The Answer Is Not Either/Or, The Answer is Both

Recently, 20 states received grants from the Centers for Medicare and Medicaid Services, an agency of the U.S. Department of Health and Human Services, totaling $15 Million to fund the development of programs that reduce reliance on police by connecting people experiencing mental health and substance use crises with behavioral health specialist and critical treatment, according to a CMS news release.  At first glance, these grants could be viewed as only supporting stand alone response models of crisis response services; however, if we widen the view, we can see that funding and support of only one type of model is a short-sided reaction to public pressure without truly understanding either the crisis system or law enforcement response.  It is also not specified in the funding that program development and design must center on stand alone crisis response teams.


A healthy crisis system includes a robust menu of services to meet the needs of each individual.  As such, a healthy crisis system needs to have both a stand-alone team and a team embedded with law enforcement; and teams that can communicate well with one another, in addition to other crisis services including crisis respite centers, psychiatric emergency departments and emergency medication prescribers.  This is not an either/or, better/worse, more important/less important scenario.  Each spoke of the wheel is vital to its function.


In Roberts’s Crisis Intervention Handbook (Roberts, 2000), a model comprehensive community crisis system is discussed.  This includes:  telephone crisis services, walk in crisis services, mobile crisis services, access to crisis residential unit, emergency psychiatric crisis stabilization, and critical incident stress management.  When discussing mobile crisis services, a case scenario is presented broken down using Roberts’s seven stage crisis intervention model.  He states, “Because of various inconsistencies and misinformation provided by the client on the initial phone contact, the major problems were unknown at the time of dispatch.  It was not until the crisis worker and the police officer arrived on the scene that the critical nature of the problem was identified.”  Herein lies the problem with putting the full focus of crisis services solely on the shoulders of crisis response programs that are not inclusive of law enforcement: it leaves out those calls which cannot be safely managed without a law enforcement presence.  In order for crisis teams to respond safely, it is important that the individual meets all of the following criteria:  they are not displaying any violence, has no weapon, the individual is agreeable to stay safe until the mental health responder can arrive, no crime has been committed, they are voluntarily agreeing to get services, there are no medical needs including overdose, and the individual has not consumed drugs or alcohol.  The rest of the calls are where the embedded teams come in.


Crisis systems need response teams that are not inclusive of law enforcement.  Voluntary individuals who are experiencing distress should not need to have involvement with the criminal justice system in order to get help.  However; it is of vital importance that we do not let the decision makers forget one simple fact, law enforcement will forever be responding to crisis in our community.  Embedded models of response must have a seat at the table and must be equally implemented in communities who desire to create a most effective crisis system.  When systems make decisions that are reactionary versus thoughtful; the results can be catastrophic.


In reality, even communities who have a robust menu of crisis services available will still have law enforcement responding directly to individuals in crisis.  In addition the challenge of crisis response teams which are not embedded with law enforcement leaving out those calls which cannot be safely managed without a law enforcement presence, it also leaves out those calls which may have an underlying behavioral health component which would never be screened to a non-law enforcement crisis team.  For example, an individual calls 911 to report he can hear a woman screaming on his neighbors property.  No way would this call screen in for a crisis team; however, upon arrival, officers discover there is no woman in distress on the neighbors property, in fact, the house is vacant and no one is there (confirmed by a building search).  The reporting party presents as “odd” to the officers.  Having cleared the original complaint, it would be easy for the officers to walk away.  However, the officer arriving happens to have a mental health professional with him and responded in the event there was a victim who may need support.  Instead, the mental health professional begins taking with the reporting party and quickly ascertains that he is experiencing paranoid auditory hallucinations.  This is not uncommon for him when he forgets to take his medicine.  The mental health professional is able to develop a crisis safety plan with him and they coordinate taking him to a family members home after making a stop at the pharmacy to pick up his medication.  The ability to have the mental health professional on scene to make an immediate assessment facilitated:

  • The reporting party was able to get his necessary medication.
  • The reporting party was able to be connected to a family resource who would provide him with observation until he was stable again.
  • They prevented additional calls to 911 which would take valuable resources away from the community and others in need.
  • They prevented further decompensation – including hospitalization, as was the case for this person when they continued without medication in the past.


We also forget that community crisis response teams are often focused solely on individuals who are experiencing a mental health or substance use crisis; but what about those individuals who find themselves in a crisis who have no diagnosis.  By definition, a crisis is “a time of intense difficulty, trouble, or danger.”  This is so varied person to person.  If we leave out the human component of crisis definition, we are, in fact, failing a large majority of the population.  One could argue that the mere fact that someone has had to call 911 is, in fact, of itself a crisis.  We do not call 911 to tell them about our best day or experience. . . we call when something is wrong, sometimes terribly wrong.  Perhaps a runaway adolescent is being reported by their parents, someone discovers their house has been robbed and their most prized possessions taken, or an elderly spouse who wakes to find the love of their life has passed away as they slept.  Crisis work is not intended to be something that “we” do for “them,” it is something that we all do for one another. 


Creating a variety of services that meet individual needs in the moment, we create healthier communities.  Thus our Mission:  Creating the RIGHT response, at the RIGHT time, by the RIGHT people.


References

Roberts, A.R. (2000) Crisis Intervention Handbook.  Oxford University Press.

Roberts, A.R. (1991).  Conceptualizaing crisis theory and the crisis intervention model.  Contemporary perspectives on crisis intervention and prevention.  Englewood Cliffs, NJ:  Prentice-Hall

Crisis = Danger + Opportunity

By:  Marla Johns, M.S.President/CEO Crossroads Consulting 360, LLC



During the Cuban missile crisis, John F. Kennedy said, “The Chinese use two brush strokes to write the word ‘crisis.’  One brush stroke stands for danger; the other for opportunity.  In a crisis, be aware of the danger – but recognize the opportunity.”


While this is primarily true, in reality the second brush stroke has multiple meanings and not “opportunity” alone.  It is more said to be something similar to “change point” and is included as a part of the Chinese word for opportunity; according to Sinologist Victor H. Mair of the University of Pennsylvania.  In the United States, numerous politicians and public speakers have used this as a call to action.


While this is primarily true, in reality the second brush stroke has multiple meanings and not “opportunity” alone.  It is more said to be something similar to “change point” and is included as a part of the Chinese word for opportunity; according to Sinologist Victor H. Mair of the University of Pennsylvania.  In the United States, numerous politicians and public speakers have used this as a call to action.


Though I agree with, generally speaking, a call to action among those who provide and respond to crisis services; I see this more as a validation and affirmation of the guiding principles of CC360 and our RIGHT Program.  We need law enforcement because of the inherent danger associated with crisis work and those community members experiencing a behavioral health crisis.   Environments of crisis present an unpredictable and, at times, unsafe environment that makes response without our law enforcement partners impossible.


The bigger validation with this phrase really comes with finding opportunity, or the change point, in a crisis.  Those of us who work with human beings know just how hard finding that change point can be.  As a new graduate all those 25+ years ago, I just knew I was going to change the world  (it’s ok to roll your eyes here).  At the time, I was working in a downtown emergency department.  Day after day the same people would come through our doors.  Our “regulars” became an odd family in our work home.  We knew their stories.  We fought their demons along side them.  Yet, day after day, they would come.  I quicky lost that new grad spark in my eye, and wondered if a single life was ever going to be changed by the work I was doing.


As I sat in contemplation one evening at the end of a particularly rough shift, I was reckoning with the reality of the profession I had entered.  Maybe I was no good at it?  Maybe I wasn’t really helping anyone change anything?  I knew the local coffee shop was hiring, maybe I could make a difference there.  A curmudgeonly doctor that I worked with pulled up a stool for a little pep talk.  Now, you must know, his pep talks usually went something like this, “whatever, get over it.”  However, on this night, things were a little different.  Perhaps he too was feeling the pressure of the night; the heaviness of the work we do.  Perhaps the pep talk he was about to give was as much for himself as it was for me. 


As I shared the frustration of the revolving door for our clients, who “took me away” from other folks who had come in each evening and the needs they might have; he asked one simple question, “what about the ones you never see again?”  He then got up off his stool, grabbed another patient chart, and walked away.  At first, I thought I had just gotten another one of his stellar pep talks, then slowly the lightbulb flickered and came on.  He was right, what about the one’s who never came back?  Could it be that we actually make some kind of difference, that there was a change point for those folks?


The realization brought me through the next 20+ years of my career.  The reality is that the majority of the time, we never really know the change that we helped make in someone’s life.  The best we can do is assume that the lack of further interaction was the result of a positive impact.  It’s a bit like planting a garden.  Some seeds that are planted sprout almost immediately.  Some seeds you plant in the fall and do not see until the spring; but you have faith that the growth is happening.  You believe that the seed is changing under the soil, and you will see that change one day.  Maybe we are just gardeners planting seeds . . .


And what about those regulars who came to see us nearly every day, those people who became a part of our work family away from home?  Maybe the reality is really that they needed to belong to that family.  Maybe we were all they had.  For those people, it is possible that the change associated with the demons that kept them interacting with the medical and law enforcement environment each day were also the things that helped them to have human contact that they may not otherwise have.  The compassion, empathy and concern we provided might just have been the only times they felt the warmth of the human spirit.  For some, I know it was also one of the few times they felt the warmth of a bed, a blanket and a pillow.  Perhaps their lives were changing too.  Their seeds just took longer to grow and needed much more nurturing.


That curmudgeonly ER doctor has long sense retired; but I do think of him often, especially in moments of frustration, exhaustion, and the overwhelming need we encounter.  It helps me to remember we are doing the RIGHT thing and that our mission matters:  Creating the RIGHT response, at the RIGHT time, by the RIGHT people.

A Picture’s Worth a Thousand Words – So Is A Logo!


The idea behind the business was clear and so was the idea behind what I wanted to represent with the logo.  It was important to me to create something that represented both law enforcement and mental illness.  Something that demonstrated the coming together of the two professions.

 
The “thin blue line” is a team that typically refers to the concept of the police as the line which keep society from descending into chaos or darkness.  Blue, of course, is the color most typically thought of as the color of the law enforcement uniform.  One of the earliest uses of the phrase was found in poem by Nels Dickmann Anderson, titled “The Thin Blue Line” in 1911.  He was referring, in the poem, to the Army who wore blue uniforms at the time.  It’s use became more commonly known following the use of the term in speeches by LAPD Chief, Bill Parker, in the 1950’s and was then appropriated as the name of a television show, “The Thin Blue Line.”  The symbol is, of course, a royal blue line in a field of black.


In the 1800’s, green was the color thought to be used to label people thought to be mentally ill; but the use of the green ribbon for mental health awareness is less widely known.  However, since the introduction of Mental Health Awareness Month in 1949, the green ribbon has been used in representation.


When I originally took the logo design idea to E. Sierra Media (https://esierramedia.com/) I thought I knew exactly what I wanted . . . a green ribbon being pinned on by the thin blue line ribbon.  Easy, right?  Nope.  His team took that original idea and transformed it multiple times until I could decide on the final design.  The picture you see in this blog shows the progression from my original idea to the final logo product we are using today.

Final Logo


Crossroads – Represents the Crossroads that Law Enforcement find themselves when looking at crisis response in communities.


Consulting – obviously, it’s what we do!


360 – Widen the professional view to a full 360 degrees (it also happens to be our area code)


Blue Ribbon outlined in black – represents our law enforcement partners


Green Ribbon – represents our mental health professionals


To us, our name and our logo represent our life’s work.  Our mission and our desire to create something magical in every community by creating the RIGHT response, at the RIGHT time, by the RIGHT person.

Why An Embedded Model?

The original idea behind the model created by CC360 actually occurred in 2008/2009 with the implementation by our consulting team of an embedded program to address chronic mentally ill and homeless.  Fast forward twelve years to the “should we send a social worker instead” debate occurring around the country today. 

The first publicly funded, organized police force with officers on duty full-time was created in Boston in 1838 after businesses had started hiring people to protect property and guard the safe transport of goods (https://time.com/4779112/police-history-origins). Thus, the focus to “protect and serve” originated as well.  In February 1968, the first 911 call was made in Alabama.  By the end of the 20th Century, 93% of the United States was covered by a 911 system.  Young children are taught when they need help, call 911.  There is no idea of trying to teach community members to ferret out the type of help that is needed . . . it is just the expectation that if you need help, you call, and help will come.  


So, over time, policing transformed from “protecting and serving” into an expectation to be all things to all people at all times.  Even with the one-day implementation of a 988 system, there will never be a time – repeat, there will never be a time – where law enforcement is not responding to non-criminal crisis events.  Similarly, there will never be a time when our mental health system does not need the assistance of our law enforcement partners – again, never.  We say this with certainty and guarantee.  As such, the need to respond with the appropriate tool for the appropriate situation is imperative. 
So, over time, policing transformed from “protecting and serving” into an expectation to be all things to all people at all times.  Even with the one-day implementation of a 988 system, there will never be a time – repeat, there will never be a time – where law enforcement is not responding to non-criminal crisis events.  Similarly, there will never be a time when our mental health system does not need the assistance of our law enforcement partners – again, never.  We say this with certainty and guarantee.  As such, the need to respond with the appropriate tool for the appropriate situation is imperative. 


This leads to the question we are most frequently asked is, why did we choose to develop and support a fully embedded model.  The answer is not one simple thing; but a variety of factors that influenced our decision.


First, the vast majority of communities have some sort of siloed crisis response program for community members who are experiencing an identified mental health crisis where sometimes mental health professionals take the lead and other times law enforcement is called to respond.  It looks different depending on the region, but typically those community members who are in crisis and are volunteering for services are able to access crisis support services.  It could be through telephone, telehealth, or in-person response depending on the situation and area.  


Recently, while attending the International CIT conference, we were able to attend multiple sessions in which the issue of whether to dispatch a mental health team without law enforcement was discussed.  It was also the consensus of those in attendance, and those presenting on the topic, that this response level is appropriate only in very limited circumstances.  These include when the caller is not displaying any violence, has no weapon, the individual is agreeable to stay safe until the mental health responder can arrive, no crime has been committed, they are voluntarily agreeing to get services, there are no medical needs including overdose and no drugs or alcohol on board.  We agree, under these circumstances, a non-law enforcement response would be appropriate.  However, we think you will agree, this is a very restrictive list and does not, in fact, represent the types of calls that our program advocates an embedded team would respond to.


We are all aware that call categorization is often not inclusive of the underlying reason the call originated.  By integrating a mental health provider with, at times even, officers on patrol assignments, we advocate for teams to prioritize response to calls which are identified as:

  • Suicidal/homicidal subject 
  • Repeat calls to dispatch regarding non emergent content
  • Calls regarding “persons of concern” (i.e. exhibiting psychotic or odd behaviors) or welfare check calls for persons who have been described as having a behavioral health condition.
  • Requests for dispatch regarding individuals in continual crisis who are over-utilizing emergency services or law enforcement
  • Civil disputes
  • Domestic Violence (physical and verbal) and family disputes
  • Victims of Crime
  • Death notifications
  • Calls coded as “mental”
  • Missing/runaway juvenile
  • CPR in progress
  • Homeless 
  • Substance use 
  • Disturbing the peace
  • Trespassing


As you can see, this expanded response definition allows for a response to “crisis” and not just a response to “mental illness.”    This expanded response gives community members the necessary support to meet their needs. 


Our second reason to advocate an embedded model is the significant financial savings in comparison to operating multiple mental health response teams in a geographical area.  Most times, our consultants are able to identify community resources who can pool resources, personnel, and equipment in order to create teams without a significant hit to the budget.  Let’s face it, everyone is trying to do more with less.  The need to work together to face staffing shortages and financial restrictions are more important than ever.


Along the same lines as fiscal responsibility is the ease and speed by which models can be implemented, which is our third reason for developing this program model.  Again, by working with existing programs and using existing policies and procedures; programs can be implemented in a significantly shorter period of time than having to start from scratch.  


Finally, we believe in a shifting culture of law enforcement.  This is a subtle happening in departments who utilize embedded mental health professionals.  It is not quantified.  It is not even easily articulated.  But it is the magic that happens when law enforcement agencies change the lens with which calls are seen.  Different questions are asked.  Different language is used.  Not better, not worse, but different.  


It is our dream that, one day, every patrol officer will be paired with a behavioral health crisis response expert.  A reality?  Not likely.  But it speaks to the value we believe this partnership can bring to policing our communities.  Thus our Mission:  Creating the RIGHT response, at the RIGHT time, by the RIGHT people.

Are We Making A Difference?

Are We Making A Difference?

The question that is never an easy one to answer with behavioral health services is how do we measure success?  How do we prove we are, indeed, making an impact?  We try to find things to measure like a decreasing number of calls to 911 or the number of times someone uses behavioral health services, but none of these really measure what we do every day…the impact we know we see in the faces of the community.

Making a difference, in the behavioral health setting, means something different to each person.  We often use the phrase “meeting someone where they are at.”  This doesn’t mean physically meeting them where they are located; but meeting them emotionally where they find themselves.  For one person, the biggest crisis they have ever faced is a speeding ticket; thus leading to a behavioral health intervention on the side of the highway.  Did we reduce measurable recidivism for that person?  No.  However, the influence that a listening ear had on that person’s life cannot be discounted.  For someone else, their crisis involves a combination of serious mental illness, substance use, and homelessness.  We cannot expect a change in behavior overnight; but a warm meal and a new pair of socks does, in fact, change that person’s life and set them, perhaps, on a changing course.

Being invited into someone’s life at their worst moment is a gift of extreme responsibility.  What we do in those moments, can change a life forever.  Occasionally, we are lucky enough to see an immediate change.  More often, however, we simply plant a seed.  Like any good gardener, we recognize that every seed germinates and grows at a different rate.  

It is not our job to define a crisis, it is our job to respond to it.  In the words of Anne Frank, “how wonderful it is that no one need wait a single moment to save the world.”  

Are we doing the R.I.G.H.T. thing?  You bet we are. . . one seed at a time.

Tips for the Street: Active Listening

One of the most important skills when interacting with a person who is experiencing a behavioral health crisis is active listening.  The good news?  Anyone can do it!  Here are six phrases you can use to help:

  • “Do you mean . . .” the makes sure you understood what they were trying to say
  • “It sounds like . . . “  another way to provide clarification and demonstrate empathy
  • “Really?”  this phrase demonstrates encouragement to keep speaking and elaborate
  • “I’ve noticed that . . . “ by pointing out observations you are demonstrating you are paying attention to verbal and non-verbal communication
  • “Let me make sure I have this right.”  Summarizes what you have heard the say to validate you have been listening and understanding.
  • “I’m sorry.  That really ___.” Name the situation (stinks, is terrible, must hurt) to verbally acknowledge how crummy the situation is to validate their emotions.