Epilogue

A comprehensive behavioral health crisis system with a complete continuum of services is an essential element of safetynet health and human services for any community; the same as is true for police, fire and emergency medical services. This report has outlined the measurable criteria for design and implementation of an ideal behavioral health crisis system for any community. These criteria can be used by states, counties, managed care organizations and other accountable entities to evaluate their current crisis systems, determine opportunities for improvement and steadily make progress toward creating the type of behavioral health crisis system that would best serve their communities.

But an ideal crisis system means much more than adhering to a list of criteria. An ideal crisis system is most meaningful when we consider what difference it can make in the experiences and outcomes of real people in need, as well as the difference it can make in how community resources are utilized. Let us consider the experience of Mr. Y, the young man with mental illness who was eating bananas in the convenience store without paying for them, whose tragic experience of arrest and incarceration was described in the introductory section of this report.

What would have been different for Mr. Y if he had been fortunate enough to live in a community with an ideal crisis system such as the one described here?

Let us consider what might have happened differently, step-by-step, from the moment that the store owner called 911. For the moment, we will not consider all the ways a community with an ideal crisis system might have intervened earlier when he was picked up for vagrancy or during other previous encounters with law enforcement, emergency rooms or homeless services.

In an ideal crisis system, the 911 call center immediately triages the call for whether the issue involves someone with a mental health crisis and determining that this is the case. If there is no immediate risk of violence, the dispatcher notifies the CIT-trained officers to go to the scene while also contacting the mobile crisis team. When the officers arrive, they immediately notice how terrified – and hungry – the young man is acting and they behave in ways to help him not feel further threatened. This is further supported by the mobile crisis team workers.

Mr. Y tells the officers that he has no place to live and he eats bananas because other foods are “dangerous” and possibly “poisonous,” but bananas are protected by the peel. The officers take time to persuade the young man that they do not want to arrest him but would like the crisis workers to help him find a place to stay temporarily where he can find some people to help him and food that is safe for him. They let him know that they appreciate how hard it has been for him in the street and they want him to have a chance to get back on his feet.

After some time, Mr. Y agrees to voluntarily have the mobile crisis team bring him to the crisis center. The store owner is told that the crisis center can pay for the bananas if he wants, but he says that he is happy that the young man is getting help. At the crisis center, he is brought into the Living Room area, where he is met by a peer counselor, who introduces him to the rest of the team and gets him a banana to eat. The peer explains that he also used to be homeless and scared, but eventually he found people he could trust to help him, he got some good medical treatment to get healthy and now he is working to help others. Mr. Y is intrigued, but still skeptical. The peer works with him to let him know what other safe foods they might be able to find in addition to bananas and eventually puts together a decent meal.

The whole team is very welcoming and hopeful to Mr. Y, and accepting of the fact that he has been using marijuana to help himself relax on the street. Mr. Y is appreciative of the fact that no one seems to be trying to force him to do anything and he is grateful for their efforts to find him safe food and not challenge him on his fears of being poisoned or the fact that he is in possession of marijuana. They help him get acclimated to the crisis center and start to find out more of his story, as well as inquiring about whether he has any family who might be worried about him.

After a while, Mr. Y lets them know how to contact his grandmother. They find out the following story from her:

His grandmother was greatly relieved to hear about Mr. Y from the crisis center. She reported that even while living on the streets he usually came to her home about twice a week to ask for money and eat a banana or other food that he believed was safe that day. She explained that she was terrified he had been killed on the streets and had been calling local hospitals and even the morgue to try to locate him. She revealed that he had been raised primarily by her in what she described as a “good Christian home” and explained that his mother had “problems of her own,” had been diagnosed with schizophrenia, (although his grandmother thought it was probably laziness) and had “run off” by the time Mr. Y was four or five years old, not to be heard from again.

His grandmother reported that Mr. Y was a nice boy who was helpful to her and gave her no trouble as a small child. She said he had been treated for asthma since he was a child but was otherwise healthy. However, he had learning and behavioral problems in his elementary school years and repeated the 4th and 7th grades. Reading was particularly difficult for him, and he would “act up” in class. By the 9th grade, he was missing a lot of school, but was never in “special classes.”

His grandmother noted he was “hanging out with a bad crowd” and suspected he might be using drugs. She believed he started using marijuana regularly at that time and continued to do so whenever he had access to it, stating, “I know how that nasty stuff smells.” He dropped out of school in the 11th grade. He was employed for several years in an uncle’s car wash business and initially did well, moving into a small apartment which he shared with someone his uncle knew. However, his attendance and his behavior there had been erratic over the previous year or so, and finally his uncle had to let him go.

He tried to get other jobs – at fast food restaurants and Walmart – but was never successful. His roommate kicked him out for not paying the rent and he could no longer stay with his grandmother as she had moved into a senior apartment. She said that Mr. Y. was “not himself” and that although he had never been aggressive towards her, he was not taking care of himself, declined to shower or wash his clothes and would sometimes “talk out of his head” when he visited her. He stayed at the shelter until he had used up his 45 day per year maximum and had been out on the streets since. At the shelter, he was withdrawn and seemed to be mumbling to himself at times. He had been living on the street for only a few weeks prior to the incident at the convenience store.

The grandmother spoke to Mr. Y on the phone and told him she was very happy that he was somewhere safe and said that if he stayed there a few days and got some help, she would come visit and bring him some money. He seemed pleased with that.

After the crisis center, with help from the peer worker, performed a medical screening and a brief psychiatric examination, it was determined that Mr. Y was suffering from a psychotic illness but had no acute medical needs. He was currently clearly paranoid and attending to voices but was not agitated as long he was not challenged and he seemed to be feeling safer in the crisis center.

Mr. Y was offered the opportunity to stay in the crisis stabilization unit at the crisis center for a few days until next steps for him could be figured out. With the support of the peer, he agreed. He was offered medication in the crisis center but was too frightened to accept it. The peer suggested he think about it while he was in the crisis unit and shared his own experiences with finding medication helpful. Mr. Y agreed to think about it.

After two days of support and food in the crisis stabilization unit, Mr. Y began to accept small doses of medication. He was very nervous at first, but found that he felt less frightened and was able to eat more foods. He was transitioned to a crisis residential program where he met new staff, including peers, who continued to help him feel welcome and safe.

The crisis residential program was able to link Mr. Y with community services through its relationship with emergency housing programs in the community. They involved his grandmother in ongoing service planning as well, and her input helped him to trust the process. Further, the crisis collaborative in the community built a strong relationship with housing and homeless services because the mobile crisis team provided outreach on request to all the housing programs and, in turn, housing services could arrange emergency placement in shelter plus care for individuals coming out of crisis. Under the guidance of the crisis coordinator for the whole community, the crisis residential unit was able to coordinate and prioritize Mr. Y for attachment to a mobile intensive crisis intervention team that could work with him for several months to support him in his temporary housing and eventually transition him to ACT services.

Mr. Y was encouraged not to use marijuana, but he only agreed not to use it inside the shelter plus care location and the crisis team continued to work with him on how to make better decisions about marijuana use in service of his recovery goals. Mr. Y was also able to accept a medical examination and had medication prescribed for his asthma.

After a period of weeks in the crisis continuum, Mr. Y was much less psychotic, but still quite ill, and developed a level of trust with an array of community providers. He had a temporary place to live with community support, reconnected with his grandmother and he had NOT been arrested and had NOT been hospitalized.

More importantly, he had hope. He said to his team: “I am beginning to trust you people. Maybe someday I can help other people just like you do.”

This is the value of the ideal crisis system!

We hope your community finds these materials useful in improving behavioral health crisis services so individuals and families in crisis with serious behavioral health conditions can more easily receive the help they need – and deserve – wherever, whenever and for however long they need it.

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