Yale Psychiatry Grand Rounds: March 25, 2022

March 25, 2022

Yochelson Lecture: "Beyond Beds: Trends in Crisis Services"

Debra A. Pinals, MD, Clinical Professor, University of Michigan

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00:00I'm very pleased to introduce
00:03you to Doctor Pineles,
00:06but I just wanted to give a
00:08little bit of background.
00:09For those of you who are
00:12new to our grand rounds,
00:16we've been very fortunate in that the.
00:21Yochelson family back in the early 1980s.
00:25Gave an endowment to our department.
00:30Or what was a lectureship at that time?
00:36And over the years,
00:38the Yale Investment Group has.
00:41Gradually expanded that lectureship
00:44into the ability to invite a scholar to
00:49come and spend a week with us and we
00:52work them to death by having them give
00:55grand rounds up at CVH case conferences.
00:58Work with the PG two fellows or
01:02or residents and our fellows.
01:05And it is really turned out into a.
01:09A very nice.
01:11Ability to invite people and get
01:14their input into our program
01:16as well as them letting C,
01:19as well as letting them see what we do.
01:23So.
01:26Just let me give a little bit of
01:29background here. Doctor yochelson.
01:34I went to Yale and was in the
01:37psychology department. And.
01:40Uh was doing very well there,
01:43and when he graduated he wanted
01:45to stay on on the faculty.
01:48But interestingly enough, at that time,
01:51Yale had a quota system for the number
01:53of Jews that could be in the department.
01:56And the department instead offered him,
02:01offered him to go to medical school here.
02:05So he took that up and became a
02:09psychiatrist and was in Buffalo
02:10for a while and then went to
02:13Saint Elizabeth Hospital,
02:15where he began a big study on
02:17looking at the criminal personality
02:20with another psychologist Stanton
02:23Census Salmon and they produce this
02:27three volume set which has waxed
02:30and waned and peoples interest
02:32over the years about the the.
02:34The meaning of it and trying to
02:37look at how criminals were different
02:39than people with mental illness.
02:45The they did looked at spent hundreds
02:49of hours with 255 criminals and this
02:53was all done at Saint Elizabeths
02:57when it was associated with an IMHO.
03:01Uh. And. So. The Yochelson family
03:10consists of the following.
03:12John and Bonnie are usually here
03:15in the audience with us and. No.
03:21I have been very gracious with their
03:24presence and contributions to a number
03:27of other areas in our department.
03:31John, I think it's in the middle of working
03:33right now and will will review this later,
03:36but he was here with us last night.
03:40To give you some and I some idea of who
03:44the prior lecturers and scholars were,
03:47you can see we have a pretty good array of
03:51who are well known in the forensic field.
03:55Both attorneys as well as psychiatrists.
04:01In the last few years we had Ray Patterson,
04:04John Bradford, Peter Ash,
04:06Renee Bender, Bill Resnick,
04:09Reid Meloy and Doug Mossman.
04:11And we began with Allen Stone and
04:13Myrna Diamond and Alan Dershowitz.
04:15So Paul Appelbaum, who are all
04:19well known leaders in the field.
04:24Deb is the director of the program
04:28in Law ethics, director of Forensic
04:31Evaluation Services for the University
04:33of Michigan and the medical Director,
04:36Behavioral Health and forensic
04:37programs in Michigan.
04:38Department of Health and Human
04:41Services for forensic psychiatry.
04:43Comprable to in some ways what
04:46Charles DK does here in our state.
04:50But she has had intimate contact
04:52with both state and university,
04:56both Michigan and in Massachusetts
04:59for a long period of time,
05:01and so has become very familiar
05:03with the kind of problems.
05:05That we struggle with.
05:09She trained earlier in Ohio.
05:12That did a medical internship as some of
05:16us did back in some part of our history.
05:20And then did her residency
05:22at mass Mental Health Center.
05:26And, uh, also a common.
05:29Place that a number of US George
05:32Heninger and I both also trained there.
05:38And then did a forensic
05:41fellowship up in Harvard as well.
05:44I won't go through her whole 79 page CV,
05:48but she. As you know,
05:51close to 70 peer reviewed Articles,
05:5431 book chapters, 2 books.
05:57On stalking Abal Uation
05:59for civil commitment.
06:02She's had a number of appointments,
06:05both in Michigan, case, Western and Harvard.
06:11And a wide variety of research
06:14interests, including schizophrenia,
06:15as she did some early work on ketamin.
06:20Legal regulation of psychiatric practice.
06:26And financing of behavioral health services.
06:31Opiate use disorders. Law enforcement.
06:37And disaster behavioral health.
06:41She is the current chair of the
06:44Council on Psychiatry and Law of the
06:47American Psychiatric Association and
06:49has had a long history as having
06:51a number of us with that group,
06:54which I consider the best
06:56continuing education in our field.
06:58And so she has worked on developing
07:01position papers and position and
07:04resource documents for the APA.
07:06On a variety of very topical subjects.
07:11One of which will be part
07:14of the discussion here,
07:16both on guns forced medication,
07:18competence to stand trial.
07:23And she's also been active in the
07:26American Academy of Psychiatry Law,
07:29which is our subspecialty organization,
07:32and has been the President.
07:38Tell me this does not look like Deb Pineals.
07:44I just noticed that I've had
07:46this on and then I couldn't.
07:48No, but not note the resemblance.
07:52So. Deb has been involved in the
07:57area now as all of psychiatry.
08:01Of what has happened in the post E.
08:03Institutionalization movement,
08:05the movement of patients
08:07into correctional facilities.
08:09Trying to get funding for people in the
08:13community to get diversion services.
08:16Housing that goes along with it
08:19and the enormous backup now in
08:21both forensic systems around
08:23the country and emergency rooms,
08:26and I think she's going to talk about
08:29some of the efforts to try to deal
08:32with how that has spread across the country.
08:34So with that,
08:36let me let them take over.
08:38Thank you.
08:42Well, thank you and I never saw that self
08:44resemblance until you pointed it out.
08:46I used that picture quite a bit for
08:49some of my talks, but thank you Howard,
08:51for that lovely introduction.
08:52And most of all, thank you all for honoring
08:55me with this prestigious opportunity
08:57to be the Yochelson visiting scholar.
09:00It's been quite an experience I've
09:02enjoyed every minute of it and
09:04I'm excited to share with you.
09:06Kind of a whirlwind tour of policy and
09:09activity that I've been involved in, and.
09:12I'll tell you the story about
09:14what I'm calling John beds,
09:16trends and crisis services.
09:22As I begin, my Howard already gave
09:24some of my background in addition
09:26to the titles that he said I,
09:28I do provide psychiatric expert witness
09:30work as well as systems consultation
09:32and and a consultant of Pew Charitable
09:35Trust and several federal entities.
09:38I don't have any conflicts of
09:40interest related to this presentation,
09:42and just as a reminder,
09:44these opinions in this talk are
09:46my own and not of other persons or
09:49entities with whom I am affiliated.
09:51So let me start by telling you
09:52what I plan to do,
09:54and then hopefully I'll be able to accomplish
09:56these learning objectives with you.
09:58First, I want to discuss current
10:00efforts to examine mental health
10:02services beyond beds and to help you
10:04understand what that actually means.
10:06Then I want to describe the
10:08evolution and launch of 988,
10:09which, interestingly enough,
10:10when we were talking about a variety of us
10:13were talking about what topics to present,
10:15and I mentioned 988,
10:16it wasn't clear to me that a
10:18lot of people had heard of it,
10:20so I would be very curious if somebody could.
10:22In the chat,
10:23if people had say whether
10:24they've heard of it or not,
10:25and somebody can give me that feedback,
10:27'cause I can't really watch
10:29the chat while I'm talking,
10:30and then finally I want to discuss
10:32the promises and challenges for the
10:35crisis services continuum of today,
10:37and I will warn you that some of this is.
10:41A lot of this, not my talk,
10:42but a lot of the work is a work
10:44in progress and there are many,
10:45many issues and many,
10:47many sensitivities around some of the
10:49issues that people are talking about
10:51at the policy table in terms of how
10:53best to meet the needs of people in crisis.
10:56So again,
10:57just to go back,
10:58the first goal is to discuss
11:00current efforts and to examine
11:01mental health services beyond beds.
11:03It's not clear exactly where
11:05to begin in this story.
11:06You could begin far before 1963,
11:09but I figured this is a good place in
11:11the historical development because a
11:12lot of people point to this and say
11:15about how President John F Kennedy
11:17passed the community mental Health
11:20Centers Act and identified that mental
11:24illness and developmental disabilities.
11:26As being among the most critical
11:28health problems he noted with his own
11:30family experience that they occur
11:32more frequently affect more people
11:34require more prolonged treatment,
11:35cause more suffering by the
11:37families of the afflicted,
11:38and waste more of our human resources
11:40and constitute more financial drain
11:42than any other single condition.
11:44Of course, again,
11:45he was touched with this with his own family,
11:49and,
11:49you know,
11:50we will never know if he had not been shot.
11:53How the world of Community mental
11:55health might have unfolded after this.
11:57Tractors past,
11:58but Fast forward to 2017 where I'm
12:01going to continue the journey and help
12:03you understand what we're talking
12:05about at at state and federal levels.
12:08In 2017 there were endless endless
12:12articles in endless jurisdictions
12:14of the problems that we were facing.
12:17It seemed everyone was burdened
12:19backlog and waiting for beds and
12:21whether it was waiting in jail or
12:23waiting in emergency departments.
12:25These problems were getting picked up.
12:27I would like to say that today
12:29the problems are solved,
12:30but I can tell you that I asked my last
12:32students to pull articles on similar
12:34topics and they have no shortage of.
12:37There are no shortage of articles
12:38that still come out to this day,
12:40but that doesn't mean that we aren't
12:42trying to turn a very big ship and
12:45move it in a better direction so that
12:47what we have to do is vision a future.
12:50But nevertheless in 2017 with
12:53this problem arising I was.
12:57And many access to care and
12:59health care questions.
13:02Behavioral health issues being questioned.
13:05I was given the opportunity and asked
13:06on behalf of the National Association
13:08of the State Mental Health program
13:10directors to write a paper to try and
13:13help the media understand that we can't
13:15build ourselves out of this problem.
13:18There was a lot of advocacy to expand
13:21state hospital beds because of the
13:23idea that they had been contracted and
13:25we're in this mess because of that.
13:27And so, although in this paper we
13:29don't say we don't need more beds.
13:31What we tried to articulate is that
13:34there is no calculation that is known
13:37to be exactly accurate for what beds
13:40are needed in a particular jurisdiction,
13:43because much of it involves
13:44understanding what else is available
13:47as an alternative to beds in the old
13:49days when state hospitals were the only
13:51resource for any number of ailments,
13:53whether it was a neurocognitive
13:55decline in condition, neurosyphilis,
13:57intellectual disability,
13:59poverty, what have you?
14:02They were the catchall places
14:04where people went in addition to
14:06people with serious mental illness.
14:07But we have a whole host of
14:10other types of of.
14:11Opportunities now going on
14:13and ways that our policies,
14:15including the Americans with
14:16Disabilities Act and other things
14:18are having us look at what can be
14:20done in a Community based setting.
14:22And so my colleague Doris Fuller,
14:24who was a former Washington Post journalist,
14:26and at that time was the head of
14:28the treatment advocacy Center.
14:30Worked with me to coauthor this paper,
14:33which was, interestingly enough,
14:35jointly released because these the
14:37treatment advocacy center is not always,
14:39you know,
14:40advocating for the same things
14:41that state mental health program
14:43directors are advocating for,
14:44but in this particular moment in
14:46time there was a joint decision to,
14:49through the help of the substance abuse
14:51and mental Health Services Administration,
14:53which funded the work to help people
14:55understand that we need to think beyond
14:58beds and to really look at the vital role.
15:01Of a full continuum of psychiatric care,
15:04just like we see in medical care and
15:05through a technical assistance work group,
15:08we came up with ten recommendations.
15:10First to recognize the importance
15:12of the vital continuum.
15:13To get clear on terminology of even
15:16what a bed means to look at what we
15:19can do to reduce the penetration
15:20of population and illness from
15:23just from criminal,
15:24legal and juvenile justice settings
15:26to look at emergency treatment access.
15:29What psychiatric beds offer.
15:31Data driven solutions.
15:33The importance of linkages
15:34so that people just don't,
15:36you know,
15:37fall off the radar when they are
15:39leaving one place or another.
15:41One support system or another.
15:43The use of technology,
15:44the importance of expanding the workforce,
15:46including the peer workforce
15:48and the importance of expanding
15:50to nontraditional partners,
15:52including faith based organizations.
15:54Families with lived experience and the like,
15:57and this paper has been cited.
16:01Over and over again and really
16:04has tried to help address some of
16:06these important policy issues.
16:08In fact,
16:09the EPA has undergone under
16:11President Jeff Geller
16:12a workgroup looking at bed need and
16:14will be issuing a report from that
16:16task force and looked at that paper
16:19too as one of its informational items.
16:21The other thing that was happening in 2017
16:24and if you were at some of my other talks,
16:26you might have heard me talk about this,
16:28was that there had been a Group A
16:30promulgation of this sequential.
16:31Intercept model which was established
16:34and you know it was developed in 2006,
16:372006 in a psychiatric services article
16:40and then adopted by policymakers and
16:43advocates and essentially incorporated
16:45into the 21st Century Cures Act and
16:48basically what the Sequential INTERCEPT
16:51model is is is it's almost like a
16:53public health approach to the over
16:55penetration of people with mental illness
16:57in the criminal system and basically
16:59what it says is if we can identify.
17:01Where they are in the path towards
17:04deeper end criminal involvement and
17:05intercept that path and re-route them
17:07into more appropriate treatment settings.
17:10We can potentially bend that curve
17:12and reduce that penetration when
17:14the model was first developed,
17:15it started with the law enforcement
17:17intercept because it was recognized that
17:19you don't get into the criminal system
17:21without an interaction with law enforcement.
17:24However, in 2017.
17:25Colleagues at the at Policy
17:29Research Associates led by Dan Abru,
17:32added INTERCEPT 0 to the Sequential
17:35Intercept model,
17:36recognizing that the crisis care
17:38continuum would be the the way
17:40to avoid in the 1st place,
17:42requiring that police encounter.
17:44In addition,
17:45many things were happening around that time,
17:47and these are just things that
17:49are that were available.
17:50There were many different
17:52crisis centers established.
17:53There was a rent something called
17:56the Restoration Center that
17:57had been established in 2014,
17:59trying to do some police based diversion.
18:02There were the zero suicide protocols
18:04to help reduce the risks of suicide and
18:07suicide rates were going on going up,
18:09and so there's been a lot of funnels that
18:12have sort of pointed us towards looking at.
18:14Crisis services from there through
18:16the National Association of State
18:19Mental Health program directors.
18:21I and some colleagues also helped establish
18:24other papers that you can see online.
18:27These are in the grey literature.
18:28One was called Boulder,
18:29Goals better results which was really
18:32trying to identify like we do for cancer.
18:34Very high level goals like 0 homelessness,
18:380 suicide to try and really helps us
18:42as policymakers and and you all as
18:46practitioners to really try and drive,
18:48change and make things different like we've
18:51seen in many other medical conditions.
18:53And furthermore,
18:54in 2019 there was a look across the
18:57seas at the international community to
18:59see what was happening in different
19:02dimensions to help learn from their
19:05experiences as opposed to only
19:08having the other other countries
19:09learn from the United States.
19:11It seemed that we could learn from
19:13them and then, lo and behold,
19:15COVID came and we have seen,
19:17as you know, major major system shifts,
19:21and we are still reeling from those shifts.
19:23And there is nothing that is totally
19:26settled with our experiences.
19:29Ironically, in February 2020,
19:31just as COVID was emerging in the United
19:36States, Samsa issued the national
19:38guidelines for behavioral health
19:41crisis care best Practice toolkit.
19:44And this toolkit got a lot of
19:46attention by people paying attention,
19:49but frankly, because of the timing,
19:51it it perhaps didn't get seen as much,
19:54but it remains now.
19:55A lot of people are talking about it.
19:57It has become sort of a a Bible if you will.
20:01Of policymakers around what the
20:03goals are for crisis care and.
20:06And again,
20:06I'll be curious if someone can
20:07tell me at the end how many people
20:09had heard of 988 so from there
20:11another paper was written in 2020.
20:14That people recalled meeting need crisis
20:16services meeting needs saving lives in
20:19which we were trying to imagine the future.
20:21Looking at our current
20:23problematic crisis system,
20:24which all too often involves a
20:26person in crisis where the only
20:28option is 911 or law enforcement.
20:31And that means an arrest or an emergency
20:34department which is flooded with
20:35psychiatric patients who maybe don't
20:37need an emergency department level of care.
20:39And obviously,
20:40if there is an arrest,
20:41we've got all sorts of other issues that are.
20:44Lead to negative consequences when that
20:47may not be the appropriate response.
20:50And So what we envisioned with SAMHSA
20:52with the National Association of
20:54State Mental Health Program directors
20:56was a model crisis continuum that
20:58really looked more robust with
21:00more elements within that continuum
21:02that could meet people's needs as
21:05they had them at different levels
21:07with different types of staffing.
21:09The use of peers,
21:11more community services while
21:13using evidence based programs.
21:15But a whole range of approaches
21:17beyond just the emergency department
21:19or law enforcement response,
21:21and furthermore,
21:22even going upstream as we keep
21:24doing with this intercept idea,
21:27is trying to build in warm lines
21:29where people can call so that
21:31you can avoid a crisis and that
21:33would be the ideal altogether.
21:35The core elements in the guidelines
21:38and toolkit included having a
21:40regional or statewide crisis call
21:42center that coordinated in real time,
21:44deploying mobile crisis everywhere, anywhere.
21:47Having a 23 hour crisis receiving
21:50and stabilization program and using
21:52essential crisis care principles
21:55with a service array that would
21:57include suicide prevention.
21:58Person centered care strategies
22:00to meet people in distress,
22:02whether they have a mental
22:03health condition or a substance,
22:05use, condition, or both.
22:07Reducing the use of psychiatric
22:09hospital beds if those were not needed.
22:11Providing a resource to eliminate
22:13psychiatric boarding in the
22:15emergency departments and providing
22:17a viable solution to the drains
22:19on law enforcement resources in
22:21the community and being crucial in
22:23reducing fragmentation of mental
22:25health care and essentially Samsa,
22:27has been positing the idea.
22:29At these crisis hubs would be warm,
22:32welcoming and available to anyone,
22:34anywhere,
22:35anytime regardless of insurance
22:36or any other issue that they would
22:39be trauma informed,
22:40person centered and link people
22:42to clear pathways if next
22:45steps are needed. In addition,
22:47there's a lot of discussion about how to
22:50blend technology with human resources
22:52by utilizing an air traffic control
22:54methodology of of routing calls and
22:56making sure that the highest priority
22:59calls are getting the quickest response.
23:01Utilizing GPS tracking.
23:02For example, if there's a safety
23:04issue where an individual needs to
23:06be given a more immediate attention,
23:09access to data systems to understand when,
23:11for example, Doctor Crystal has an
23:13opening in his clinic that somebody could.
23:16Make an appointment for and also looking
23:19at data to help inform best practices.
23:22Also taking lessons learned from
23:24what's happened with COVID-19 and
23:26testing access and access to services
23:28that people have through 211,
23:30which nationally is kind of an
23:33information line for resources.
23:34If you want to find your local domestic
23:36violence shelter or you want to
23:38find a local mental health provider,
23:39many states utilize 211 for this information,
23:42so it would be an amalgamation of all
23:44of these activities and in many ways.
23:47A lot of what was happening.
23:49Was really looking at driving forward
23:52some of the recommendations that had
23:54come out of that original beyond beds
23:57paper on building out that continuum
23:59focused on the crisis care continuum
24:01and establishing other elements.
24:03So now you understand a little bit
24:05about where this beyond beds framework
24:08comes from and what the thinking is
24:10is to really build a robust continuum
24:12of care so that we can get people
24:15into beds when they need them,
24:16but not have people waiting for them.
24:19Or or going into them if they don't
24:21need them and also helping people
24:23get out of them when and discharge
24:25to appropriate settings so that more
24:27people who need them can get in.
24:29So that brings me to my second goal,
24:32which is to describe the evolution
24:35and launch of 988.
24:38Alright,
24:38So what is 988 and where did it come from?
24:42Well,
24:42first of all you have to understand the
24:45context so we there are many catalysts
24:47that have driven us to where we are today.
24:49In the crisis response system
24:51as I and I've mentioned,
24:52many of these,
24:53but we have suicide rates that people
24:56are attention paying attention to.
24:57We have COVID-19 the opioid overdose crisis,
25:01which is now equally a methamphetamine
25:04crisis.
25:04We have these problems with needing
25:06more jail diversion.
25:07And then we have this huge new
25:09influx of of concerns about law
25:11enforcement and their involvement
25:13in mental health crisis prevention
25:16services for children and adolescents.
25:18Many,
25:19many states are getting sued and trying
25:21to build out better practices for children.
25:24Connecticut has some very good models
25:27but we have lots of places where the
25:29mental health systems are getting sued.
25:31Regulations are making it difficult
25:32to achieve some of the goals and we're
25:35having to modify lots of different things,
25:38including laws.
25:38I can tell you in Michigan,
25:39we've modified our commitment
25:40log twice in the last six years.
25:42Since I've been there.
25:44So many things are driving the
25:46need for a better crisis response system,
25:49and of course, as I mentioned
25:50in the law enforcement category,
25:52rather than defaulting to a law
25:55enforcement crisis response,
25:56many people have been talking about
25:58for a long time more than just be a
26:02specialized police response like CIT.
26:04When police are necessary,
26:05a collaborative police based police
26:07based mental health response.
26:09Or just a mental health response when that
26:12can be done appropriately and safely.
26:15And this is a really exciting
26:17area of development.
26:18So in July of 2020,
26:21almost a year ago,
26:23the FCC passed the the the rule,
26:27the ruling that 988 would be
26:30the new number for the National
26:32Suicide Prevention Lifeline.
26:34I don't know how many of you have
26:35those magnets for your refrigerator
26:37or signs for your offices,
26:38which frankly you should have,
26:40and it gives a number for this
26:42national suicide prevention lifeline.
26:44But it's a long number people
26:46had difficulty remembering it
26:48and there was a lot of advocacy.
26:50Just on that issue alone,
26:52to make a simpler number for people
26:54to call for suicide prevention and
26:56so 988 became a reality in 2020.
26:59Now it has not gone.
27:00Live it it is going to go live this
27:03year in July and many states are
27:06gearing up vigorously for this.
27:09Having received planning grants and
27:11doing a lot of ramping up activities
27:13because it will be a national number.
27:15And when you think about it in the
27:18world before 911 when people had to
27:20call 1 number for poison control.
27:21Another number for fire,
27:23another number for a heart attack.
27:26A lot of lessons had to be learned
27:28to to develop a 911 system and now we
27:32are introducing A988 system so it's exciting.
27:36It's scary.
27:37There's a lot of work to be done and and
27:39still a lot of lessons to be learned.
27:42But there are states that are
27:43passing legislation to make it a
27:45reality to figure out how it's going
27:46to get funded and all sorts of
27:48details that have to be worked out.
27:50You may have seen this with.
27:52This is such a hot issue.
27:53You may have seen that this was
27:55written about in the New York Times a
27:56couple weeks ago in an in an article
27:58that sort of warned that maybe
28:00we're not going to be ready for it,
28:01and so I'm just going to tell you
28:02some of the things that are happening.
28:04And yes,
28:05there is a lot of work still to be done.
28:08So in 2020,
28:09around this same time this paper
28:11crisis services meeting needs saving,
28:14lives was written to really try
28:16and look at this crisis service
28:18array in a deeper way,
28:20trying to understand how to make
28:22services accessible, interconnected,
28:24effective and justly applied.
28:27And in that work we did a survey of
28:29mental health leaders around the country,
28:31and they identified a number of
28:33concerns and bear about barriers
28:35that might come up around 988.
28:38Implementation first of all,
28:39workforce shortages has been
28:41a huge issue on the minds
28:43of any mental health leader.
28:45Also, there were concerns about how
28:46do we address the needs in rural
28:49communities compared to urban,
28:50do we have the right technology?
28:52Do we have the right crisis
28:54system infrastructure?
28:55Do we have the funding?
28:57How are we going to meet the needs of
28:59diverse populations and geographies?
29:01Do we have sufficient bed
29:03capacity for crisis beds?
29:04If we identify a crisis and
29:06somebody needs to go to a bed?
29:08For even a brief period of time,
29:11and how are we going to ensure
29:1324/7 availability like 911?
29:14And how are we going to look at
29:16what law enforcement emergency
29:17medical and mental health system
29:19collaboration is going to look like?
29:21And then a couple of mental health leaders
29:23talked about legislative barriers,
29:25so this was a survey done in 2020.
29:28So now the key areas of focus that are
29:30going to shape our future outcomes
29:32are really what we're working on.
29:34And there's several areas that
29:36I just want to highlight.
29:38One is that we have this pandemic that
29:41has been kind of in our way in a major way,
29:44and there's a lot of work in
29:46disaster behavioral health.
29:47Looking at emotional responses to disasters,
29:50and this is just a graph that I use a
29:52lot of times in my in my talks about this.
29:54These issues is that there's there's
29:57this collective community response,
29:59but one of the things we understand
30:00with COVID is that it's a very
30:02variable response for the community,
30:04because some people may have been
30:06more directly impacted with.
30:07With death in their family or with
30:09their loved ones with getting the
30:11illness everybody pivoted around
30:12the lockdowns and things like that.
30:14But it's really a complex aftermath
30:17and what we've been seeing through
30:19the CDC's Household Pulse survey,
30:21which is done every two weeks and
30:23has been done through the pandemic,
30:25is that we're seeing about 30%
30:27of Americans reporting anxiety
30:29or depression on validated scale
30:32screening scales that look like
30:34they're pretty significant.
30:36And this I've been following
30:37these maps in my role.
30:39Because I report out on our COVID
30:43you know our regular COVID calls.
30:46This is pretty concerning that we
30:48have this many people in distress.
30:50It's not surprising,
30:51but it is pretty concerning,
30:53especially for people like all
30:54of us in this audience who are
30:56trying to meet the demands.
30:58While the demands may be growing.
31:01There's also a lot of lessons
31:03learned in COVID about disparities.
31:05There were there were similar lessons
31:07learned in the 1918 pandemic,
31:09and and I think it's worth understanding
31:12how the different waves of that
31:15pandemic affected different populations
31:17at different times depending on
31:19neighborhoods and socioeconomic status,
31:21and we saw the same thing with COVID-19.
31:25We've also seen how disparities impact
31:28these deadly outcomes with law enforcement.
31:31And that the disparities in prevalence of
31:34negative social determinants of health.
31:36And so we know that any services
31:38that are built out have to be
31:40built out with a lens of
31:42equity and trying to figure out how
31:44best to do that is complicated.
31:46And so we also have these challenges
31:50of the workforce where you know,
31:52are we going to have the workforce we need,
31:54or do we need to expand the types of
31:56individuals that would be working in this
31:59crisis domain to help address the needs?
32:01Of course technology has
32:03been greatly advanced,
32:04but there's still places where
32:06there may be limited access to
32:08equipment or the Internet even,
32:09and so if we build out a crisis service,
32:11that's something like a 911,
32:13but for behavioral health crisis,
32:15will we be able to meet those needs?
32:18So where do we go from here?
32:20The needs clearly are still great.
32:22There's clearly a lot of
32:24challenges that still remain,
32:26and we have a lot to sort out in
32:29this 2021 ready to respond compendium
32:32of papers that I helped work on.
32:35There's many different threads
32:37that we built out,
32:40and if anyone is interested in this,
32:42these are available at the Nashville website.
32:44They're free, downloadable,
32:45really useful papers to
32:47understand what's happening.
32:48And in this we identified several priorities.
32:51One is to continue to drive the policy
32:54and funding for expanding and achieving
32:57a full continuum of psychiatric services.
33:00The second priority related to
33:03rebuilding and rebooting a robust,
33:05diverse and well qualified workforce trying
33:07to bring people back into the workforce.
33:10Many states are looking at things like
33:13loan repayment programs and other
33:15incentives to drive younger people,
33:17or people who might.
33:18Otherwise,
33:19turn to other professions back into
33:21the world of mental health services.
33:24Also expanding telehealth practice.
33:27While ensuring ongoing quality
33:29and access priority,
33:31four is fostering integration of
33:33disaster behavioral health into
33:35emergency preparedness and response.
33:38Priority five being considering
33:40creative financial opportunities to
33:42maximize access to crisis response
33:44and other community based mental
33:46health and substance use services
33:47with no wrong door,
33:49so states are literally looking at
33:50whether you know to use some of the
33:53same cell phone taxes that we have
33:54that some that contribute to 911 or
33:57other payment mechanisms to help fund
33:59this type of infrastructure that's necessary.
34:02And there's the idea,
34:04of course,
34:04that we need to focus
34:06intentionally on diversity,
34:07equity and inclusion to reduce the
34:09disparities in mental health outcomes.
34:11And I'll say a little bit more
34:13about that later and then priority.
34:14Seven that we identified was to
34:17enhance interconnectedness with
34:18other systems and across borders
34:20for improved global responses we
34:22saw in the pandemic that we are
34:25not alone in the United States that
34:27these waves move across borders
34:29and needs move across borders.
34:31And just like we have to.
34:33Figure out how to work between you know
34:35Connecticut and Michigan if necessary,
34:37because these call centres
34:38the way it works is.
34:39The idea is that most of the calls
34:41are supposed to be handled locally,
34:43but if the all the local lines
34:44are tide up they will get bounced
34:46to another region and that region
34:48is going to have to have that
34:51interconnectedness to know what's
34:52available in the existing region.
34:54And so there's a lot going on
34:57around that interconnectedness.
34:58So that is the story of 988 and
35:03a background to what is coming.
35:07And now finally my last goal for you is
35:10to discuss the promises and challenges
35:12in a little bit more detail because
35:14I've touched on a few that obviously
35:17bring up some controversial issues,
35:19but I want to dive into
35:21them a little bit more.
35:23So first of all, realize that people
35:25are really excited about this.
35:27This was from our mental
35:28Health Commissioner survey.
35:29One commissioner said.
35:30We are very excited about the
35:32work of 988 and what it means for
35:35individuals experiencing a mental
35:36health crisis in the United States.
35:37We look forward to continue work to
35:40realize the vision for all Americans.
35:43It is a lofty, lofty test.
35:44And remember that mental health
35:47commissioners have traditionally
35:48been focused by design by statute,
35:50by funding on the seriously
35:53mentally ill population.
35:54While they remain the state
35:56authority on mental health matters,
35:58and so now when we talk about 988,
36:01we're not just talking about people with
36:03serious mental illness who are served
36:05in a community mental health system.
36:07We're talking about me and you,
36:09and anybody who calls the number
36:11who's in a behavioral health crisis
36:13and needs some kind of assistance.
36:16So the work is broad.
36:17It's exciting,
36:18but there is a lot of things to consider.
36:21For example, lot of discussion now,
36:23about least.
36:24Intrusive measures that when somebody
36:26calls for a behavioral health crisis,
36:28how do we meet their needs in a way
36:31that will not include invading,
36:33invading their persons,
36:35but also finding ways to save lives?
36:38If we need to save lives and that
36:40means that we have to look at
36:41what are our laws and authorities.
36:43Lots of discussion now I can
36:45tell you in Michigan,
36:46we're looking at our laws related
36:48to police pickups related to
36:50the work of people that are an
36:52assisted outpatient treatment.
36:53Trying to understand where
36:55psychiatric advance directives.
36:56Fit in and how?
36:57If a responder goes out to a
36:59scene and an individual has a
37:01psychiatric advance directive,
37:02how that might play out?
37:04There's also issues with EMTALA,
37:06which is the emergency medical
37:08treatment and Labor Act,
37:10which is really was really designed.
37:13It was sort of a quote anti dumping
37:15law which was designed to say
37:17that if if people were coming into
37:19emergency departments they had to
37:21be stabilized before they could be
37:23transferred and not just transferred
37:25because of inability to pay.
37:26And so how does EMTALA fit in with all
37:29of this new behavioral health crisis work?
37:32I think a lot of that remains to be seen,
37:34and then information sharing with both HIPAA,
37:37the mental health and
37:39medical confidentiality,
37:40confidentiality statute,
37:40and 42 CFR Part 2 which governs
37:43the confidentiality of people
37:46receiving substance use services,
37:48which is more restrictive than HIPAA.
37:51We have to be able to navigate that because
37:53if the individual comes into a crisis center.
37:56Let's say in in Middlebury,
38:00but they're getting methadone
38:01treatment in new New Haven.
38:03Will there be access to that information?
38:06And these are really important
38:08things for us to sort through.
38:11OK, you can't talk about crisis services
38:13without bringing up this topic of law
38:16enforcement in the in the crisis conundrum.
38:18And I will tell you that
38:19as controversial as it is,
38:20and as much as people begin with,
38:22defund police,
38:23people are moving more towards the center,
38:26but not entirely.
38:28There's definitely still advocates
38:30that want zero involvement of
38:32police in a mental health crisis.
38:34And then there's others that are
38:37trying to look at other avenues.
38:40And I'll talk a little bit
38:41about what other avenues.
38:42Is being developed I think,
38:44where where the policies are
38:46settling is trying to get the
38:48right response at the right time.
38:50I recently showed a video to my law
38:53students of a man with schizophrenia who
38:55is wielding a knife towards his mother.
38:57His mother was frightened and called
39:00police and the police came in and
39:01and were able to deescalate him.
39:03But in the video that was shown
39:06there was a gun drawn and the
39:08law students really reacted and
39:09didn't and and talked about.
39:11Why couldn't a social worker
39:12go to that scene?
39:13There's some other mental health
39:15professional to quiet the situation down.
39:17The problem was the knife,
39:19and I think when when we look at
39:20how we're going to fix some of
39:22the problems we want to get ahead
39:24of the time where somebody with
39:26schizophrenia is holding a knife.
39:27Of course, that's the best strategy,
39:29but we still are going to need responses
39:33for situations that might invoke
39:35more of a law enforcement response.
39:37And I'll talk a little bit about that.
39:39There was a paper that was written again by
39:41my colleague Doris Fuller called overlooked.
39:43In the undercounted,
39:44it's a really interesting and good paper
39:48talking about the disproportionate.
39:50Fatality death death by police for
39:54people with mental illness and so
39:55that was a really important paper.
39:57So of course we've talked about,
40:00you know it.
40:01You in the public,
40:02you know Black Lives Matter,
40:04but the intersectionality of mental
40:06illness and race and all of these
40:08other factors really becomes an
40:10important part of the conversation.
40:13At the same time,
40:15there are States and it's
40:17seeing it now in media reports.
40:19And I've personally seen it in a case.
40:21In Michigan,
40:22where the the effort to keep law
40:25enforcement away from behavioral health
40:28crisis may backfire in certain situations,
40:31and in some cases we've seen law enforcement
40:34refusing behavioral health calls.
40:36In fact,
40:37I testified in a federal court.
40:39In a conversation unrelated
40:41to law enforcement,
40:42but the judge was asking me
40:43questions about what are we gonna
40:45do about the fact in Washington
40:47that the police this was in the
40:49papers that the law enforcement
40:50were refusing behavioral health
40:53calls and so we have seen I've seen
40:57in other jurisdictions where the
40:59mental Health Center has called for
41:01help and the law enforcement because
41:03of fear of litigation and not not
41:05fully having clarity on their roles.
41:08At this point we're concerned about.
41:10Intervening and then you have
41:11the risk of people with mental
41:13illness being left to languish.
41:15So we really have to get
41:17to the right balance here.
41:19I worked on these issues with my colleague,
41:21Matthew Edwards,
41:22who's a historian and specializes in
41:25a lot of areas of racial justice.
41:27And we wrote this paper called Law
41:29Enforcement in crisis services.
41:31Past lessons for new partnerships and
41:33the future of 988 and what we talked
41:35about was the importance of law enforcement,
41:37emergency medical services,
41:39and behavioral health.
41:40Partnering and coordinating as we go
41:43forward and recognizing that there
41:45is a long and complex history of
41:48collaboration to help individuals get
41:50into treatment and keep communities safe
41:53and we need to learn from those past
41:55lessons about how to drive future models.
41:58And so he he Doctor Edwards is
42:00a specialist again in in history
42:02and one of his areas of focus.
42:05He's written extensively about the
42:07Freedom House ambulance service,
42:09and I've learned a lot from him.
42:10It's a fascinating account of the 1960s
42:14to 70s community based idea of it.
42:17There was a socio medical program that
42:20aspired to encourage black enterprise
42:22as a black run paramedic service.
42:25And frankly, it's set national standards in.
42:28EMS training and delivery for
42:30meeting the needs of people in
42:32their own communities by people
42:34of their own communities,
42:35and it supplanted what was otherwise
42:38happening with white police,
42:40firefighters and morticians.
42:41And again,
42:42it's set national standards in emergency
42:45medical services and became a model
42:47for many public health systems and
42:49it improves social and professional
42:51outcomes for paramedics while providing
42:53high quality service and care.
42:55It became highly visible through members
42:58of mark to members of marginalized
43:01populations in in positions of leadership,
43:04and so it was a real hallmark
43:05and a way to think about how to
43:08meet the needs of communities.
43:10Unfortunately,
43:10overtime there was a complex factors
43:15that sort of included looking
43:18at things kind of more uniformly
43:19and without an equity lens,
43:21which led to racial neutralizing
43:23standardization and then expansion
43:25of super ambulance services and
43:27monetization that led to its replacement,
43:30and therefore I think there are some
43:32really important lessons to learn about.
43:34How do we build proper modern
43:36standards but still pay attention
43:37to how to meet the needs of people?
43:40An out of hospital context and
43:43in that mobile crisis interface.
43:45And so we've been focusing a lot in
43:47some of the work we've been doing.
43:49Doctor Edwards, and I.
43:51I'm looking at these different
43:53populations that might have neat
43:54that will have different and unique
43:56needs for these systems to meet,
43:58including people of different race
44:01and ethnicities, immigrant needs,
44:02non English speakers,
44:04the LGBTQ plus community,
44:06children and adolescents, older adults,
44:09persons with intellectual and
44:10developmental disabilities,
44:11and even those with medical complexities
44:14or intersectionality of all of the above.
44:16And so it's a tall order to
44:19have crisis services meet.
44:20The needs of these diverse populations.
44:23But some of the things we can learn is,
44:25you know, thinking through prior police
44:28strategies that might have been overly
44:30zealous in preventive approaches,
44:32that in fact led to the over
44:35incarceration of black populations
44:36as well as underwhelming responses,
44:39leaving communities with high social
44:41determinants to struggle on their own.
44:43And again,
44:44looking at the intersectionality as we
44:46think about behavioral health responses.
44:47Of mental illness and race and the role
44:50of intergenerational trauma and cycles
44:52of violence and poverty and what that
44:54is going to mean when people come out to do.
44:56These mobile responses and so we have
44:58to build this into the mental health.
45:00Behavioral health crisis
45:02response of the future.
45:04So lots of work going on about out
45:06of hospital which is really the
45:08medical term used for when you go
45:10out and you do CPR in the street
45:12we're now seeing paramedics being
45:14able to induce buprenorphine for
45:16people with opioid use disorder.
45:18Out in the communities I'm giving,
45:21you know naloxone,
45:23but even inducing coupon orpheon
45:25could be an out of hospital approach
45:27where where people could get
45:29medicated and you could envision
45:31a future where somebody who,
45:32let's say is off their medication,
45:35is having a psychotic break where
45:37the hospital responders the medical.
45:40The crisis responders might be
45:41able to engage that individual in
45:43a dialogue and even engage them
45:45in initiation of treatments.
45:47And So what can we learn and that requires?
45:49Again, a lot of partnership,
45:51so people are really looking at
45:53blended and innovative models.
45:54More and more,
45:56including emergency medical services,
45:58mental health services as well as
46:00law enforcement so that the right
46:02responder comes at the right time.
46:04Now is law enforcement really necessary?
46:08I think there will always be situations
46:10that are high risk weapons suicide by COP,
46:13otherwise known as victim
46:15precipitated homicide.
46:16Law enforcement assisted
46:18suicide barricade situations.
46:19In hostage situations and I'm
46:21just going to tell you from my
46:23own very personal experience,
46:24this was a standoff not far from my
46:28own home and where I was called.
46:31I work a lot with our local sheriff
46:33and I was called to be a subject
46:36matter expert in vivo in this 36
46:38hour standoff where a young man
46:40with presumable mental illness and
46:42substance use disorder had held
46:44his parents hostage with firearms.
46:47Luckily the parents were able to leave.
46:49There was a SWAT team that had brought
46:51in community mental health case managers.
46:52On their team that we're working,
46:55and together they were able to
46:57gather information from the parents.
46:59Learn more about the this man's history,
47:01bring data to the table,
47:04calm the response if you ask me what my
47:06job was when we did the after action review,
47:09my job was to say,
47:10why do you have to act now?
47:12Let's wait it out and overtime,
47:1536 hours later I was not there for 36 hours.
47:18But over 36 hours they were able to
47:21successfully have this man self surrender.
47:24No one was injured.
47:25It was an unbelievable thing to witness,
47:28but I would say these are the kinds of
47:30situations where a mobile mental health
47:32crisis is not going to be sufficient.
47:34And so we have to bring these lessons
47:37forward and involve ourselves and
47:39think about how trauma informed
47:41practice is really building training.
47:45Really, building training of the
47:47workforce to think about these
47:49complex issues engage peers,
47:50and have partners at the ready and on call,
47:53such as law enforcement when it
47:55gets beyond what people can handle.
47:57Now, let me turn just quickly to the
47:59national Suicide Prevention Lifeline.
48:01'cause that's where 988 starts.
48:03And it started in 2001 and it eventually
48:06became titled the End and SPL in 2005.
48:10It has a central switchboard
48:13connecting callers and crisis centers.
48:16In 2013 they added crisis chat
48:19services and in 2021 crisis tech
48:21services and they have received many
48:24many calls since the inception.
48:27There's also something called
48:28the disaster distress.
48:29Help blind which really expanded
48:31in the wake of kovid.
48:33And so here's some data that just
48:36looks at calls from 2020 and you can
48:38see that NSPL has received over 1.8
48:41million calls around the country,
48:44so there's clearly a need and the
48:46thought is that because the number is
48:48hard to remember when 988 rolls out,
48:50we'll probably be seeing many,
48:52many more calls.
48:55The data from Madeline Gould,
48:57out of Columbia and her colleagues
49:00are really compelling to show that
49:02suicidal crisis callers were able to
49:05have significant reductions in intent to die,
49:07hopelessness and psychological pain
49:09during the context of the crisis.
49:11Call that the callers and in crisis
49:13collaborate with the call center
49:15on interventions.
49:16Most of the time,
49:17so it does not require kind of a
49:20forced intervention to save a life
49:21and that emergency services are
49:23deployed in about half of the calls.
49:25And most of them can be dealt
49:27with just by talking and users of
49:29crisis services that are that are
49:31using chat services are younger,
49:33showing us that we need to have different
49:36modalities for different populations.
49:38And now there's a lot of work going on.
49:39Looking at the 911988 interface,
49:42my colleagues at Pew Charitable Trust,
49:45Tracy Velazquez and others put out
49:47a press release and of a study that
49:51they had conducted of 233 call centers
49:53around the United States in 27 States
49:55and they identified few responding
49:57calls centers having staff with
49:59behavioral health crisis training,
50:01having limited options for
50:03specialized response,
50:04and need for mental health and substance
50:06use to sort of resources to get to people.
50:09And also in need for improved data to
50:11understand how many of the 911 calls
50:13are really behavioral health crisis.
50:17So that is a lot of information to cover.
50:19There is still much more work to be done.
50:22As I said, we're we're sort of
50:24building the bridge as we walk on it.
50:26Lots of complex questions,
50:27and so I would just summarize and say
50:30that crisis services are absolutely
50:32in a state of change and it is a key
50:36component of this of this idea that
50:38building state hospitals is not the
50:41direction that society will be moving in.
50:44There are too many reasons why
50:45that will not work anymore.
50:47And and should not work anymore.
50:49But we need to have a robust continuum
50:52of care and an array of services for
50:55people with mental health conditions,
50:57just like we do for people
50:59with medical conditions.
51:00And perhaps the beginning of
51:02that road is crisis services.
51:04I would argue that we'll be going
51:06back to intercept negative one,
51:07which is basic.
51:08Your basic mental health services
51:10and prevention strategies so we
51:12can avoid crisis in the 1st place.
51:14And and I'm not alone in thinking that,
51:16and so we're really building out this.
51:18Crisis service as a model,
51:20but it's expanding the scope of really
51:22trying to potentially rebuild the
51:24Community mental health system in the
51:26way that Kennedy had envisioned it,
51:29with a more robust and
51:31seamless infrastructure,
51:32that's going to require people
51:34like you at Yale and other places.
51:36Don't just let Columbia do the
51:38work to do research 'cause we
51:41don't know for what works really.
51:43We don't know whether these models of
51:46collaborative mobile crisis response.
51:48What works,
51:48we don't know what staffing
51:50patterns should look like.
51:51We don't know what there's not a lot of
51:53data on protocols for when a caller calls,
51:56and how does the how do the
51:58triage lines work.
51:59You know,
52:00we need researchers to invest in
52:02these crisis services so that the
52:05policymakers and practitioners can
52:07really start to build out a an
52:09array of services that are more
52:12based in evidence than anecdote.
52:15The current system is clearly overwhelmed
52:17with need and workforce challenges.
52:19I'm sure New Haven is is also
52:22experiencing similar Ed boarding
52:24and all of these other factors that
52:28play into the system challenges,
52:31so we really need to inspire a
52:33workforce and that's why in part
52:35I was particularly excited about
52:36being the Yochelson visiting scholar
52:38because inspiring a workforce has been
52:41part of my professional colleague,
52:42but we all need to do the work
52:44and I think the yochelson.
52:46Lectureship helps to inspire that
52:48workforce to stay in the game and to
52:51help keep being to meet the needs of
52:53people that were serving who hark
52:55seeing us in their most desperate times
52:57and so crisis services up tomorrow
53:00will likely look very different.
53:02Maybe not tomorrow,
53:03maybe not.
53:03In July of 2020,
53:05but envisioning what they could
53:07look like in five and 10 years
53:10is really an exciting opportunity
53:12for us and I would urge you all
53:14to stay abreast of the latest.
53:16And jump on the train and get involved.
53:19And with that I will stop and take questions.