Moving Toward a Comprehensive Crisis System
An interview with Kana Enomoto, Acting Administrator, Substance Abuse and Mental Health Services Administration. This interview originally appeared in the Crisis to Recovery issue of the National Council Magazine.
What are the priority areas SAMHSA has defined when it comes to improving crisis services for people with mental health and substance use concerns?
At the Substance Abuse and Mental Health Services Administration (SAMHSA), we recognize that crises cause great disruption for individuals, families and their communities. These are critical times for intervention to get people into treatment and ultimately, recovery.
We want to help communities build, fund and maintain robust crisis services and systems. We focus on crisis systems because we recognize that multiple groups have to be engaged—behavioral health providers, housing agencies, police and other first responders, courts, child welfare, hospitals and others who make determinations about involuntary detainment. Community members, including families, peers and community institutions, need to be involved as they are often aware of who needs to be trained and can help prevent crises before they happen.
We also look at strategies to address specific types of crises, such as suicide (see more in Richard McKeon’s article, page 10), disaster crises (through the disaster technical assistance center and emergency grants) and overdose prevention (such as naloxone distribution).
Are there promising crisis services, practices or programs you would like to see more widely adopted in communities across the United States?
We need to do more to promote the use of advance directives for people with serious mental illness to be sure that they have some say over what happens to them when in crisis.
Providers need to work across law enforcement, emergency response, education, businesses and non-emergency dispatch (i.e., 211 lines) to train for immediate response and de-escalation, but also crisis and safety planning. Crisis Intervention Team (CIT) training is effective; we need to be sure that every law enforcement official who would like to have that training has access to it.
One promising practice is ConnectionsAZ’s Crisis Response Center in Tucson. This is a new facility built to provide an alternative to jail and the emergency room. Law enforcement brings in half of the 1,110 people they see per month and they never turn them or walk-in arrivals away. What’s unique about this model is that recovery support specialists and peer-run groups provide one-on-one interactions with families, conduct phone follow-up and lead the grievance process. They provide acute care beds and urgent care with mental health and peer services. It’s really the best of all worlds.
What partnerships should community behavioral health agencies prioritize to create seamless crisis services?
Community providers play a vital role in making sure linkages occur so that people get well and stay well. Follow-up to releases from the emergency room, jail or prison— times people are at risk and we need to do as much as we can to ensure no one falls through the cracks. That takes resources, workforce and time.
Funding is a huge issue in crisis response because it is unclear who pays for what. When you have a fire at your house, they don’t ask you what type of insurance you have. They just show up. And communities have a way to pay for that. In behavioral health we’re not quite in the same situation. Communities need to partner with state Medicaid and county public health offices to understand the range of resources available and how to pay for these services for everyone in the community.
Some of the critical partnerships that need to happen are with hospitals. St. Anthony Hospital in Oklahoma City established a mental health admissions office in the emergency department to conduct behavioral health evaluation prior to bed placement. This reduced wait times for people with mental health concerns from two hours to 20 minutes. For the emergency room overall, wait times reduced from 44 to 24 minutes. And the hospital experienced nearly 20 percent reduction in hospital admissions. That simple type of intervention can have a huge impact on your whole community.
What are some examples of innovative uses of technology for crisis response/prevention?
People need to have a way to get in touch and have a rapid response when they’re feeling distressed. Technology allows us to be with people where they are and to bond in real-time rather than waiting for a 9-to-5 interaction.
We are pleased that people are using our mobile apps. Both Suicide Safe and Disaster Distress are robust tools for first responders and health care professionals to easily assess and refer people wherever they are. Other apps such as Suicide Safer Home, MY3 and ReliefLink give people tools to ensure they are safe and supported during high-risk times and provide linkages to places to get help, such as the National Suicide Prevention Lifeline. The Lifeline receives millions of calls a year and our 24/7 chat service is really taking off. It is saving thousands of lives.
Predictive technology has a lot of potential. Content analysis of people’s chats can detect changes in behavior and language to predict crises. Counselors at Centerstone of Tennessee use biometric sensors in smartphones and other devices to monitor changes in behaviors or potential risk to check in via a call or do a screening. We have to proceed with caution to ensure people have their privacy protected and ensure providers are comfortable getting and making use of the data.
How can behavioral health providers (and other community agencies) take a leading role in improving the crisis system?
It is not just up to behavioral health. Other systems like Emergency Medical Services (EMS), businesses and hospitals feel the pinch of the challenge of managing crisis. Officers are unsure where to go and hospitals deal with long wait times in the emergency room. Providers can convene these relevant players. Everyone has something to offer. We have to ask, how can we help each other?
Providers can also help build behavioral health literacy and awareness of resources. Through Mental Health First Aid and efforts like the Campaign to Change Direction, communities are learning to recognize the signs of distress, precursors to crisis and where to go for help.
In five to 10 years, what will every behavioral health crisis system include?
Crisis systems must strive to be comprehensive, to have a unified approach, to adequately share patient information and to ensure continuity of care through all stages of treatment and referrals. We released a paper a couple of years ago, Crisis Services: Effectiveness, Cost Effectiveness and Funding Strategies, that outlines the core crisis services once a crisis occurred (23-hour crisis stabilization, short-term residential, warm lines, peer crisis services, etc.). Systems need to include activities oriented to prevention, early intervention, stabilization and postvention. All are important components.