In spite of efforts to improve mental health systems of care, for many decades those living with mental illness have suffered devastating proportions of mistreatment. Deprived of adequate care, appropriate supports, dignity and freedom, their capacity to achieve and maintain recovery has been severely impaired. Overcrowded state hospitals and attempts to honor the civil rights of their occupants led to deinstitutionalization; the overwhelmed, inadequately funded and poorly conceptualized community-based treatment that followed resulted in limited or no access to care. To this day, insufficient and disorganized resources contribute to decompensation, hospital recidivism and dispositions that put people on the trajectory into the criminal justice system.
Lack of strategic funding and programming and adherence to treatment guidelines that do not necessarily reflect current best practices have affected certain segments of the population in particularly devastating ways. For many individuals who are unable to access care in the community, the only option is to access care through the some of the most costly and inefficient points of entry into the health care delivery system including emergency rooms, acute crisis services and, often, the juvenile and criminal justice systems. It is interesting to note that while the expenditures in the area of forensic mental health services are often near the top of a state’s mental health budget, the level of expenditures on front-end community-based services intended to promote recovery, resiliency and adaptive life in the community are often near the bottom. Further, people who are receiving the front-end community services that are available still need a full continuum of behavioral health crisis services to respond quickly and appropriately to prevent or minimize adverse outcomes at the times when their mental health and/or substance use conditions may be at risk of decompensation.
Difficult to navigate and inefficient points of entry have resulted in barriers to accessing preventive, routine and competent care, including adequate crisis response. Last year alone, more than 56% of all adults living with serious mental illness and about 62% of all children living with severe emotional disturbances in need of treatment in the public mental health system had no access to care (SAMHSA, n.d.). Furthermore, despite recent research that has led to the identification and development of increasingly effective, evidence-based interventions for mental illness and substance use disorders, such treatments have yet to be adequately implemented by many service providers in the public mental health system. Patients seeking care turn to crisis services that are, unfortunately, not available or are insufficient for their needs. The consequences of the failure to design and implement an appropriate system of community-based crisis intervention care for people who experience mental illnesses have been disastrous. Substantial and disproportionate costs shift from considerably less expensive, front-end services in the public mental health system to much more expensive, often more disruptive, back-end consequences of hospitalization, homelessness and/or arrest and incarceration.
The following report was written by the Committee on Psychiatry and the Community for the Group for the Advancement of Psychiatry. I worked with them before on a project to help psychiatrists and systems of care develop skills and policies to respond to people living with mental illness who have found themselves in the criminal justice system. I am turning to them once again, asking for guidance on how to educate leaders of systems of mental health care, payers, judges, policy planners, legislators and those living with mental illness and their families, about creating a crisis system of care that will facilitate access, enhance assessments, encourage appropriate referrals and ensure supports are in place to allow for recovery.
This Committee’s response has been to offer this report which defines the essential elements, measurable criteria and best practices as an ideal crisis system. It recommends a redesigned and transformed system of care oriented around ensuring adequate access to appropriate prevention and treatment services in the community and developing collaborative cross-systems relationships that will facilitate continuous, integrated service delivery across levels of care and treatment settings. Recommendations are made for the development of a comprehensive and competent mental health crisis system that will prevent individuals from decompensating, instead quickly and effectively linking them to appropriate services. Under this ideal system of crisis care, there will be programs incorporating best practices to support adaptive functioning in the community, programs that stabilize these individuals and link them to recovery-oriented, community based services that are responsive to their unique needs. By designing an appropriate and responsive system of crisis care for individuals living with mental illnesses and/or co-occurring substance use disorders, people will be served more effectively and efficiently. Public safety will be improved and more costly services will be reduced. Lives will be saved.
It is my fervent hope that this ideal crisis system will be embraced, endorsed, adopted and funded. My thanks to the committee for their diligence, expertise and commitment.
As the CEO of a local comprehensive behavioral health crisis services provider in Michigan, I lead Common Ground, a 50-year-old nonprofit that started as a volunteer crisis line. Our core purpose is “helping people move from crisis to hope.” Over the years, we have expanded our crisis continuum in response to community gaps in crisis services. We added crisis stabilization, mobile crisis, crisis legal clinic, victim assistance, sober support, text and chat to our crisis line, crisis residential, crisis parent support partners, youth crisis shelter, support groups and a variety of other crisis services that serve children/families and adults with co-occurring intellectual/developmental disabilities, medical, substance use and mental health challenges.
The Committee on Psychiatry and the Community for the Group for the Advancement of Psychiatry provides a much needed framework to advance local conversations and influence community planning for community crisis services within the context of a system. The report provides the necessary components for each level of the behavioral health crisis system and details about which crisis services are most effective and how they should be organized. Whether the reader is a citizen, crisis provider, emergency services partner, payer or public entity, the guidance is clear and can be implemented at a local level. After all, all crises are local.
As I continue to learn more about the necessary components of a behavioral health crisis continuum, I have come to understand that this conversation is decades overdue when compared to other community-based emergency services. The opioid crisis, increased suicide rate and behavioral health emergency department boarding affect all people and are important reasons to modernize our behavioral health crisis system as a community benefit with accountability, performance standards, adequate funding and in the context of an emergency services community system – a system built for ALL people, not just those with or without a specific type of insurance.
As a provider of crisis services, I think this report offers inspiration as well as practical guidance to crisis providers large and small, rural and urban. There is something for everyone to make their local crisis system better. In addition to offering a road map, the ideal behavioral health crisis system offers a vision for what is possible in our communities.
Due to an underfunded mental health care system and a common misperception of the danger presented by people with mental illnesses, law enforcement has become the de facto behavioral health crisis response service. However, when law enforcement officers respond to mental health crises, their options to address the situation are limited. Too often, the result is the person in crisis penetrates further into the criminal justice system via arrest or is simply left without intervention or links to behavioral health care.
This is not an indictment of law enforcement. Rather, law enforcement agencies deserve to be applauded for their valiant efforts to fill a gap that an inadequately funded behavioral health care system has created. However, law enforcement cannot repair the failings of the broken crisis system. There will always be a role for law enforcement services in any crisis response system, and every community deserves to have a cadre of specially trained patrol officers to fill that role, but law enforcement should not be the primary gateway into care.
Access to quality behavioral health care services for all members of the community must be a priority. Fortunately, we are starting to see gradual improvements, from only having the option of calling 911 and getting a police officer at your door to being able to call a crisis line for crisis resolution, support and linkage. In some communities, we are seeing the development of non-law enforcement crisis response teams – some involving certified peer providers. Dedicated crisis centers capable of addressing the behavioral health care needs of the person in crisis are being established. While these developments are promising, they exist within a fragmented behavioral health care system where barriers and access disparities are more the rule than the exception.
This report recognizes the need to transform crisis response systems. It clarifies the definition of a crisis response system as being more than just the initial response. It highlights the need to have managed and coordinated processes and services in place to address the behavioral health care needs of all people, in a timely, compassionate and effective manner. This report provides a framework for systemic change.
It is with great hope that this report will bring together governmental agencies, service organizations and communities in a collaborative spirit to transform crisis response systems into true essential services.
The phone rang on a Saturday in the late afternoon. The voice was distraught, frustrated and scared, “He was taken in by the police and is on a 72-hour hold. He has been there for two days, and I don’t know what to expect.” That Saturday call, like many others I receive, was particularly worrisome for me as a BIPOC (Black indigenous person of color) because the police had been called to respond to mental health crisis of a Black man. Statistics are very clear about outcomes of police interactions with those with mental health conditions and even more devastatingly clear when those interactions involve Black or Brown men and or women. Phone calls and emails like this from around the country are a normal occurrence for me; but they should not be.
When people are in a mental health crisis, what to expect at the basic level of treatment and services before, during and after the crisis should not be a mystery. Instead, people like me, who experience periods of extreme distress and our loved ones rarely know where to turn and when or how to get help. And when help is sought and/or forced upon people, as in police interactions, we are thrown into a dark abyss of the mental health crisis system. How does one avoid the abyss, and when in, how does one get out?
There is a story about a man who fell in a well. Many people tried to help him out, shouting advice from above. Finally, someone crawled down into the well to help. The man exclaimed, “Why would you come down into the well, now we are both stuck?” The person replied, “I was in the well before and I know the way out.” It takes someone who has been there before to shine the light in the darkness and lead the way out of the abyss.
I am fortunate that I have made my way out of the abyss of fragmented mental health care with the help of others. I have worked in the mental health field at the local, national and federal level as a peer provider, CEO, advocate and executive. Yet and still, the phone rings and the calls remain the same. So many fall into the abyss. People are lost, their support system confused, without a guiding star or map to help them navigate the systems of care to support their recovery, especially when in crisis. Our crisis system needs help. The people we serve not only need help, but deserve it.
With the keen insights, research and practical experience of a diverse group of providers, peers, family members, payers, researchers and administrators, “The Ideal Behavioral Health Crisis System” was written as a both a vision and practical set of expectations for what crisis systems should be. It is akin to the person in the story who dropped into the well to help the man out – the man in the well symbolizes the system that is in desperate need of help. It is the very type of document we need to not only reduce the confusion, frustrations and fears of those we serve, but also for our systems and the people who work in them. The ideal behavioral health crisis system serves as that beacon of light shining on paths of what can be done to avoid falling into the abyss, in turn leading us to systems that support the journey of those experiencing a behavioral health crisis to a flourishing recovery trajectory.
The phone rings….
Crisis services represent the best kind of proactive intervention to support recovery and in this way get ahead of an often-difficult illness process. As a psychiatrist, I have come to appreciate that engaged peer-driven services can make a great difference in the arc of a person’s recovery process. I became a psychiatrist to help my dad, who was a wonderful man with a very bad illness. Crisis services were something I wouldn’t have understood as a young son. I even suspect my family wouldn’t have had the wherewithal to figure out that they existed. I now understand how valuable crisis services can be, and how educating the family and their loved ones is essential on how to best use these services.
Even if they existed when I was young, I don’t think our family would have been able to use crisis services. As a boy, I felt like I never could recall that my dad even had recurrent episodes of bipolar disorder; so too the rest of my family wanted to forget. Society was also supportive of this kind of amnesia, given how powerful shame and stigma was. I have learned that one thing is true – one must recall the challenge before you can plan for it.
My experience was in the 70s and 80s, in the days before famous people were out with their bipolar disorder and before the National Alliance for Mental Illness (NAMI) became a major force in support and education. The atmosphere was shame-filled, making mental illness hard to recognize, much less proactively plan responses and services. We now live in a time when it is more acceptable to live well with a psychiatric disorder and when families can more easily speak about it. The person living with the challenge and their family have more opportunity to experience it without blame or shame. Now we can plan for it and develop proactive crisis plans before the next episode.
Shame stopped my family from understanding what the options were, but I am sure that the options at the time in my Detroit Ford Transmission plant suburb were either Northville State Hospital or outpatient care. Today, like so many others, Northville State Hospital is closed. Yet today we would likely have proactive ways to identify his triggers, to proactively plan to reduce the frequency and intensity of episodes. If well-funded, designed, and staffed, crisis services could be a major addition to the menu of treatment options. Without the backup of a long-term stay at a state hospital, crisis services could be lifesaving.
As I aged, I recognized discernable patterns in my dad’s episodes. There turned out to be an every-other-summer pattern of mania and psychosis. I also came to appreciate there were discernable patterns in dad’s speech and behavior when he was beginning to have an episode. This pattern was ideal for proactive planning. The Systematic Treatment Enhancement Program for Bipolar Disorder study later taught me that this kind of pattern is in fact quite common. Crisis services, had they been a resource, would have been a gamechanger for our family.
To be clear, the ability to talk about his illness and get support from NAMI would also have been essential. I think you must be able to see the challenge and to name it in order to plan for it. With a comprehensive crisis service and the ability to name and speak of the challenge, I now see it would have been possible to avoid so many hard moments in our life of police at the door, arrests and court time.
This realization that a major mental illness is something a family can love someone through, plan for and reduce the impact of is something I came to learn as a practitioner and as NAMI’s Chief Medical Officer. Let’s reduce the number of families and their kids who are living in silence and shame. I learned the hard way that love is a lot, but it isn’t enough. A culture of openness and discussion about these hard topics is essential. NAMI is here for you to have that essential element. Proactive and essential services such as crisis services described in this thorough document by the Committee on Psychiatry and the Community for Group for Advancement of Psychiatry are the second half of that crucial equation.