I WANT TO PUT CAHOOTS ON WATCH

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The ongoing spirited conversation about emergency mental health reform and community response protocol is getting tired. When I say exhausted, I mean it is about time we reach a consensus.

Today, and I’ve said it before, we stand at an impasse—the boiling point of new reform just around the bend. 

The issue that hinges on the docket today is Emergency Mental Health. More specifically, crisis intervention, crisis calls, 911 mental health dispatches, and other emergent mental health crises in the community. 

I am so fearful that this process (the legislative process that dictates the provision, execution, and law, how it is defined and carried out, etc.) will get hijacked and derailed. We advocates must focus on how all this talk will translate into a workable framework for handling emergency mental health interventions.

This subject has only gotten more controversial over the last few years. In my opinion, the rift between advocates and lawmakers, and mental health professionals have more to do with the definition of response than with how to handle the implementation of theory and practice in the field when responding to a real crisis. This is because definitions vary across disciplines, state lines, and mental health professionals. 

With the reinvigoration of social justice issues plaguing our country, this issue will only get more attention. As our society reevaluates the intersections of disability, mental health, and social inequity, we can be sure the ‘spirited’ nature of this debate will drone on and on without an answer. I only hope all the enthusiasm is put to good use. Hopefully, some of this good use will be through this blog article and real productive debate and reform will come.

For the same reason, advocates argue with each other. Passionate people from all walks of life don’t always agree with the way things are in society or should change in the future.

But is that true with this conversation? Specifically, why are we still at odds? Why haven’t we reached a consensus and passed the debate phase of how this talk will translate into the new policy. When are we going to reform the way crisis intervention works in the community?

Probably, when more definition is laid out around ‘crisis’. I am a social worker. I am also a person with lived experience. I can tell you that what is a crisis for one person, may look totally different than for another person, even with the same disorder or problem, or diagnosis. Now, imagine, two people are presentation totally differently and then add in location (city versus rural), context (domestic situation), etc., etc. My point is that every situation is different, even for ‘mental health crisis in the community. Therefore, it is so hard to come up with a protocol for each situation and how to train and educate responders is so complex and needed, and urgent.

Without a consensus at the level of language, ‘camps’ have formed. Experts are divided on which mental health professional (e.g., psych nurse, social worker, peer advocate, psychiatrist, paramedic, etc.) and intervention strategy is best equipped to respond to emergency mental health ‘crises’ in the community.

Right now, as it stands today, there are several approaches, both programmatic, and stylistic, depending on the professional bend of the worker and his or her education, training, and experience practicing. 

In terms of programs, some do a prescreen. Programs will screen people in crisis ahead of time either through a provider that calls out of concern or through the person in crisis calling to self-refer themselves in lieu of going to the ER or calling 911.

This sort of ‘soft landing’ in the mental health system is what NYC and other cities are now doing to divert traffic to ER’s and other mental health crisis triage centers across the country. They also act as a hospital diversion competent to systems where hospital beds are short and in cases that are more social than psychiatric which the hospital is an inapropriate fit.

I learned much about what it means to be in crisis, and about the systems in place to address them as a social worker, and as a peer advocate. While I don’t think social workers make great first responders in some crisis situations, I think peers make even less of a fit in these situations. Certainly, social workers do not belong going into homes where there is the additional risk of violence without other, auxiliary professionals present.

Social workers need to be part of a larger community response. But right now, the system is limited. 

When it comes to fulfilling the vision of community response there are few options after ER rooms and the few cities with limited and overextended crisis response teams assisting folks in crisis to a softer landing in the system.

When it comes to sending in a wide network of collaterals, organic, paid, and specialized personal, right now, ACT Teams and the CAHOOTS model are the nation’s front runners.

ACT, CAHOOTS, and other interdisciplinary teams) utilize prescreening methods, and go out on crisis interventions with folks already enrolled and in treatment on their census.

For people in crisis and not already on the census of an ACT or CAHOOTS team are new to the systems radar. These folks who are off the systems radar may present a degree and risk of violence to a crisis response team.

Even less clinically prudent, there are crisis’s and no prescreen mechanisms in place to the hand of clinical information to team responding in the community. Talk about a double-blind nightmare. This is also the reality of clinicians every day who respond to mental health calls in the community without enough data to safely handle crisis intervention.

In the end, more work, education, and training need to be invested in the social work education and clinical training before social workers should walk into potentially threatening environments without other seasoned responders.

My recommendation, which is already beginning to become a reality, is to have police and social workers working side by side. Right down the setup of the police station itself, these social workers can be regular members of the police force and community to cross-pollinate intervention strategies with the prescient and its staff.

For nonthreatening interventions, in many states, including my home state of New York, and the county of Westchester, ACT Teams call the local police department for every emergency crisis intervention for patients on their census. In other states out west, CAHOOTS teams respond to non-threatening situations, and even act as a mobile hospital diversion team for many homeless, and substance abuse related issues. CAHOOTS is known to respond to folks that aren’t even on their roster or are new the mental health system. 

When it comes to ‘crisis’ response, the readiness and effectiveness of crisis intervention will require more education, practice time, and to a lesser extent, additional training for all field workers. 

In social work, the Social Work Accreditation Boards, the ASWB: Association of Social Work Boards and other regulatory bodies credential and assess content areas’ rigor in disciplines of education and curriculum. A lot more is lacking but let us start somewhere. Curriculums needs to bridge an academic understanding of what it means to be in ‘crises. We can start with arming peers interested in doing this work with real skills and interventions beyond Social Work 101. I am afraid learning ‘Motivational interviewing’, and basic de-escalation strategies is not a sufficient skillset to take on emergency response calls.

We also need to think about what practice means given the current state regulatory instruments already established for determining if which of these disciplines, IF ANY, are ready and competent to perform the crisis work.  The heart of my recommendation is to advance both the curriculum of the peer workforce and practicum towards readiness in crisis intervention AND social work education in addressing violence and safety issues in threatening environments. 

What would this look like, and how can states, and local agencies roll it out? One pathway forward, on the level of education and practice, is to require peer internships to have a much more elaborate and specific crisis intervention component beyond what is currently offered as a tandem or extra component to their certification. In my opinion, the current broad ‘forensic’ certification, simply isn’t enough when we are talking about peers going into potentially dangerous environments alongside with police.

This just seems like a terrible plan. Before we make a big mistake and prematurely throw both peers and social workers in precarious situations where there can be the potential loss of life, why not pause and reevaluate these aspects of the peer education and social work intervention first? In the very least, lets agree what a crisis is before we intervene in one.

About the Author

J. Peters

J. Peters is the Editor-in-Chief of Mental Health Affairs.

Award-winning book author and Bold 10 Under ten award recipient J. Peters, LCSW. Through his work as a Licensed Clinical Social Worker. Mental health therapist and disability rights advocate Mr. Peters fights for those without a voice in various care systems, such as the New York City Department of Social Services, the New York State Office of Mental Health, or the city's Department of Corrections.

Mr. Peter's battle with Schizophrenia began at New London University in his last semester of college. Discharged from Greater Liberty State Hospital Center in July 2008, Jacque's recovery was swift but not painless and indeed brutal after spending six months there.

He has published several journal articles on recovery and mental health and three books: University on Watch, Small Fingernails, and Wales High School. He is also a board member of the newspaper City Voices. Mr. Peters currently sits on the CAB committee (Consumer Advisory Board) for the Department of Mental Health and Hygiene in NYC and the Office of Mental Health (OMH) as a peer advocate.

Owner of Recovery Now in New York, a private psychotherapy practice, Mr. Peter's approach is rooted in a foundation of evidence-based practices (EBP). Jacques earned a master's degree in Social Work from Binghamton University and worked as a field instructor for master's and bachelor's level students in NYC.

He is blogging daily on his site mentalhealthaffairs.blog, Mr. Peters regularly writes articles relating to his lived experience with a mental health diagnosis.

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