity and worth of each individual. In November of 2020 The Vera Institute for Justice issued findings after conducting an extensive review of data and case studies across the United States regarding the intersections of the justice system and people experiencing health crises. The Brookings Institute, also issued a report that same month titled, Innovative solutions to address the mental health crisis: Shifting away from police as first responders.

Champlain College’s Center for Community and Social Justice Fellow, in partnership with two student research assistants embarked on an effort of discovery using qualitative interviews and research to determine what efforts were already in place here in Vermont and the feasibility of a CAHOOTS model statewide. For clarity, it should be noted that when referring to health we are including both physical and emotional health. During the course of this research project for the Center for Community and Social Justice, we benefited from the generosity and honesty of participants in discussing their work, and this model with us and giving freely of their time. We are grateful, as well, to the many leaders, advocates, consumers and activists who are exploring justice and health equity practices in the state and working towards solutions.

The State of Vermont has a long history of identifying and responding to mental health needs in the communities using police, sheriffs (elected) and mental health professionals/outreach liaisons and peer support workers (NAMI-VT, Turning Point). The Vermont Department of Mental Health, issued a report in 2017 titled, “History of Vermont’s Public Mental Health”, shared with the State Legislature. It outlines the timeline of mental health services for children, families and adults dating from the late 1800’s until recently. It also highlights the evolution of a movement both into and out of institutionalized care, the changes in both philosophy and practice as well as delivery. Vermont has historically shared an ongoing co-existence of service delivery models that include the use of police and emergency responders in the delivery of care in the mental health system. This includes mental health transports to health facilities (including hospital emergency departments, the state hospital, hospital diversion programs, short term residential assessment beds, and addiction treatment) Law enforcement is also part of the system of care related to temporary protection orders, abuse and neglect cases (adult and children, ex. CPS, APS) and assaults (ex. CUSI). This community “reliance” is evident since the inception of care delivery, documented as far back as the 1800’s. At that time elected law enforcement roles intertwined with the sociologists, medical professionals and social workers addressing poverty and dislocation through Eugenics Study and boarding school placements. Vermont's own embedded history of response involved the targeting and criminalization of vulnerable populations, particularly those whose identities include indigenous, black and brown community members as well as intersecting marginalized identities. (See Eugenics apology 2021. Racial Justice Resolution 6/26/20 Burlington City Council, NAMIVT advocacy priorities 2021) Today the statute Title 33 is a legal partnership between child and protective services in response to a community concern. Similarly “welfare checks” often are relegated to police simply because they are a 24/7 delivery-of-service provider. Community providers and private citizens will ask law enforcement departments to respond, despite the fact there is often not a known safety concern(interviewees). Additional evidence of this reliance can be seen across Vermont where many healthcare/mental health communications currently state on their outgoing phone messages, websites etc. that if this is an emergency requiring immediate attention, dial 9-1-1. This further highlights the relationship with Emergency Dispatch services, situated in law enforcement settings, which have the challenging role as decision makers, to determine whether the nature of the call is medical/mental health, fire, violence, crime, imminent risk, or can be considered a non-emergent call. In July 2022, the National 9-8-8 system will go into effect, an emergency crisis line for mental health needs. This will potentially add additional community partners to the system of care through designated mental health agencies, as contracted dispatch centers. The underlying intention is aligned with the diversion philosophy of CAHOOTS. Vermont’s own practices of diversion can be found in Adult Drug Treatment and Mental Health Courts, Community Justice Centers, Peer Support Workers/Recovery Peer Support Specialists (mental health and substance use disorders) at emergency departments, and of course the older models of crisis hotlines such as for suicide prevention, intimate partner violence and sexual assault. The current system of care for mental/healthcare in Vermont is heavily strained due to challenges in attracting and retaining psychiatric care providers, clinicians (especially those who represent the BIPOC and/or bi-lingual identities, public and private clinicians and those trained to address co-occurring disorders. This has resulted in long waiting lists, delays in treatment protocols, and most concerning, people "giving up" on care seeking. Vermont Care Partners reports, as of "February(2021)... 364 adults were waiting 30-90 days for mental health services, and 190 children and youth were waiting 12-60 days."(WCAX.com) It is estimated that 1 in 5 people in the United States are living with a mental illness, and 1 in 4 people who are shot and killed by police have a mental health condition. (NAMI.org) Black and Hispanic people in the United States are killed at a disproportionately higher rate than Whites in police encounters. Accordingly, only one in three Black adults who need mental health care receive it. (NAMI.org) In 2017, the State of Vermont began a listening tour to learn about the needs of Vermonters from as many areas and perspectives as possible, as required by legislation passed in the statehouse(Act 82, Section 3(c) of the 2017 legislative session and as amended by Act 200, Section 9 of the 2018 legislative session). This led to the final report by the Department of Mental Health, issued in January 2020, outlining a plan for action based on concerns and challenges. The resulting investment in actionable changes will seek to address Access and Equity in Healthcare delivery, as noted in the Vision 2030 plan shared below on this site. The concerns of healthcare, police/safety, healthy environments, justice, economic stability are all intertwined, and considered part of the Social Determinants of Health. "Strong research evidence has revealed the multidirectional links between mental and physical health and illness. Thoughts, feelings and health behavior have a major impact on physical health status. Conversely, physical health status considerably influences mental health and well-being" (2008 WHO Mental Healthcare report) So although this research team sought to learn about a crisis team response what became clear is that the preventative care measures across the state, crisis support access during critical incidents and follow up care including health care infrastructure all impact who, how and when various team members have a role in responding to an emergency. And, as a rural state with limited healthcare access due to geographical challenges, transportation limitations and technology deserts, the model of 24/7 emergency response falls to police, and until we address the defunding of mental health care that began in the 70's and became increasingly depleted in the 1990's and beyond, we will engage the only 24/7, in person, legally obligated responders-police, for welfare checks, behavior escalations in children, adults with dementia, intimate partner conflicts, and behavioral concerns related to substance use disorder. A study by the advocacy group The Treatment Advocacy Center/Road Runners, found "the amount of time spent transporting people with mental illness by law enforcement agency survey respondents in 2017 sums to 165,295 hours, or more than 18 years. 21% of total law enforcement staff time was used to respond to and transport individuals with mental illness in 2017. This result is substantiated by remarks we've heard from interviewees and the report from the Vermont Human Rights Commission.

Across Vermont, leaders and frontline workers have been building alternative methods and integrating cross disciplinary responses to emergency mental health incidents for years. Southern, Central and Northeastern Vermont have cultivated these collaborative partnerships between designated mental health agencies and law enforcement, and the National Alliance of Mental Illness Vermont Chapter, and PathwaysVermont. In the most populace, Chittenden County, there are long standing contracted positions with Howard Center and local police departments. Additionally, law enforcement agencies including the Vermont State Police, local police departments and localized Sheriff departments have formed partnerships with community experts such as the Vermont Peer Service Organizations, Vermont is considered an 83% Rural state, using the definition per USDA. There are 237 towns, 14 Counties, and a little over 643,000 people. As is common in rural states there are localized responses based on the population, area of coverage, resource access, and funding. The result of these varied characteristics is that Vermont has a myriad of responses, some more formed and functional, and funded than others and this has bred both creativity and gaps, and even perhaps a sense that collaborative partnerships are a choice to be made by each county. The following is a list of roles and basic job descriptions for crisis responders.

• Dispatchers-"Civilian staff serve as call-takers and emergency communication dispatchers...to the citizens and visitors of Vermont. There are about 64 full-time and part-time call takers and emergency communication dispatchers who provide 24-hour-a-day emergency dispatching. The role of emergency communication dispatcher is critical to delivering quality emergency services in Vermont." (vsp.vermont.gov/dispatch)

• Crisis Intervention Team (CIT) -Members of the Crisis Team meet people in one of our offices, in a hospital Emergency Room, or in other appropriate settings in the community to provide crisis stabilization support, screen individuals for hospitalization or use of a crisis bed, or respond to a critical incident or disaster in the community. The integrated Crisis Team has psychiatric consultation available 24/7. (HCRS.org/crisis-services.php)

• EMS (Emergency Medical Services), "municipal based, private under municipal contract, private, or volunteer rescue squads or hospital based Advanced Life Support agency/providers whose sole purpose is to provide EMS to a municipality or group of municipalities.(a) BLS (Basic Life Support), an EMS agency providing a level of basic life support service to a community.(b) ALS (Advanced Life Support), advanced EMS provided by paramedics or EMTs with advanced training and who may not necessarily be part of a community’s BLS service".(e911.vermont.gov) "There are nearly 180 ambulance and first responder agencies in the state, and most of our nearly 3,000 licensed EMS personnel are volunteers.....providing emergency medical treatment and transportation of sick and injured patients." (healthvermont.gov)

• Vt State Police/Local Police/Sheriff-VSP "provides primary law enforcement services to approximately 200 towns, 90 percent of the land mass, and 50 percent of the population in Vermont." (VSP.Vermont.org). There are 14 elected Sheriffs, 56 Police Departments with a range of 3-91 officers at each locale. "Law enforcement officer" is defined as "a member of the Department of Public Safety who exercises law enforcement powers; a member of the State Police; a Capitol Police officer; a municipal police officer; a constable who exercises law enforcement powers; a motor vehicle inspector; an employee of the Department of Liquor and Lottery who exercises law enforcement powers; an investigator employed by the Secretary of State; a Board of Medical Practice investigator employed by the Department of Health; an investigator employed by the Attorney General or a State's Attorney; a fish and game warden; a sheriff; a deputy sheriff who exercises law enforcement powers; a railroad police officer commissioned pursuant to 5 V.S.A. chapter 68, subchapter 8; a police officer appointed to the University of Vermont's Department of Police Services; or the provost marshal or assistant provost marshal of the Vermont National Guard."(as defined by State Legislature). Police "prevent and respond to crime and disorder"(Interviewee). The individual expectations for the job description are lengthy, and an example can be found here at BurlingtonPD.

• Embedded Worker- A person who holds an undergraduate non-specific degree, is passionate about engaging in a crisis role and completes required training as a certified Qualified Crisis Responder (Title 18 of the Vermont Statutes Annotated,Section 7101(13). They are employed by a Designated Mental Health Agency and contracted by the police department to work for them which includes responding to calls with police and/or independently. The State Of Vermont has recently begun hiring for 10 Embedded Worker positions, 1 for each VSP barrack.

• Community Resource Officer (CRO): A civilian role (non sworn officer), responsibilities include responding to animal-related calls and non-criminal calls, parking issues, noise complaints, need to know more about this actual definition. (BPD as example)

• Crisis and Warm Lines: This includes private non profit hotlines, and support lines which may also receive funding by Department of Mental Health, Vt Network Against Domestic and Sexual Violence member organizations.

• Peer Recovery Coaches: "A Recovery Coach creates a partnership with people in recovery from addictions. A coach helps people to: create a vision for their recovery; identify and remove barriers to recovery; navigate through the human services system; access community resources; connect with recovery services, including treatment facilities, recovery centers, and mutual support groups" (Vermont Recovery Network)

• Peer Support Specialists: "People who have like experiences (who) can better relate and can consequently offer more authentic empathy and validation. It is also not uncommon for people with similar lived experiences to offer each other practical advice and suggestions for strategies that professionals may not offer or even know about."(mentalhealth.vermont.gov/services/peer-services)

• Community/Street Outreach Teams: "Outreach Specialists work in partnership with local and regional law enforcement to respond to individuals with unmet social service needs, often due to mental health or substance use issues." "The Street Outreach team works with individuals in the downtown Burlington Business District who have mental health, substance use, homelessness, and unmet social service needs. The team helps to coordinate services for those individuals, and the primary goal is to increase access to services for all individuals. A secondary goal is to address concerning behaviors that require immediate intervention but do not rise to the level of an emergency response. The Team works closely with service providers, police, and merchants to address behaviors that may impact the downtown area, stigmatize vulnerable populations, or put them at risk of losing access to resources or incurring criminal charges. (Howard.org)

• Community Affairs Liaison: "The Community Support Liaison (CSL) will be a trained professional focusing on services associated with homelessness, substance-use disorder, mental health, and persons with chronic service needs. The CLS will be an integral part of a team that uses timely and accurate information to implement effective tactics and strategies to reduce the need for a police officer’s response to calls for service that do not have an immediate public safety or criminal component." (BurlingtonPD job posting)

Additional collaborative roles include Special Units for Investigation(CUSI), and School Resource Officers (Winooski School District description) were not included in this review as they serve a select population, however they do offer important examples of collaborative partnerships between law enforcement and mental health/health services.

To become better informed on the issues surrounding this topic in Vermont and to prepare for interviewing we began by gathering Vermont Census information, fiscal and police county budgets, and identifying designated mental health agencies. We reviewed the Vermont Police Academy Certification, curriculum and training programs. As a team, we identified key stakeholders within each county designated mental health agency or hospital and law enforcement whether that was the Sheriff's, State Police and local law enforcement. We reviewed details about Eugene, Oregon CAHOOTS program and about the types of calls their team responds to within their community. This informed our development of interview questions for community responders here in Vermont.

We read about how to effectively conduct qualitative interviews and practiced using the data collection tool when interviewing each other, and then adjusted the tool and our styles as needed. We then determined which community stakeholders were essential to hear from regarding feasibility of this model and to learn more about initiatives underway. As qualitative interviewing was a new skill, we intentionally reached out to community experts we had some prior knowledge and potential for report, including previous instructors, job supervisors or personal connections who are employed as experts in the field. This accounted for the first 4 interviews.

Method:

We conducted qualitative interviews with professionals from all over Vermont to gain more perspective and gain information about what kinds of programs exist here in Vermont communities, and people's perspectives about this work. We used an IRB approved questionnaire, and process to ensure consistency in our lines of inquiry. Interviewees were identified by reviewing roles people held and also through recommendations made by other interviewees, as well as reviewing local news stories, attending conferences, listening to radio and podcast interviews and simply cold calling people in areas of the state where we wanted to learn more about practices in the region of the state.

We interviewed a total of 25 professionals and were intentional about reaching out to the people in all parts of Vermont, particularly focusing on outreach to the more rural parts of Vermont. Eleven were law enforcement personnel Eight program administrators, four mental health direct service staff, two emergency medical service providers, and two dispatchers. Each person was counted as one for the primary work they did, be it law enforcement, mental health, administrative personnel, medical response, or dispatch. It is important to note that almost everyone we interviewed brought experience, be it lived or professional, representing one or these disciplines or areas of focus (mental health, substance use disorder, law enforcement, medical training, military training, law, mediation, public health policy etc.). It should be noted that due to limitations of our study design to include interviews of those with lived experience, we intentionally pursued two opportunities through NAMI VT events in which people with lived experience on two panel discussions, discussed their interactions with responders in moments of crisis. (May and June 2021).

Interviews were conducted in teams of two, often the two research assistants, and at times with the Research Fellow. Most interviews were conducted virtually using Zoom, GoogleMeet, or landlines. Meetings were not recorded digitally, and instead note taking occurred on a google form, using confidentiality practices. On a few occasions, research assistants were able to meet at the office of the interviewee, or at the Champlain College library. Consent for participation was obtained at the start of every conversation, as per IRB protocol. Each meeting lasted approximately 1-1.5 hours.

The primary focus of each interview was to learn about individuals' experiences with collaboration, the types of needs each agency was being asked to respond to, and what some of the challenges they faced in the delivery of service in the community. In terms of collecting the data, we recorded the answers which we used to measure results.

A Sample of Questions:

• What type of training and or education did you receive or was required of you prior to taking this position?

• Have you received training in any of the topics on this list(read a list of concerns noted on the CAHOOTS site as common requests)? AND, Have you received training in any of the topics on this list?

• What other disciplines/professionals do you most often interact within your daily work?

• How does cross discipline collaboration occur currently when you're responding to a community need? (for example through post incident phone referral, paperwork generated automated inclusion of additional services, in real time hotline response, “dispatched” as team, etc.?)

• What has been helpful about those collaborations?

• What have been some of the challenges with those collaborations?

• How do you think a shared response between social workers, medics and law enforcement might impact how you deliver services?

• If Vermont leadership approached you today and asked how and where to use the American Cares Act mobile response team medicaid dollars(15 million), how would you like to see this money invested?

Common Themes:

Collaboration: Interviewee comments showed the simultaneous value of collaboration in sharing the work, and also the lack of consistent collaboration and communication with law enforcement, and mental health providers. Each agency was noted as physically or philosophically isolated in their own area of practice and there wasn’t much time, money or intentionality in conversations occurring between agencies which included not sharing of information or expertise. In locales where there are embedded workers, based in police departments, those reciprocal working relationships with the officers are stronger. They work together to respond to community needs with the embedded workers. Teams we heard from and panelists at two NAMI.org events (Ernie & Joe Crisis Cops panel, NAMI-VT Annual Conference) concurred. Frequent comments about collaboration included, “We need more street outreach teams”, “we are so lucky and glad to have a program like street outreach, I wish there were more members and more state-wide street outreach with 24/7 available”(Interviewee) “A lot of times someone with substance use disorders are dealing with other issues as well, maybe homeless shelters. Collaboration has been so helpful. Education is always at the core so we bring education around our mission about dismantling stigma. I have learned so much through community organizations so I don’t think we will ever be able to go without them, we cannot exist in silos because how can you support someone in a silo?” (Interviewee)

Role Clarification: Responders and administrators also noted the lack of role clarification between the agencies of law enforcement, mental health, paramedic, and more. Police balance their role to prevent and respond to crime, with social service needs including, welfare checks, Department of Children and Family interventions, and mental health concerns that intersect with safety, and domestic disturbances. “Sometimes people might feel like their toes are being stepped on, I might call a provider and they could be defensive because like I call to get information they think it looks like they aren’t doing their job. We try not to give off that vibe and it usually doesn’t mean we can’t fulfill their duties.” (Interviewee). One consideration we heard often was that "it has to be the right person, to do this work", and they have to be adaptable to workplace cultures. This mirrors what is be echoed by both protesters, mental health responders and law enforcement across the United States. This goodness of fit seems correlated to a teaming mindset in which role clarification is key. For one person to trust, another there must be a sense of reliability, respect and understanding of what each person brings to the scene in terms of skills.

Financial Constraints: Providers and administrators alike expressed concerns related to budgeting and funding. Comments around lack of workforce due to low wages, large caseloads, large geographic coverage areas, and strained community relationships to pass municipal and statewide budgets. Our interviewees, across disciplines, shared how challenging it is to deliver care with restricted budget hours. One of the interviewees said “the more is better” when it comes to having resources to collaborate, and ideally prevent critical incident calls. “I go to work everyday trying to keep my community safe”(Interviewee) Another shared how calls related to mental health are very high and very complicated to address. Vermont no longer has a public psychiatric care hospital. This “revolving door” in emergency departments means that many people have an interaction, the need is unmet or service is unwanted and “we see them again the next day”.(interviewee). Another stated, “We (referring to police) don’t need more money, don’t give more money to us”, invest it in the social services that are lacking. (Interviewee) Others noted they are grant or annually funded-or-not and this precarious funding impacts service delivery. EMT's/EMS/Paramedics service providers are largely notably isolated from the discussions about collaborations in a formal sense and also report being underfunded. Many run deficits of 1 million dollars while trying to serve large swaths of Vermonters who live in rural areas.In one striking example shared by an interviewee, “we are only paid when someone accepts a transport to a hospital. If we provide care to someone for a diabetic episode, substance use disorder medical need, car accident, or other physical crisis” on scene and they refuse transport for follow-up care then we do not get paid for any of the services rendered.(Interviewee). This results in deficits when ambulance service and EMT/EMS/Paramedic care is an essential community service but insurance does not pay. Two respondents shared their concerns over cost, noting they didn’t particularly like the CAHOOTS model stating issues with expense and that the police department already has similar programs, and Vermont will have a different model while sharing consistent philosophy with CAHOOTS.

Training:

Interviewees shared they receive limited mental health training as that is not their area of focus, their primary training even then is focused on de-escalation and not trauma informed interactions or best ways to approach people experiencing a crisis. Many report learning this as they go through their careers.(Interviewees) “To start, I would like to see much more sensitive trauma training, involving more places for conversation for certain issues and experiences.” (Interviewee) and “We are in difficult times, it is easy to alienate one group of people but we need to come together and have the conversation. Sometimes people don’t see what people go through because they are not in their shoes. People often forget that the first responder responds to many unexpected risks, and trauma.”(Interviewee) In fact, Almost every interviewee said “more resources” in terms of mental health services, more money invested in social services and to have more programs such as street outreach teams. “There are situations where there can be diversions (to mental health), it doesn’t need to get to that criminal level.” (Interviewee) “So much is saved... police time, the person isn’t written up as a criminal”(Interviewee)

The concerns of healthcare, police/safety, healthy environments, equity, justice, economic stability are all intertwined(WHO2008), and considered part of the Social Determinants of Health. So, although this research team sought to learn about a crisis team response, what became clear is that the preventative care measures across the state, crisis support access during critical incidents and follow up care including health care infrastructure all impact who, how and when various team members have a role in responding to emergencies. And, as a rural state with limited healthcare access due to geographical challenges, transportation limitations and technology deserts, the model of 24/7 emergency response falls to police, and until we readdress the defunding of mental health care that began in the 70's and became increasingly depleted in the 1990's and beyond, community practices will rely of the only full time 24/7 in person responders-police, for welfare checks, behavior escalations in children, adults with dementia, intimate partner conflicts, and behavioral concerns related to substance use disorder.

Currently, there are innovative efforts underway to respond to Vermonters in their time of need. Additionally, providers of care are developing ways to better prepare, train, reflect and collect data on what is working, how to best deliver services, and to host collaborative conversations. These efforts to plan, deliver and reflect are critical for adapting services across Vermont to incorporate the lived experiences, feedback and collective wisdom of our healthcare safety net. Statewide, several organizations are advancing these efforts, PathwaysVT, Team Two, NAMI VT in particular are offering interdisciplinary training, community conversations and events that address the intersection of everyone's various roles in responding to a community member in crisis. In report after report the recognition that Health Care and Mental Healthcare are interwoven needs, is strongly evidenced.

Promising initiatives to embed mental health responders, and substance use disorder responders at points of contact in medical settings, on the streets, and in our homes are evidenced in pockets across the state. Washington and Franklin County have embraced a collaborative model, using embedded workers in law enforcement and hospital settings. Chittenden County's designated mental health agency, has recently expanded the Community Outreach Specialist Program, to multiple towns, working in and closely with law enforcement teams. The State of Vermont Department of Health has created a Health Equity Initiative to address access barriers. Vermont's Department of Mental Health has created it's road map (Vision 2030) to rebuild infrastructure necessary to prevent, divert, and provide care that is timely, person-centered, community-based and affordable.

Teaming

A common theme heard from the law enforcement professionals interviewed for this project is evidenced in this quote, "we want mental health to respond or come with us, and when we call them up they say, we don't have anybody right now"(interviewee). Mental health professionals consistently echoed sentiments in this quote, "one of the things that really important is that you should respond quickly but that has to be factored with getting enough information before you go out there, that can be fatal."(interviewee) "I don't get extensive safety training from the mental health agency" (interviewee) In fact, in learning about the system of care in Vermont, it seems most teams of responders, mental health, law enforcement, paramedics/EMT's, peer support specialists are all "making do" with limited human capital, siloed training focus and a depleted infrastructure to distribute follow-up care options. As is common in rural states, people wear many hats. The National Institute for Health hosted a discussion about the issue of mental health services in rural settings, and one expert stated "there needs to be no wrong door". Dispatchers for 9-1-1 stand ready at this door open for communities, and in July 2022, 9-8-8 will also become an active emergency number specifically for mental health concerns. In 2020, Dispatchers responded to 209,990 calls across Vermont. As one first responder stated, "the after study never really represents the whole story because we have to protect people's privacy-the public never hears the authentic story", and "the good news is quiet because of HIPPA and confidentiality".(interviewee) Dispatchers will need various "doors'' to divert consumers, and to direct emergency responders as they prepare and arrive on scene. Financially investing in this care network is how the system can effectively, and collaboratively respond to non-criminal calls to law enforcement, as has been stated in the Vision 2030 report. The use of stats offered by CAHOOTS type intervention models is that 10% or less of calls are diverted, and does not effectively reflect what we heard across Vermont about the complexity of 9-1-1 calls. In fact many calls do not outwardly state a mental health crisis however, after arriving on scene, law enforcement responders find components clearly evident, as do dispatchers, who stay on calls until help arrives, and who have to pivot as a full story emerges and they activate all necessary responders. Interviewees told several stories about how arriving on scene it became clear that the description of need described on the initial 9-1-1 call was limited. Reflections by mental health responders noted there were times when safety risks meant they could not intervene until police became involved. From the police perspective, upon arriving on scene, it was clear the issue included a mental health component. In a rural state like VT, it is the embedded worker model that seems to be gaining momentum. This model received positive reviews from many of the stakeholders we heard from. Mental Health workers work within police units and respond to calls with police. In Vermont this is now in place in Franklin, Washington and Chittenden Counties to various degrees. Soon, all 10 Vermont State Police barracks will contract with their designated mental health agencies for an embedded mental health worker. Those we spoke to about these partnerships say the need is evident for a 24/7 model, and right now it's a 5 day-week, 40 hour-week model. Benefits named included, clarity of roles, shared expertise, critical incident processing, skill sharing and a more effective intervention/result for the community members. Interviewees and panel experts (community events attended during this study), shared the complexity of calls for help and resulting action steps. They stated how training and collaboration impacted the success of the intervention, supported follow-up contacts, and positively impacted appropriate use of services, (i.e.support call vs. crime to report). Alternative crisis diversion and response teams such as the Street and Community Outreach Teams, are contracted by local municipalities (Burlington, South Burlington, Shelburne, Winooski, Williston, Colchester, Essex, Hinesburg, Milton, and Richmond) with the goal of reducing law enforcement involvement and increase collaboration as needed, for the best possible outcomes. Broader community needs addressed include the physical and emotional needs for those who are unhoused, noise complaints between neighbors, mental health issues and non-criminal disturbances.

Training

Many law enforcement interviewees reflected that simply their "presence could cause an inflammatory response and escalate the situation".(interviewee) Scholars such as Dr Joy Degruy and Resmaa Menakem, educate about the potential for embodied trauma responses in relation to contact with others, and the necessary self work, for all professionals and individuals in the processing of experiences. Sonny Provetto, Director of the Vt Center for Responder Wellness, created a center specifically to address the need for trauma healing for police, fire, and rescue, and in this youtube podcast, tells the story of how this benefits the worker and thus the larger community. In 2015, The Cambridge Massachusetts police department and city developed a guide titled Guide For A Trauma-Informed Law Enforcement Initiative, and began implementing the practices in 2016. Their reasoning follows:

"First, police are often in situations where they, themselves, experience trauma. Their professional training has not, traditionally, given them adequate tools to manage their own reactions and feelings during and following traumatic incidents. The result is high rates of depression (Wang et al., 2010), post-traumatic stress disorder (PTSD; Marmar et al., 2006), alcohol use disorders (Leino et al., 2011) and suicide (Miller, 2006). Second, police are frequently responding to individuals who are experiencing trauma; examples include victims of street violence, domestic violence and sexual assault. Without some understanding of how trauma affects perception and memory, officers are likely to inadvertently re-traumatize those who look to them for help. In Cambridge, the transition to becoming trauma-informed started in the early-mid 2010s through various training initiatives that focused on mental health, vulnerable populations, and de-escalation. The trauma-training initiative grew from there. Third, the communities most likely to be the focus of community policing are also the communities which, themselves, may have suffered or are suffering trauma due to economic and racial injustices, police brutality and/or other recent events." (Guide For A Trauma Informed Law Enforcement Initiative)

When asked about areas of expertise of the interviewees who are first responders, we found extensive examples of interdisciplinary backgrounds in their educational, training and job roles prior to serving as emergency responders. In fact, many interviewees stated how fundamental this was to their capacity to engage in cross-disciplinary work effectively and bring different perspectives beyond the training they received for their current role. Administrative guidance, regulatory management and training expectations for the various roles are set by, Office of Professional Regulation and Department of Mental Health (mental health, Peer Recovery Coaches, Peer Support Specialists), Criminal Justice Council and Department of Public Safety (law enforcement, dispatch, sheriffs), Vt Department of Health (EMT's/EMS/Paramedics).

One noted area of strain is who should do what, when and how. Moments of crisis are not the time to have to sort this out. Interviewees shared several examples of when there were disagreements in the moment related to those questions. Thus training together, case studies, running scenarios, regular meetings in which stakeholders come together and review and reflect is essential and missing from most of the professionals ongoing instruction and training. Across the interviews we heard again and again about the constraints of time, workforce and opportunity to come together. The planning and reflecting happened best when people were on their way to and from a critical incident scene, in between calls in dispatchers offices, in conversations in large work rooms among colleagues, and when people with lived experiences were able to meet ahead of a crisis and formulate a plan, or give feedback after an event. What again is missing is the time all together. Team Two and CommStat/SubStat have been two highlighted examples of this work mentioned many times by interviewees as a positive opportunity to "come together" with dispatch, police, mental health, and those with lived experiences to work through case scenarios and better understand each person's role, legal limitations/obligations skills, strengths and perspectives. Unfortunately, Team Two is often attended only ONE TIME in a person's career post academy or new worker training, and Compstat/Substat, after changing facilitation to department of health, meets less often, and has spotty regional attendance with the stated reason of workforce deficits. Training together provides opportunities for each to become aware of the capacities, restrictions and possibilities each role brings to a critical incident in the community. In several instances, both mental health responders and law enforcement professionals reported stories about how a vehicle accident, overdose death, death by suicide, intimate partner violence or mass casualty scenes became a time for trauma informed interactions, both in terms of the investigation process, death notification, and follow-up processing of the event. Again, leaders have substantiated the need for healing necessary to sustain and be effective, practice with humility and without biases in crisis work. This is supported in research as well. (Samhsa.gov) Secondary benefits of training and working alongside one another may be increased skill building, establishing safety protocols (issue named by interviewees), accountability to one another and the community individuals being served for respectful, supportive and just outcomes. In fact, many interviewees across roles shared how much they have learned from one another in terms of new skills, which has led to more effective, safe and lasting outcomes in terms of all participants' well-being. Thoughts of "we wish" we had more time to go to training and learn with each other, but we just don't have the resources to take time away or pay workers was heard from both mental health and law enforcement responders. One team stated they had an "epiphany" when we asked them about training, that they would carve out time in their local on site training to talk about mental health needs, using the expertise of an embedded worker from a mental health agency. Another said, I wish (meeting) was still happening, it was really helpful, I think I'll ask about that again". (Interviewee) In reaching out to some of the coordinators about meetings and trainings, many stated "that's a good idea, we could probably include "them" in that training"(interviewee), in response to questions about including other disciplines in their comprehensive trainings.

Delivery

This initial review of Vermont's methods, intricate system of care, dispersed service delivery model cannot be fully understood in it's whole in this brief glimpse conducted from March-June 2021. What is clear though is that like the Vermont Emergency Management Plan, which "ensures the people and communities of Vermont have the capabilities to prevent, protect, mitigate, respond to, and recover from natural and man-made threats and hazards in order to enhance the safety, quality of life, and economic vitality of the State and its citizens.", we need a similar shared training and collaboration protocol to provide regular coordinated opportunities to prepare to respond to the health complexities unique to our state. Team building requires knowledge, perspective and respect and this can be fostered with regular, intentional connections outside the moments of crisis. As money gets re-allocated away from police budget lines into public care and safety roles, it will take care to restructure teams and define roles. These training opportunities can nurture these partnerships. Team Two travels the state, and if expanded could offer refreshers each year with new case scenarios. The Coordinator of the program has built a network of training partners who work in cross sectional positions in the state. Monies could be saved from police budget lines where travel and day long training eat away at overtime. Another option would be to address this issue as the public health crisis that it is, and host the training under the umbrella of the Department of Public Safety and Department of Mental Health. Other options would be for partner organizations to open up attendance to conferences and workshops more regularly at low cost to "interested partners'' outside the discipline. An example of this practice is Mental Health First Aid. Train the trainers often have historically opened slots and reached out to community partners to fill extra seats, and now has a virtual option, As the forward thinking, community centered system of care we seek to be according to the Vision 2030, we will need to bring our partners along to think about inclusionary practices that reduce barriers to new knowledge and skill building.

American Psychological Association Feb., 24, 2014 - "Black Boys Viewed as Older, Less Innocent Than Whites, Research Finds"

Burlington Police Department "Your Burlington Police Department" (PowerPoint June 26, 2020)

Brattleboro Report "Final Report on the Community Safety Review Process" (December 31, 2020)

Brookings Institute - "Innovative solutions to address the mental health crisis: Shifting away from police as first-responders" November 23, 2020) and "How the-American Rescue Plan Act will help cities replace police with trained crisis teams for mental health emergencies" (June 22, 2021)

Cambridge Massachusetts Guide for a Trauma Informed Law Enforcement InitiativePDF

Cahoots Campaign - Mental Health First BTV (began by Robin Freedner-Macguire)

Ernie & Joe: Crisis Cops hosted by NAMI VT

Human Rights Commission newsletter 2016-"When Did Prisons Become Acceptable Mental Healthcare Facilities?"

Montpelier Police Department PowerPoint (undated-2020 data)"Crisis Intervention Team (CIT) Program Montpelier and Washington County"

National Alliance for Mentally Illness - Crisis Response

Substance Abuse and Mental Health Services Administration (SAMHSA-U.S. Department of Health and Human Services) Crisis Services- "Meeting Needs, Saving Lives 2020"

The Treatment Advocacy Center-May 2019 "Road Runners: The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental Illness"

The Vera Institute: "Behavioral Health Crisis Alternatives: Shifting From Police to Community Responses"

United States Census Bureau: Vermont Quick Facts

UMass Amherst Special Collections "Justice for Woody"

Vermont Care Partners - Team Two (see newsletter for "Good News)

Vermont Criminal Justice Council - About the Criminal Justice Council and Vermont State Police Academy Basic Training

Vermont Department of Public Safety - Vermont Emergency Management Training Exercises

Vermont Department of Public Safety - Vermont State Police Academy

Vermont Department of Mental Health - Vision 2030: A Ten Year Plan for an Integrated and Holistic System of Care 1/28/2020

Agency of Human Services-Department of Mental Health- Vermont Peer Service Organizations

Washington Post - Fatal Force

WCAX video Northfield Standoff ends peacefully