Emergency response to a mental health crisis

When someone is in the midst of a mental health crisis they need something other than police or fire departments to arrive on the scene. That's why some cities offer mobile crisis teams and short-term stabilization as an alternative to jails and emergency departments. Learn how the emergency response to mental health crises is evolving and what it feels like to be in crisis.

This episode does discuss suicide attempts. If you need support right now, you can call the National Suicide Prevention Lifeline at 1-800-273-8255. They are there to listen.

Transcript

[00:00:00] Anne: Welcome to Mental Health Mosaics from Out North, an arts non-profit located in Anchorage, Alaska on the unceded traditional lands of the Dena'ina People. I'm Anne Hillman.

In the United States, one of the first things we're taught to do in case of an emergency is to call 9-1-1. But there's a problem -- if you're in the midst of a mental health crisis, 9-1-1 can't always provide the help you need and there aren't many other options. 

I spoke about the need for better crisis response resources with Katie Baldwin Johnson, the Chief Operating Officer at the Alaska Mental Health Trust. Katie says that response to a mental health crisis shouldn't default to uniformed police officers. 

[00:00:46] Katie: individuals that experience a mental health crisis Often don't have the services and the resources in the community to best respond to those individuals in a way that doesn't require a uniform law enforcement officer, uh, to be a part of that equation in some way And also, doesn't require an over-reliance upon our hospitals in our emergency rooms, as the primary place for people to get help. And that dynamic is exactly what Alaska has been facing and still is facing currently. 

[00:01:23] Anne: Johnson says involving police at the scene of a mental health crisis has another effect as well.

[00:01:30] Katie: I think the other piece to that is that, um, it creates that stigmatization, basically, putting a mental health crisis or somebody that's experiencing that situation, uh, into a criminalized perspective. 

[00:01:47] Anne: And just a note upfront -- the Mental Health Trust provided Mental Health Mosaics with a grant to support its development. But the Trust has no editorial input on our programming. 

Katie will be back later in the show to talk about Crisis Now, a new mental health crisis response model that's taking root in Alaska and other parts of the U.S. In many places, it's already creating better outcomes for people facing a mental health crisis. 

If you've never been in crisis, it might be hard to imagine why the existing system can be so harmful. Hearing from Ta-tok might help you understand a bit better. Please note that Ta-tok's story does touch on suicide and self-harm.

[00:02:34] Tatauq: my name is Tatauq Helena Muma. Um, I'm from here in Anchorage. Um, traveled a little bit, but Anchorage is definitely my home.

[00:02:47] Anne: Tatuaq is a mother and a grandmother and loves creative outlets like singing, crotcheting, and playing musical insturments. Tataq has experienced a great deal of past trauma and grief, and bouts of serious mental illness. She attempted suicide 15 times over about 20 years. Each time was triggered by something different. Some of her suicide attempts were planned in advance, others weren't. The one thread that runs through her those experiences is that they were fed by complicated, conflicting emotions.

[00:03:19] Tatauq: Maybe it was like, I was holding in a lot of pain, but it's a lot more than that too. 

there's a lot of things I just can't talk about. You know, it's like that the shame and the guilt that goes with it, and you know, you hold these things down and stuff from down and go in circles with this, and then you have like, people that take it and just like dismiss it and act like it's not there.

Um, and then feed into it as well. And it just feels like. Everything that happened. And the trauma itself could have been lost as well during this moment. 

You start feeling a loss of control, you know, it's more than just an explosion. Cause I, I feel that, but it's feeling overwhelmed and trying to get words out that you can't, and it just, um, it just goes everywhere 

[00:04:07] Anne: from what you're describing is almost like there's so much happening and so much happening in your mind that you're almost like weighed down. But at the exact same time you feel like you're going to explode? 

[00:04:17] Tatauq: Yes. All the above. 

[00:04:19] Anne: Okay. 

[00:04:20] Tatauq: Everything, all the above. Um, and it just has no where to go. Um, and sometimes, it came out in rage at times and other times it didn't, um, it came out in tears.

Tatauq says she remembers feeling like when the police have shown up, they didn't always see that she was in crisis or listen to her. And because she was having trouble communicating about the situation, she struggled to explain what was happening to her emotionally, too. She felt like they only saw other parts of what was happening, like potential domestic violence.

and I'm sitting there suffering, I'm sitting here wondering what's going on. And, you know, everything that I had was being denied, you know, um, if I get, if I need, uh, you know, medical care, they'll let the ambulance know. Uh, so I can be taken care of.

Um, but they, you know, do what they can to ask me questions, but. I've gotten to the point where, when they asked me these questions, it gets me nowhere. Um, and sometimes, you know, and when I'm talking to people about it now, it's like, you know, you can ask for a chaplain if you need it in a, like, I know I can ask for one, but I'm also not being offered a chaplain either.

And, um, these things that I know, I don't think of when I'm in crisis and you know, these could be offered to me. Um, We have the services, but I'm sitting here left alone, trying to figure out what to do and I can't explain it to them sometimes. And it's, it comes out in anger a lot more than anything.

Cause, um, you know, I've gone through it so many times and it's just like, nobody wants to listen. It's just like, you're here to do something and pass me off, you know? And then I can go to the next person and it's like, that's not what I want. I need to be tended right now during this environment that I'm in.

Not being taken care of. So yeah. 

[00:06:19] Anne: Tatuaq says that when she's in crisis and things feel chaotic, she really just needs a safe place to talk, far from violence. And far from people making assumptions and judgements about her. But that's impossible for her to explain in the moment of crisis.

[00:06:37] Tatauq: maybe if I harmed myself or something and telling somebody, you know, and it I'm scared, you know, they're going to take my rights away, you know? So why would I tell somebody something when it's, I it's already going to do more harm than good?

It's like, we're adding trauma on top of trauma after that. 

[00:06:55] Anne: Tatauq says that she was involuntarily committed to psychiatric wards in the past and was forced to take medications she didn't want. She doesn't want that to happen again, so tries to tell people what she needs while also limiting how much she shares. It sometimes makes the problems worse.

[00:07:15] Tatauq: We shouldn't be scared of, you know, telling these people that, Hey, a harm myself and I need help and I shouldn't be ridiculed or, you know, or dismissed or denied or act like I'm not there because people talk around me. Like I'm not there. And it's like, hello. Um, I'm looking at the people, there are no psych, what about me? And then I lose all the decisions and everything that happens. Um, and you know, it makes me feel that much smaller. Um, and that, I don't matter in these moments and, you know, you lose your voice. And you sit there and left and your thoughts, um, while they make the decisions for you. 

[00:07:57] Anne: So you feel like, you feel like you're completely not heard, like you're almost invisible even though it's supposed to be about you. 

[00:08:05] Tatauq: Exactly. 

[00:08:06] Anne: And like, you don't have control over decisions that are being made about you. 

[00:08:11] Tatauq: Correct. 

[00:08:12] Anne: And this is how you feel when. When you're in crisis in general or when like emergency responders show up because you're in crisis?

[00:08:21] Tatauq: Yes. I think all the above, um, in any kind of crisis, I mean, um, just even taking the time to stop, to see what we can do some times doesn't seem like it's enough when things keep going on and on. And I'm just like, what do you do about it besides. Go emotional. I guess the best I can put it. I don't know how else to put it.

Go crazy, go emotional and just let everything out all at once is how I feel. It's what I would put it. 

[00:08:49] Anne: That's a good way of putting it because you just, I mean, you could only hold on for so long, right. Or hold, hold in for so long. 

[00:08:57] Tatauq: Yeah. That's pretty much it. Um, that's kind of where everything gets stuffed down and then kind of go around in circles with this.

[00:09:05] Anne: In the past, when you've been in crisis, have you ended up at an emergency room before?

[00:09:12] Tatauq: I've had friends take me in, I've had the ambulance called on me. Um, so it's just been different ways. Yes. Um, ambulance doesn't show up first usually. It's very rare. Um, and if they do, they usually are not equipped, um, to help me.

Um, so they're kind of lost if they'd come to show up first. Um, and they've told me that, so, um, they usually wait for somebody to come. It kind of makes it feel awkward while they sit there and wait. So it's like now what? And so like it depends if I've harmed myself, if they give me the care that I need or if I don't.

[00:09:57] Anne: Tatauq says there was one experience with a police officer who really helped her and treated her like a whole person.

[00:10:05] Tatauq: I will say, like you say, um, I did have an officer, a lady who did, um, when she took me into the hospital, um, She heard my bullshit and she said, you know what? I just want to listen to you. And she sat there and said, what's going on? And she got down to the bottom of it and she, cause I know you really need help. And she goes, you know, this is what I can do. And she took me in and I know I was detained, but once she took the handcuffs off of me, she actually gave me a hug and she did us in front of everybody there.

And it just. 

We need more of that. We really need more of that because just the way she made me feel was like no other, um, when she did that, like you said, it was like the first time I was heard and I felt like was the only time, but I hold on to these kinds of moments too, more than people think so. Yeah.

I'm telling you that that day made a difference. Really made a difference that day.

[00:11:18] Anne: Tatauq is tired of feeling alone because of her mental health issues. She's speaking up about these topics to show what she's overcoming. She doesn't want people to feel sorry for her. She wants them to advocate for systems change.

She says what would really help her in the long-term to break the cycle of crisis after crisis is having folks who check in on her regularly and in-person after the immediate crisis is over. Someone who can help her navigate local resources and help advocate for her. She needs what is starting to be provided through things like the mobile crisis teams and the Crisis Now model.

Crisis Now brings together mental health crisis management solutions that have worked in communities across the United States. It's framed around the idea of meeting people where they are at and providing the right type of care immediately. For most people, they really just need to be listened to and connected to resources. 

The Crisis Now model includes both telephone support, like crisis lines, and in-person support from people who are trained to deal with mental health issues and de-escalate crises. 

In Alaska, there's always someone available to listen through the Careline, which is based in Fairbanks. The people there understand the challenges Alaskans face and know how to help. They will listen and connect you to local resources if you need them. Their number is 1-877-266-4357. And if it's after July 16, 2022, no matter where you are in the US, you only have to call 9-8-8 to connect to a local crisis line. 

Statistics show that for about 90 percent of the people who call a crisis line, that support is enough for dealing with the immediate issues. For others, they need someone to arrive in person. That's where the mobile crisis teams come in.

Problematically for Alaska and other rural places, the teams are mostly in urban areas. Logistically it's too hard to have them in really small communities. But it's clear that mobile crisis response teams are effective. There have been these types of programs in Arizona, Oregon, and Georgia for decades. They decrease the strain on emergency response systems and connect people in crisis with the care they need in that moment--and after. They launched in Fairbanks and in Anchorage in 2021.

In Fairbanks, mobile crisis teams include mental health clinicians and peer support providers, who are people who have faced their own mental health issues and have had to navigate local networks of support providers. 

Kerry Phillips is one of the peers who works for The Bridge and she also answers calls at the Careline. Before that she had worked as a 9-1-1 dispatcher. We spoke in late 2021, about a month after the mobile crisis team started responding to calls.

[00:14:24] Kerry: I am Kerry phillips and I am the team lead for the mobile crisis team in Fairbanks, responding, to call outs from our nine 11 center for people that are in any type of crisis, either with law enforcement and fire department, or just with myself as a peer and with the clinician.

[00:14:44] Anne: What is this whole process like? Like what is it from start to end? 

[00:14:49] Kerry: Um, so it kind of depends, like every call is going to be unique. Um, I guess for me, it's a little bit different because I worked for a nine 11 service for 11 years, and then I've also worked for the state suicide hotline at Careline.

And so I've done this over the phone for years. And so doing it in person is just really not that much different other than you have more of a connection. Um, I think you can do a little bit more. And I think sometimes when somebody is going through a mental health crisis, no matter what it is, um, having somebody there to be able to validate their feelings and to empathize with them, I think it's just another, a better.

At better step up for them, you know, trying to keep them out of jail or out of the hospital, which nine times out of 10 doesn't really do anything for them except make the problem worse. 

[00:15:46] Anne: So can you talk about like, what this is like from your perspective is someone who's worked with nine one, one, like when a call comes into nine one, one, how do you know if, if they just need peer support and a clinician versus if they need something

else.

[00:16:01] Kerry: So. For me, it's kind of a, um, a gut instinct. If they're not violent, um, if they're not actively suicidal to where they have a plan and they have the means, like they've got a gun in their hand, um, you know, and they've locked themselves in a room we've gone on a call like that. Um, but obviously law enforcement was present.

Um, you know, um, if somebody calls in and is just very lonely and is thinking about suicide and they're not fighting. They have no known weapons than sending a peer. And a clinician is going to be a little bit better than sending a pair of clinician in the police department because when the police department shows up that usually escalates, you know, no fault to them, but when a man shows up or a woman shows up in uniform and you're having a mental health crisis, it usually escalates it a lot more than it should.

[00:16:51] Anne: Have you been there?

[00:16:53] Kerry: I just know from, um, the 9 1, 1 side of thing or the Careline center thing, um, a lot of people know that we're mandated reporters. And if you, if there's an imminent harm to yourself or to other. We have to call law enforcement. And a lot of people don't like that.

And if it's going to piss the caller off more, if I'm talking to them at the Careline, I don't even tell him I'm sending law enforcement. So I can at least keep them on the phone and keep them where they're at until law enforcement can arrive. , and it's usually just cause they one, because they're going through a mental health crisis or two, because they've just had a bad experience with the police department before, you know, so it's, it's a little different.

I think every 9 1, 1 dispatcher would, you could give them all the same call and some would respond to it by sending out, just appear in clinician and some would be on the safer side and send peer clinician and fire department. It's just kind of a, it's a judgment call. I mean, a lot of nine 11 is it is a judgment call.

There's a lot of discretion. 

You had to listen to your gut and it was always, you know, when in doubt, send them out.

[00:18:01] Anne: Kerry says that when the mobile crisis team receives a call, they often get a little of bit history about the caller if it's available. That helps them know when it's safe to go by themselves or when it's good to have others on the scene with them. Her team has also spent time explaining what they do to the police department, so they know when to reach out.

We've gone to a couple of roll calls with the police department for the guys on the street to let them know, Hey, this is why we're here. This is what we do. And they've asked me that. Well, they're like, well, if we know we have to take someone to the hospital, do we still call you guys? Well, yeah, I would because if you call us and we're able to calm them down and commit them to safety, then you don't have to take them to the hospital.

[00:18:51] Kerry: There's been a couple of times we've helped people just over the phone. Like there's a lot of people that kind of call 9 1, 1, um, on a regular basis for. Um, not 9 1, 1 related things. They should not be tying up a nine 11 line for it. And so that's where we can kind of step in.

And instead of them calling nine 11, they could call us and we could talk to them on their phone or they could call the Careline. Some people still don't know about the Careline. 

[00:19:20] Anne: Kerry says she also explains to police officers that they are there to help the entire emergency response system be more effective.

[00:19:29] Kerry: Our number one goal obviously, is to help people. We want to be able to get them to the services that they need, you know, to become healthy, productive members of society and whatever way that looks good for them. And then number two is to help take a load off of you guys. Cause you aren't clinicians, you aren't mental health responders. And you know, as much as I know that you show up on a scene in uniform with a gun on your hip, that's going to escalate the scene nine times out of 10. So we want to make it less stressful or less busier or less annoying for nine 11 for the fire department for the police department. Because we don't have a lot of police officers either. We are very short staffed.

Another major role of the mobilc crisis team is to provide long-term support for people. Mental health crises aren't one-and-done events. 

So we don't just go and see them the one time out in the community and that's it. We do follow up and make sure we can connect them to services.

Make sure they have a ride. So the person on followup, that's all they do, whether they go to the person's residence or meet them where they're at or if they just talk to him over the phone, we don't just see him the one time say, Hey, these are the people that can help you in this, drop it. Cause it's not going to do any good. And I'm sure that's what people have done to them their entire life when it's come to stuff like this. 

[00:20:43] Anne: As Kerry and I were talking, she received a call. She immediately grabbed her purse and an iPad that she'd use to write down information about the situation once she arrived on scene. Then she headed downstairs to wait for the mental health clinician. She was wearing everyday clothes and looked like a person you'd see at the grocery store. Her presence was calming and normal. We sat in the echo-y hallway and continued chatting. She wasn't sure what to expect that evening

[00:21:16] Kerry: So again, every call is different. It really just depends on the needs of the person, whether they just needed someone to talk to. If they needed somebody to talk them off the ledge.

Um, if they needed to go to the hospital, we could take them again, as long as they're not violent, you know? Um, I think I was taking them to the hospital again, would be a lot calmer, but the police department to hear that. I know this from experience. Um, if the police officer transports you, and as long as you're not violent, not agitated, not being abrasive.

All they do is just pat you down and put you in the back of the car. They don't cuff you, which is helpful. But again, some people on a mental health crisis can't remain calm. And yet putting cuffs on him going to make it 10 times worse, you know? So if we could take him rather than law enforcement or the fire department would it be a lot better. 

[00:22:15] Anne: At what point do you decide it's okay to leave the person?

[00:22:18] Kerry: Again, it's kind of like a gut instinct. Um, You got to make sure they'll commit to safety if they were suicidal, um, if they're, um, intoxicated or high or whatever that, as long as they're okay, just to like maintain themselves and help themselves, you know what I mean?

Um, really is again, some discretion on your part and it's kind of nice that you have two people there, um, that you can like go back and forth being like, okay, this is the reason why I think we should let them stay here. And these are the reasons why I think we should transport them. You know what I mean, but we always kind of err on the side of caution.

Um, and that's why I come up with when in doubt, you know, send them out to where we would send them to, um, the hospital, or even sometimes just calling a family member saying, Hey, this is what you know, with their permission. This is who I am. This is what's going on. Could you come over and stay with them for a little while.

You know, we can always go that route. I've done that at the Careline where I've called people's sisters and say, Hey, you're kind of going through something. This is what's going on. I would feel more comfortable if somebody was there watching her. Are you able to do that? They say yes, then great. If they say no, and then you're going to have to like reevaluate and be like, okay, I don't feel comfortable leaving you here alone.

You either go to the hospital or we're gonna have to find somebody else to come over. But as long as they can commit to safety and you know, they're not on a level 10 anymore, and they're back down to like a two or a one that I'm okay with leaving 'em.. 

Kerry says the in-person calls can last a few minutes to a few hours. Either way, having the mobile crisis teams on scene lets officers respond to other community needs. It also prevents people from being taken to the hospital or to jail just because the police don't have the capacity or the skills to help them. 

Moments later the mental health clinician arrived in a generic, unmarked SUV and they were off to help the earlier caller.

So what if the mobile crisis team can't provide the care people need? Then what? 

That's where the gaps in Alaska still exisit. One place people go is to the emergency room. As Katie Ballwin Johnson, from the Mental Health Trust, explains, the emergency room isn't the right place for a person having a mental health crisis. 

[00:24:42] Katie: an emergency room department is a very sterile environment and it's overstimulating and it's, uh, you've got people changing shift. You've got, you know, just, uh, you know, a lot of light, it's not a calming environment and it's an artificial environment really. 

[00:25:04] Anne: Katie says that can lead to dangerous conditions for both the patient and the healthcare worker. Not every hospital employee is trained to handle mental health crises. That's why the Trust, behavioral health care providers, and other organizations across the state are trying to build out the Crisis Now model. One of the major missing components are 23-hour stabilization centers.

[00:25:28] Katie: And that's really what this, this whole component of care is, is a stabilization setting that is, uh, trauma informed that is highly staffed by people with lived experience. In combination with mental health professionals and it's really a multidisciplinary team, but it's a setting where anyone can go and, when they need it and that they will be received.

And, um, those folks that are working in that program will do what they can do to help that person. Um, and a majority of the time they're going to help that individual, um, by getting them engaged in other services or help them problem solve, maybe the situations that have resulted in them feeling like they need additional support.

Um, so these, these settings alternative to an emergency room department are really key because we, we, we really don't need everybody going to the emergency room department. I mean, this is not a medical emergency. It is a healthcare emergency, but there are folks that, you know, can more appropriately respond.

And so it's, it's really about thinking about building in that additional rung in the ladder. We want more than just your inpatient state, hospitalization, hospital, emergency room departments and outpatient care. We need something that gives us more opportunity to help address the issue earlier on at lower levels of care.

That's really kind of the premise behind the stabilization setting.

[00:27:10] Anne: Stabilization centers provide recliners instead of beds and folks only stay there for 23-hours, so they can be considered outpatient treatment. They provide more support than a mobile crisis team can without adding in the trauma of a hospital. In Arizona, where the centers have been very successful, they offer most people space immediately and they always take people who are brought in by emergency responders.

Developing these in Alaska requires policy changes to support licensing new types of facilities and to change civil committment statutes. We also need new facilities to be developed and long-term committments on behalf of care providers. It's a complicated process that has been in the works since late 2018 and may not be finalized for a while.

[00:27:59] Katie: And really, I think we're looking at this as this is a reform of, of the way we are responding and how communities can more intentionally, uh, coordinate care for individuals that just otherwise are, are really falling through the cracks. And so this, this fits at a very core, core level with the trust mission, and, uh, is, you know, very important work for us to do.

Now. We know that there's always. Question about, you know, how will this be forever paid for? How will this be sustained? And, you know, we knew that there was the mechanism through the 11 15 waiver

That's a new way to get Medicaid to pay for mental health care.

that there's the opportunity to support moving in this direction. So there a synergy with that, um, long-term however, it's going to be greater than just the trust to really figure out. If the state of Alaska really wants to do better and respond better to people in crisis.

And we really want to start looking at preventing and reducing our horrible numbers of suicides and people suffering across the state that this is the work that's important for us to do. And I, I have yet to have come across somebody in our conversations with our partners and the work that we do that disagrees with that. 

We need to shift systems so people get the care they actually need. And Crisis Now is already starting to help Alaska get there.

This episode was edited by Jenna Schnuer, produced by me, Anne Hillman, with audio mixing by Dave Waldron. Our theme music is by Aria Phillips. Mental Health Mosaics receives funding from the Alaska Center for Excellence in Journalism, the Alaska Mental Health Trust, and the Alaska State Council for the Arts. 

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