KARL BELANGER: So, it is 11:00. Are we ready to get started?
REGAN RUSH: I think we're ready to go ahead and get started. We have another panelist joining, but it sounds like she'll be here in a minute, so we'll go ahead and get started. Thank you, everybody, so much for joining this session. My name is Regan Rush, and it's really a pleasure to be here with you today. I'm the principal deputy chief in the Special Litigation Section at the Civil Rights Division at the U.S. Department of Justice. Our section handles systemic civil rights cases, many of which involve persons with disabilities, including conduct by law enforcement, conditions of confinement and correctional facilities, and the administration of juvenile justice. I help supervise the Olmstead enforcement program, and that is the ADA's requirement to serve people with disabilities in the community instead of in segregated residential and day settings. The division has Olmstead matters in over half of the states, all at varies stages of investigation, settlement, or litigation. More recently, we've had the opportunity to be involved in a few of our systemic cases involving police interactions with persons with disabilities.
Through this work, we've learned that in order to ensure that persons with disabilities, particularly mental illness, can successfully live and thrive in the community, there must be a strong, effective community-based crisis service system. We'll talk more during the session on the critical components of such a service and program. But without such crisis services, we see people with mental illness needlessly placed in institutional settings, repeatedly and for prolonged periods of time. People arrested for minor infractions and placed in jail because of the lack of viable alternatives, often exacerbating their mental illness due to jail confinement. People interacting with the police, which can lead to trauma irrespective of the outcome of that interaction. And of course suicide. We also know that due to behavioral health treatment disparities, different communities experience these harms in different ways. The panelists that we have assembled today have significant experience, personal and professional, with crisis services. In building an effective crisis service system at the state level, implementing effective crisis programs, directly supporting people in crisis, and have experienced crisis services themselves.
I'd like to first introduce the panelists, then I'll ask each of our panelists questions for about half of our time today, and during the discussion, I'd encourage you to add questions to the chat, directed at Deena Fox, and then we will answer — I will collect these questions and pose them to the panelists in the second half of the presentation. And if you would rather, prefer to raise your hand at that point, and we can pose questions to the panelists that way, that is also fine, and when we get to that point, we'll talk through the process a little bit more of how questions are going to work, but for now, I will start with the questions, and then at the end, I'd also like to reserve just a few minutes for each of our panelists to have an opportunity to provide a final thought in a lightning round session.
So first starting with the panelists. We have David Covington, is the CEO and president of RI International. David is a behavioral health innovator, entrepreneur, and storyteller. He's also a partner in behavioral health link, producer of the Moving America's Soul on Suicide film series, and international film initiative's Zero Suicide, Crisis Now, and Hope Inc stories. David previously served as vice president at Magellan health. Next we have Melody Worsham, who is a certified peer support specialist working for the Mental Health Association of South Mississippi. Melody is also a founder and executive officer for Mississippi's first statewide peer network, the association of Mississippi peer support specialists, a statewide TA provider for the Mississippi Department of Mental Health. As a peer support specialist, as well as a person living with schizophrenia and the impact of trauma, Melody has worked to establish a recovery and whole health and resiliency program for a peer-run drop-in center for members to achieve a level of recovery that's important to them.
I will also add that Melody was called as a witness by the United States Department of Justice in an Olmstead trial in federal district court. The judge's opinion, finding in favor of the United States and finding a violation of Olmstead, opens with a summary of Melody's testimony. It's a great read, I encourage you to read it if you haven't already.
Next is Deena Fox, an attorney at the Special Litigation Section in the Civil Rights Division — Deena and I work together — at the U.S. Department of Justice. Deena Fox has worked to protect areas of disability rights, juvenile justice, and the religious rights of institutionalized people. Before coming to DOJ, Deena completed a two year fellowship at the Bazelon Center for Mental Health Law, and at DOJ has worked on Olmstead statewide matters concerning people with mental illness in Delaware, New Hampshire, and Mississippi. Crisis services has played an important role in all of these cases.
Steve Dettwyler is a public health analyst at the Substance Abuse and Mental Health Services Administration, SAMHSA. Steve has 30 years of experience in developing, managing, and monitoring public mental health, addiction, and intellectual disability services at the state and local level. Steve was responsible for implementing the community services requirements of the U.S. Department of Justice's settlement agreement with the state of Delaware. Steve is the co-steward of the interdepartmental serious and mental illness coordinating committee access, or ISMICC work group, which works on access to critical care and crisis systems of care. Our last panelist is Lisa St. George, who, if she has not joined quite yet, I think will be joining soon. Lisa is vice president of peer support and empowerment at RI International. Lisa has been instrumental in the planning, development, and startup of a wide range of peer-run programs over the last decade. An expert in developing a recovery-focused in behavior health settings, she has provided training, consultation, and program development for behavioral health systems as far away as the U.K. and New Zealand.
Welcome, all of the presenters on our panel, and appreciate everybody's attendance today. I can go ahead and kick off our first question, which is to David. What are the challenges of the way things work now with regard to crisis services?
DAVID COVINGTON: Thank you so much, Regan. The challenge is that if you're in a group of national leaders with lived experience, it's not uncommon to have someone say that even if they or a friend's life was in danger, they likely would not reach out for help in our current system. The reason they wouldn't do that is because of an experience previously that felt less like care and more like punishment. The most common experience for individuals seeking out more intensive crisis care is to be hours and hours or even days and days in a hospital emergency department going through the process we call in the field "medical clearance", in order to be potentially reviewed for acceptance at a program. In Washington State a few years ago, ultimately a Supreme Court ruling found that that practice is unconstitutional and unlawful, and the Seattle Times found that despite the resistance from some of the mental health leadership, that that only occurred on uncommonly. The Seattle Times found that the average wait time was days, with outliers in the week. So it's not uncommon for an individual to be met with law enforcement. Imagine your worst day, and it's a heart attack or a car accident. Immediately, a caring, engaged professional there is there to provide support, make steps better. Even when law enforcement comes with that same caring sort of approach, the trauma and anxiety related to armed and uniformed officers being at your door, and police cars with lights blaring in the driveway, many times individuals aren't actually arrested, but they are frequently handcuffed, put in the back of the patrol car, and transferred to a hospital emergency department or something else. So it feels very much like an arrest for the individual who's going through that, again, on their worst day. These approaches are expensive, inhumane, and ineffective.
REGAN RUSH: Thank you, David. What are the core elements of an effective crisis service system? What would you want to see?
DAVID COVINGTON: So, what I would want to see is the same thing that I'd want to see if I have a medical emergency. The first thing I want is someone I can call. My son's been bitten by a scorpion, that's what I did, I was immediately on the phone with poison control, in seconds I was with a professional that could help me out. If I need something more, I need someone who can come to where I am and meet me there, and if I need more than that — it can't be treated or stabilized on the scene, at my home — if I'm a homeless person on the street or I'm at a social service agency — if it can't be treated there, I want somewhere I can go that feels humane and feels less like an institution and more like a home. That's in fact what the Crisis Now model has laid out. In states like Arizona, Georgia, and others have moved into 988 becoming, July of next year, an easy to access, three digit hotline for mental health crisis and suicide hotline prevention. For those who need more, a community-based mobile team that will come to them — a social worker or a counselor, and a person with lived experience, peer support staff, coming in more like friends in an unmarked vehicle as opposed to law enforcement. And again, for those who need it, alternatives to acute care like a 23-hour temporary observation and treatment, what we call the living room, but alternatives that law enforcement can go directly to without engaging the hospital.
REGAN RUSH: David, and you mentioned sort of this analogy to what you would do if you were bit by a scorpion. How did we get here? How did we get to the point where we have mental health crisis being handled so differently than a physical health crisis?
DAVID COVINGTON: Well, there's the answer we normally get, which is we haven't funded, resourced, or prioritized these services, even though they were initially in President Kennedy's Community Mental health Construction Act's four pillars. Crisis care was supposed to be a priority from the beginning, but it wasn't. That's usually what we get. Look, quality improvement gurus say every system is perfectly designed to get the results that it gets. So we have to own that essentially what we have in the United States is determined that in an emergency, care, compassion, and effective medical intervention is the answer. We've also determined that we don't want to reward people being in crisis, so we put forth detainment, denial of care, and punishment. So that's what we've got to own up to. 988 gives us a potential to do essentially what we did with 911 in the '60s, to begin to turn this in a different direction. But there has to be a cultural shift for those services to take root and to be effective, and that is for us to understand that any of us can be in that mental health crisis. Any of us can need those services. And we are starting to see that shift, but we've got a lot of work to do.
REGAN RUSH: You also mentioned the role of peer support specialist. Can you talk more about what are the role of peer support specialists in crisis services and also in this culture shift that you're talking about?
DAVID COVINGTON: Yeah, I think we've got two issues here in play. One, 988, it's moving forward, and if you go back to the '50s and '60s, the hospital emergency department and the medical response system looked NOTHING like what we have today, so that amazing system I described was not the case. It looked more like our mental health response. And 911 sort of cascaded us forward. 988, there are 17 states that already have pending legislation — Virginia and Utah have passed their legislation to fund 988, and the national discussion all the way up to the Biden administration and Senator Wyden and senator Cortez-Masto. All of them are talking about mobile crisis and even crisis facilities in the way I'm talking about. So there isn't the workforce out there to fuel that kind of clinical response, so we're going to need to be creative, and peer supports allows us to do that. But a second question is, who is most effective at engaging and connecting with someone on their worst day? And Brian Michard out of the University of Montreal has been arguing for 15 years that people with lived experience who are appropriately trained, and again, all our staff have to be under appropriate medical and clinical supervision, but in fact they're more effective in engaging and supporting people as they're going through an experience that, for many of them, it feels like they're the only one. It can be very scary, it can be terrifying. And to have another individual who may have been at the back of that patrol car, experienced the same challenges, and found a way forward, that in itself is an amazing starting point to lead to better success and outcomes, as an individual shifts from pain and crisis to beginning to think about recovery and even hopes and dreams.
REGAN RUSH: Just to make sure we're all on the same page, David, can you just give us a brief overview of what 988 is?
DAVID COVINGTON: So the state of Utah 7 years ago began thinking about a three digit hotline for mental health crisis and suicide prevention. The National Suicide Prevention Hotline. And many state and local hotlines out there are not well known. And people tend to call 911 in an emergency. Even when they know there are going to be consequences of that. Look, the reason people reach out for help is not because they expect a caring response, but because they're desperate and they're afraid. So Utah wanted a response that could be easy to remember, and begin to delineate a caring response, not a law enforcement response. And Senator Orin Hatch said let's get it done by going in Utah, and that's what was done. FCC designated a number, 988, another number beginning with a 9, to identify that the two most important numbers in the United States will be 911 for a public safety concern, and 988 for mental health and suicide and crisis prevention. We're only about 16 months away from when it goes live. The FCC has suggested a roadmap, states are following suit. And it's barreling down the path. So like 911 created a promise that cascaded to a better response for all of us in a medical emergency, 988 is going to supercharge the efforts going forward, and we're starting to see state Medicaid directors, mental health leaders nationwide, as well as law enforcement and hospitals coming together with lived experience and family members to thoughtfully drive that forward so it succeeds right out of the gate.
REGAN RUSH: Thank you. One more question for you before I move on to the next panelist. What is the impact of having an effective crisis system? Do you have data on that impact?
DAVID COVINGTON: So, there's been research coming out of Columbia University and Rutgers for 15, 20 years now on the effectiveness of crisis call centers. There's a fair amount around mobile teams and emerging work around the facilities. But from a payer standpoint, these services are phenomenally less expensive. It's hard to imagine how wasteful our current approach is. Our current approach is not only inhuman, ineffective, and sometimes unsafe, but it's also a tremendous waste in the way we bill over and over again as people are taken through this gauntlet of trying to get care. We did a business case analysis in partnership with Arizona Medicaid, from the introduction of these services about 15 years ago in Phoenix, and if Phoenix operated like another comparably sized metropolitan area, how would things be different because of this? We found the equivalent of 37 police officers are engaged full-time in public safety as opposed to transferring people to emergency departments. We have not eliminated psychiatric boarding waiting lists, but we've eliminated 45 years per year if you stack them up because we've skipped that waiting process. Arizona Medicaid believes there's a $2 saving for every $1 of investment, and again, Arizona has a very cost-focused Medicaid authority, it's actually called the Arizona Health Care Cost Containment System. So we introduced these services because they're far cheaper. Victor Armstrong is the commissioner for mental health care in North Carolina, and he believes that our system, as bad as it is, it is played out in much harsher ways for people of color, especially Black American. In our data, we have crisis recovery centers across ten states now, and our data shows as we interrupt this process and get them help without going to the emergency department, we're surveying between 25 to 50% more to 100% more African-Americans that would have been present in that general population. So I think the benefits for people of color in crisis and just systems overall are more humane, more effective, more cost-efficient approach. It's rare that you get win-win-wins, but this is a situation where there are wins across the board.
REGAN RUSH: Thank you. I think Lisa St. George has joined us, so I'm going to move on to her next. Lisa, can you talk about why you became a peer support specialist?
LISA ST. GEORGE: Yeah, I've been a peer support specialist for 20 years, and although I have training in social work, I found that working from the lived experience is just phenomenal at connecting with people, and I've had the opportunity over these past 20 years to see thousands and thousands of people recover. In addition, I have my own lived experience, and especially pertinent to this conversation. For instance, you know, when you are a person with lived experience, when you are having challenges, it's a very scary thing to call the police, to call for help. It isn't something that you can expect kind treatment and gentleness, as you would if you were physically ill. And so, like many, many, many people, I have the opportunity — I say that facetiously — to be in the back of a police car when I needed mental health care. And what that did was created additional trauma to one of my historical issues is trauma from my childhood, and it just doubled down on the worry and the concern and the distress that I felt, because I thought I was being arrested! For essentially having a mental health challenge. And, you know, the other thing that happened for me is that I — people didn't understand — they didn't take the time to listen. And I know that sounds silly, because when I ended up in the hospital, there was this very much, very heavy us and them perspective going on. And so the things that I needed, which was kindness, gentleness, someone to understand what was going on for me at that time, were not available to me. And it's hard to believe that, but staff had other things to do rather than spend time. And that's what people who end up in a situation when they're really significantly challenged with their mental health symptoms, is they end up in the hospital, and people there should have time. There should be a large enough staff to spend time with people, and that's not what happens. So further, when I was in the hospital, I was sitting quietly, and the staff member wanted me to move 10 feet away. And I was trying to sit near a window where there was light, where I could see outside at least, and the rest of the place where we were all housed was very dark. There weren't any windows. So I just wanted to be by this window as I was trying to help myself cope with what was happening to me. And the woman asked me to move 10 feet away, and I asked, you know, can I please just stay here? I'm just drawing, I'm just sitting here, I won't bother you. And she then stood up behind her glass bubble and yelled at me my diagnosis and told me "you, so and so — I told you to get over there." And I just, I don't know, if you knew me, I'm the most quiet, peaceful — I follow directions kind of person! I just leapt out of my chair, and someone happened to come in the door to the unit at that moment, and it sent me out into the street, and I ran, in the most dangerous part of Phoenix, in a sweater, in the heat. Because I thought I could get home and hide in my closet! And what I realized when I was running — you know, about that — years and years later... is that the reason that I was thinking that is that I was back in my childhood trauma completely. I was thinking, you know, just like I did when I was a child, that I could go in the closet and hide. And that is not what should happen to a person who is in a hospital that's there to help them. They should feel as if someone cares about them, as if someone is there to walk alongside them as they say in New Zealand, as someone who is there who understands and actually has an awareness of their trauma. The moment that they get in there, work from a trauma-informed care perspective, so that they've already asked these questions and they know what your struggles are.
So, the problem also continued with, you know, after that, I was kept in a hospital and truly, after that, needed to be there, probably, more than I did when I first came. When they got me back there.
But, you know, my stay in the hospital ended at 30 days. My insurance was done, my 30 days was up. The insurance had 30 days of time that I could spend there. And how is that appropriate medical care? So I'm not saying I wanted to be there — didn't want to be there — but to have your stay end on the day that your insurance ends is questionable to me, and not right. People should stay two weeks if they need two weeks, a day if they need a day, or longer if they need it, and it shouldn't be governed by what people are willing to pay for. I have some — I have a daughter who has significant medical challenges right now, and she's getting her medical challenges cared for according to what the need is, not according to how much money is available in your medical plan.
And the thing that's so important about 988, number one, is, you know, I was greeted by police, and it would get people out there who can help. So if you had a clinician, they would be able to help you, and if they had a peer support with them, right away there's an equaling of people. There's a leveling of the hierarchy, and there's a connection that can be made between peer supporters and the individuals through that lived experience, it's like a gateway to, you know, I get you, I understand. I know where you're walking. And just the fact that someone else could understand what's going on for you, it's very powerful. And so it breaks down those walls, and the other thing about 988, and especially the crisis receiving centers, are that, you know, you get taken, and you get assessed in an appropriate way, and someone talks to you and asks you what's going on for you. And then once they've been with you for 23 hours or however many days that you stay in this short stay, then they decide, do you need to go into a hospital? Do you need that higher level of care or not? Because it's hard, your life is disrupted when you're out of it for a month. I know many people who have lost their housing during a period of hospitalization, and that's just not right, especially when getting housing is so hard that when you go into a hospital, if your whole life is disrupted and you lose your housing and your placement and whatever, and you have to go back and sort of rebuild a community in a completely different place. All of these things are tremendously disruptive to people. So we have a system, really, as David said, that's built to work for other people, not the people that it serves. And I can tell you that, you know, years later, I did have a stay overnight in a crisis receiving center, and I was struggling, and concerned about my ability to refrain from harming myself. So I went, I took myself to a crisis receiving center, and the difference that I experienced there with the peer support present was... just remarkable! And I stayed one night, and then they hooked me up to see my doctor the next day. And I was okay! Because these things are not, like, they don't last in me for days and months and years. They last for a period of time that I've got to get through, and I should be able to go and get what I need during that period of time to keep me safe. You know, because since the other experience happened, I have an agreement with my husband never to call the police, never to ask them to come. You know, put me in a room, lock the door, but don't call the police! Because, you know, I'm afraid of that! And that should not be. If I was having a heart attack, I would never say to my husband "never call 911, I don't want anybody to come and help me." It's absurd when you think about it. But I'm not the only one who has that kind of agreement with their loved one. Many, many people I've spoken with over the last 20 years have that kind of agreement that they don't want that police interface. So 988 to me, it gives us an opportunity to change the way that we handle people in their worst moment, but it also can lead to a better system overall that really is built to help the people that it's meant to help, and that holds the highest level of hope for people. I think that that is incredibly important, that we believe in people. So, you know, I... I think that, you know, all these things will really start to transform our system of care, I hope, in really profound, effective, and wonderful ways.
REGAN RUSH: Thank you, Lisa, and thank you for sharing your story with us. I'm wondering if you can tell us an example where either you as a peer support specialist or peers that you worked with have effectively helped someone in crisis and really avoid the kind of situation that you've just described.
LISA ST. GEORGE: Yeah, yeah. So, I mean, there's been, you know, over the past 20 years, I've worked with, I don't know, hundreds and hundreds of peers in different programs, and had the opportunity to see on multiple occasions people come in for services on that day and be really struggling, and the peer support can sit down with them and begin the conversation and open the door to what's happening. And sometimes being able to talk to somebody about what's scaring you or what's upsetting you, what's distressing you, can help lower that level of despair that you're feeling at that time, or confusion. And in our crisis centers, when we have a peer-first, peer-last model that we use, so the first person an individual sees when they come in, even though they're right now currently coming with police very often, is a peer support specialist who's going to be able to help that person feel safe, because there's somebody who gets them there. And, you know, I know what this is like, I understand, I've spent time here myself, and we're here to help you. And even when people are having really challenging times and they're very upset and distressed, I've had the opportunity to observe many, many times when, you know, the peer will just sit with that person, even if they're yelling, and even if they're angry, angry, angry, and sit with them. And the situation after a period of time will calm down. Because that trust is built, and there's a huge information, trust, and relationship building that happens really quickly with peer supporters. It doesn't take hours and days! Because there's this knowing that someone else truly understands you. And it's hard to know what another heart is feeling in this, but you can see in your eyes that they really get you. And when you feel really understood, that's when you start to feel safer, and heard, and you begin to understand that perhaps this is a place where people care and they are going to help you.
REGAN RUSH: Thank you, thank you for that. And just a reminder, if everybody, if you're not speaking, to please mute your Zoom.
Thank you, Lisa. I'm going to move on to our next panelist, Melody Worsham. Melody, can you talk about why you became a peer support specialist?
MELODY WORSHAM: I became a peer support specialist so that I could give people what I wish I'd had when I first got diagnosed, and when my mental illness started really interrupting and disrupting my life. I've had issues, most of it was from trauma from childhood, and so my mental health symptoms came very, very early in life, but I ignored them. I was told that it was a sign of weakness, I need to suck it up, so therefore I did, and it wasn't until after I was already married with two children that I suddenly realized that I probably needed a little more help than just "sucking it up" or snapping out of it!
So, actually, I talked to a counselor, and she seemed to be very supportive, and she was the one that gave me the diagnosis, and that kind of like put me in the mental health, medical model world. It was my first exposure to mental health professionals. And, you know, they kept asking me what my symptoms were, and we need to medicate that out of you, that's not natural for a brain to act that way. They put me on so much medication that I was not even capable of taking care of my kids, I was falling asleep while my baby was playing on the floor. I was drooling on myself. And I kept telling them, and they said, well, you have a choice... you can either be a mom or you can stay sick. You know, this is kind of like the choices they were giving me. And I'm like, there's gotta be some way for me to do both. What's the point of medicine if it's not going to make me well enough to live my life? It's taking my life away. And part of my symptoms are paranoia, so I done made up my mind that they were trying to poison me anyways, so I refused to take the medicine, and I lied to them. I tended to opt for the symptoms of a mental illness, I tended to opt to suffer. It seemed like it was easier to deal with than the medications and the treatments that they were trying to give me.
My first encounter with hospitals was actually a good one, and I had driven across a bridge, and I decided that the bridge was trying to kill me, so I actually parked my car in the middle of the bridge and I walked off the bridge and I dialed 911. I called the police to say that the bridge was trying to kill me. And so needless to say, they knew what they were coming to, they knew who they were coming to pick up. And they hogtied me for "my safety", but when I got to the hospital, it was like a house kind of environment. It had couches and sofas and, you know, a TV, and it had a coffee bar. It was actually really beautiful, there was a porch to sit on. And when I got there, all I wanted to do was rest! It's all I wanted. I just wanted a safe place to lay down and close my eyes without feeling like something was going to happen to me. And that's what they gave me. And it was such a great experience! (Voice breaking) — as the years progressed, I moved to a different area, but, I still, because of that experience, I trusted the mental health system, and so when my mental illness got bad enough, and the crisis was coming back, I dialed 911, I had no hesitation. But this time, they handcuffed me and put me in the back of a police car, and they actually took me to the jail. And they put me in a restraint chair. It was built for full-grown men, you know, like a lot of jails are, and I only weighed like 95 pounds at the time, and as tight as they would retrain it, all I had to do was relax and I could slide right out of the chair. I would lay down on the floor, and they would look through the window, see I wasn't there, and go pick me up, and I would say, please just let me lay here. They would put me in the restraint chair, strap me back, in I would slink back out. This went on for 24 hours, until I finally said, I want a lawyer, I asked for help and I don't know why you have me here in a jail, and then they let me go. They didn't try to get me mental health help or anything. But at that point I done made up my mind that I wasn't going to call 911 for mental health help again, ever. That was many years ago, in the '80s, and during the '90s, I just went without treatment altogether, but I ended up being committed a couple times because of that. I ended up wandering around and people were concerned about me, and the doctors would tell me, yeah, you need to get on some medication because people are very uncomfortable around you, and I said, if they're uncomfortable around me, maybe THEY should take the medication!
So, you know, I just decided to stay away. I became homeless for a while just to stay away from the system, I was afraid they would find me. I found a little city park and I actually lived in a giant oak tree for a long time, the branches were big enough to sleep on and it was very comfortable, and people don't look up for people, they look through bushes, down, in the ground. I felt that as a woman being homeless, that was a safer place for me to be. And I opted to do that instead of the police seeing me again and having to go through that trauma of being treated like a criminal. So... as the years progressed, I knew that that's what I wanted, I knew that that's what I was looking for, and so when I did start seeing a counselor, I went to a Christian counselor at a church, I felt that was safer than a community mental health center, and I would be with people waiting to see the therapist and I would be talking with them. I was the only one talking in the waiting room, because everybody else was like, don't look at anybody else, just stare forward, read the warning lists on the walls, but I'm just like engaging. And I would actually ask "what are you in for, what are you doing here, how's it helping you, what are you learning from this, because I'm trying to figure out? Some way to live life, I just want to live my life". I know I have something to offer the world, and I just want to figure out a way to do that. So I started sharing with people, and one day I was doing that, and I was, they were sharing what they were learning, and I was sharing what I was learning, and I got into my counselor's office, and she goes, you don't really need to be talking to them, you could be influencing them to do things their counselor has told them not to do. You're sick, too, so you don't have anything to offer them, and they're sick, they don't have anything to offer you, it's blind leading the blind, so you need to stop talking to people in the waiting room. And I didn't feel comfortable about that either! So I'm a little bit of a rebel, you know, and I continued to fight. And it wasn't until I started just working for myself, because nobody wanted to hire me. I've gotten blatant about just telling people, I used to try to hide it, but then of course when the symptoms would come they would think I was on drugs or that I was dangerous, you know, the stigma of mental illness. And so then I was applying for jobs, hi, I'm Melody, I have schizophrenia, will you hire me, and that wasn't working very well either! So I started working for myself, and it was through some independent business associations, entrepreneurial organizations, that I actually met my current employer, the Mental Health Association. She said, look, we're trying to have a peer-driven drop-in center. We've had the drop-in center open since 1963, but this peer-driven idea is something that we're trying to pursue. Is it something that you'd be interested in looking into? And I'm like, uh, yeah! I said, you do understand that I have mental illness? She said, that's the whole reason why I'm hiring you!
I was like, okay, you didn't hear me right!
(Laughter.)
So it took me a while to digest that someone would actually hire me BECAUSE I had mental illness, I had a hard time accepting that paradigm in my world since I've been rejected this whole time because of it. So she put me through the training that the state was offering for peer support training, and she said, I want you to have all the latitude to find out how you fit, because I understand that peer support specialists can only use the experiences and the strengths that they have. So I can't — there's no one size fits all model. So you need to find out what you're able to do, and then we'll discover what the gaps are that our clients need, and find other peer supporters who can fill those gaps. And I'm like, that sounds fantastic. And I'm a teacher, I love to teach, and so I started teaching WRAP, wellness recovery action planning, dimensions of wellness by SAMHSA, because it is peer-driven, allowing them to focus on the dimension of wellness they want to focus on. How wonderful it was to see the looks on their faces that, you mean, I get to call the shots, and I get to say what I need, and you're just gonna provide it for me? How wonderful is that, instead of just being told what to do! And it's what I always wanted. So I'm like, absolutely, if that's what you want, that's what we will work on. And so they have chosen things that, in the traditional model, they're like, oh, we don't talk about that stuff, that's a taboo subject, and it's like, no, we're going to figure out, doggone it, how to get this through, because this is obviously something that people want. I've been there for 10 years now! So it's been an exciting ride, it really has.
REGAN RUSH: Thank you, Melody, for sharing your story. Thank you for being a fighter. We need more Melodies out there.
So I did want, before I move on to the next panelist, wanted to ask you to just share briefly a story of an experience of you as a peer helping a person in crisis and how that worked.
MELODY WORSHAM: Okay, and I'll actually start with my first initial experience with mobile crisis. Mississippi got mobile crisis, I think, maybe four or five years ago, it hasn't been that long. So it was fairly new at the time, and I had a mental health crisis, and I had heard that there was a mobile crisis team in my area now, so I was like, you know what? I'm going to give them a try. Well, they showed up, and one of the people that came on the team was actually someone that I was terrified of from the community mental health center.
She was someone who had coerced me in the past, told me that I wasn't allowed to have therapy or anything if I refused to take the medications, and she was one of the people on the team, so immediately I was terrified having her in my house. But there was a peer support specialist on the team that I did know, and so I allowed everyone in the house, but I had the peer support specialist sit next to me on one couch, and I made the other person and the other team members sit on another couch on the other side of the living room. And I, in my mental health state, I don't think she could hear me, I didn't think she could hear me, so I only talked to the peer support specialist. And at one point, that therapist reached into her purse, and I looked at her, and I said "if you pick up your phone and you call 911," I said, "this is my house, there's woods right out there," I said "I will be out of here in 2 seconds and no one will find me and you can't stop me, so take your hands out of your purse". And she put her hands in her lap and I told the peer supporter what was happening to me. She helped calm me down, she worked WRAP steps with me because she knew I used WRAP, and she reminded me of wellness tools to keep me well, and for five straight days, she's called me to follow up. How are you doing, Melody? And she met me at Waffle House one day just to chat. That got me through the crisis in half the time that it normally takes me, so I know that model was very effective. I've done the same thing for people in crisis, the first thing I want to do is just listen, let them talk about anything they want to talk about.
Even if they're not talking about their mental illness or what's happening to them, it doesn't matter, the fact of the matter is they just want to be heard. So sometimes I'm just hearing about the sales at the Dollar General store that they took advantage of, and it's all they want to talk about, and you know what? Just that listening helps them calm down and know I'm being heard, and this person respects me for who I am and they're meeting me right where I am.
Eventually, after listening, they do say "this is what I need, help me figure out how to get it." And so it's customized. I'm an expert on myself, and you're an expert on you, so you're the only one that can tell anyone what you truly, truly need at a particular time. And so just that listening has made such a difference in people's lives, that they can just get on with their lives a lot quicker, and just like we were talking about the medical treatment, if we get the right care immediately, that heart attack doesn't turn into a lifelong disability. That I can just get on with my life, I can still go exercise, I can still have a family, I can still play. The same thing with mental illness: The sooner I can just get myself to manage — I can't cure it, but I can manage my mental illness and just live my life — living my life is the goal, not being symptom-free.
REGAN RUSH: Thank you, Melody.
Let's move on to Deena, our next panelist, Deena Fox. Deena, can you talk about why DOJ includes crisis services in its remedies for Olmstead violation?
DEENA FOX: Sure. So what we look at when we're figuring out what remedy would be appropriate in a particular case, is we look at what problems we're seeing on the ground in the course of our investigation before we file a case. And so in the cases where we seek crisis services as a remedy, it's because we have seen that there are people who are being essentially pushed upstream in the system because there was not a service in place that could help divert them earlier on. So, where people are going straight into a hospital or state hospital service, where people are getting, as we've talked about a lot already today, law enforcement engagement rather than assistance to connect with services, and where there is just not an alternative for people prior to unnecessary hospitalization. Then we look to see, we need to add that piece of the system to prevent the Olmstead violation of the unnecessary institutionalizations that are happening. And we've seen that also now, we're looking outside the context of our more traditional Olmstead cases, but also in matters, for example, with law enforcement. In our office, we're looking at ADA violations that may be violations of a failure to accommodate in the police response, for example.
REGAN RUSH: Can you talk about examples of DOJ agreements and consent decree requirements around crisis services?
DEENA FOX: Sure, so I think you'll hear some reflection of many of the things that David talked about in describing broadly what has been proven to work in the crisis world, and so, core components that he mentioned would be a crisis hotline, which hopefully in the future will be just calling 988, and we won't need to include a crisis hotline, because everyone will have one. So a crisis hotline where all calls can be collected, and then sent on. Then the mobile crisis team that Melody was just describing, which is a core element of the service system that can divert many of the folks who cannot be diverted just through response over the phone. And then also small short-term crisis stabilization, either through peer-run apartments, or someplace, out of someone's home if they're having a crisis in the home and they need either medical care or more focused peer support for a short period of time, usually, you know, 2 or 3 to 5 days, with a return back to their home in that time so that they don't experience the problems that Lisa was talking about in terms of losing housing or jobs, etc.
Also, in some matters, we have requirements around coordination with law enforcement, CIT teams, and other education for other parts of the system to prevent people from being sent into law enforcement, justice system, direction rather than getting the care and support that they need.
REGAN RUSH: Absolutely, Deena, I'm really glad you mentioned the law enforcement piece, because certainly something that's a focus of our section right now is also to really look at how we can, in our police cases that really look at pattern of practice of unconstitutional policing and other violations of federal law regarding policing, really looking at ADA claims and how we can, with the ultimate goal of really diverting people from law enforcement responses through dispatch and others in the first place. First place. That's something we're very actively interested in, and if folks are hearing about issues in local communities where there's high interaction between the police and people with disabilities, irrespective of what those outcomes can be, we're definitely interested in hearing more about that, and Deena can put our email address in the chat so you know how to reach out to us, so, thank you, Deena.
DEENA FOX: Yeah, and I can just say real briefly, in the Baltimore consent decree that our office entered related to that police department, some of the key aspects designed to resolve ADA violations were training of CIT officers, all officers being trained in crisis intervention, training of dispatch to reduce police interaction with people who are in a mental health crisis, the assignment of a crisis intervention coordinator, and the development of crisis intervention plan for the city to do an to do an assessment of what the needs were in the system, and then data collection, which will help inform further developments in that system.
REGAN RUSH: Great. Deena, can you talk a little bit just briefly about the results, the impact of the requirements in consent decrees regarding crisis services?
DEENA FOX: Sure. Based on some of the reporting in the Delaware agreement, which was the point of our earlier mental health, Olmstead agreements, which is now concluded, and we'll hear more about it from Steve in a minute, but some of the outcomes there were: Mobile crisis diverted 90% of people from hospitalization or criminal justice involvement, who called for assistance. The monitor found that the crisis stabilization centers diverted at least three-quarters of people who were evaluated there for further inpatient services. And the people who were evaluated and served at the crisis stabilization center were being referred by mobile crisis, police, ERs, so these were people who already had opportunities at diversion previously, and also were being diverted from those criminal justice involvements that we talked about. Mobile crisis response time averaged 40 minutes at the conclusion of the agreement, which, again, is kind of closer to in line with what we're looking for in the 911 response. And when law enforcement had the opportunity to use a crisis stabilization center, so a short-term crisis residential placement, instead of an ER, it took them only 10 minutes to do that drop-off. So it incentivized police to use these crisis services rather than going to an ER or an arrest, which would take a lot more time for the police officer. And so we want to make it easy. We would rather if there's no need for law enforcement, for them not to be involved at all in that process, but to the extent that they are involved, we want to make it easy and incentivize use of appropriate mental health services rather than either hospitalization or arrest.
REGAN RUSH: Great, thank you, Deena.
Let's see, I'll move on to our final panelist, Steve, but just a reminder that if folks have questions, to go ahead and start putting them into the chat so that we can collect them. You can direct them to Deena Fox, and then I will have time here at the end to pose some of your questions to the panelists.
So, moving on to Steve, you had developed a crisis service system in the context of a DOJ settlement in Delaware. Can you tell us about what the critical components of the crisis service system was? And I think we've heard quite a bit about the crisis hotline, about the mobile crisis, so maybe focus a little bit on some of the issues regarding, or the program around crisis apartments and walk-in center.
STEVEN DETTWYLER: Okay. Yeah, Delaware did develop the components that you've heard a couple times today. The hotline, the mobile crisis, the diversion, the receiving centers. What we also developed was peer-run respite apartments, and we — the crisis diversion centers had not existed in Delaware prior, so those were a new development. I think the most important part of both of those — one of the most important parts of both of those that really changed the system in Delaware for people needed services, was not just the introduction of peers, but the central role that peers played in both of those. Both of those centers, those types of services, the diversion centers and the apartments, were run, managed, decisions were made by trained peers. It was an exceptional addition to Delaware, Delaware did not really have much of a peer program prior to this, and it really made it work. You heard the statistics on the diversion programs we had.
Most of that was achieved through the efforts of the peer programs that we have. We also had to develop a number of other services that weren't specifically crisis services, but they were needed in addition to the crisis services. The crisis services are essential to a well-functioning mental health system, but they're not sufficient in and of themselves. So we also developed a number of services that worked in conjunction with crisis. For example, we developed intensive case management programs that had not existed previously, and the intensive case managers were directly tied to the diversion centers. Because people come to the diversion centers, they're assessed, they're helped, a plan is made about what's going to happen next, hopefully that's hospitalization, which we were very successful at averting hospitalization, but they needed a next step, and the intensive case managers were the folks that would help them with the services and supports that folks said that they need in the community, it was critical.
REGAN RUSH: Can you talk about just, in implementing the agreement, particularly on the crisis service side, what went well and what challenges did you hit?
STEVEN DETTWYLER: What went extremely well, and it started at the beginning of the introduction of DOJ into Delaware, was that the governor's office said "let's do it". There were people that worked for the state at the time that had experience with other states with settlement agreements, and knew that you could fight this in court for years, for decades, but you're going to end up at the same place, so why don't we do the right thing right now? And with the support of the governor, and then the secretary of health and social services and all the way down, it was extremely positive. It worked really well because DOJ came in with a clear idea of the types of outcomes it wished to achieve, both metrics and programmatic. It worked well because DOJ and the state worked together on really fleshing that out. You know, it's not enough to say that you want diversion programs. You really had to figure out what type of diverse programs. You had to find out what other parts of the state needed to be adjusted, developed, in order to work well with the DOJ requirements.
So for example, one of the things that — DOJ didn't come in saying we needed to change, but we realized, Delaware realized right away that we did, was how people are detained, what laws govern the detention of folks in a psychiatric crisis, and what the terms of that were. And the laws that existed prior to DOJ coming to Delaware really did not support the goals of both DOJ and the state mental health system. That worked out really well.
Some of the things that probably would have worked better, that didn't work so well, was that Medicaid was not at the table when we first started talking with the Department of Justice. Eventually they were involved, but they weren't at the beginning, and Medicaid is a critical component of this. They spend most of the money in the states, in all states for mental health services. If they're not at the table, then their input, their own constraints, their own ideas may not be incorporated. And a DOJ settlement agreement is fairly short. Delaware's was five years. It's not a lot of time to change these massively complex systems. So it would be very important in any state to have Medicaid involved at the very beginning.
Another concern I have is sustainability. Settlement agreements, they start, they have conclusions, and it's over. There's a lot of money tied up in these things, there's a lot of competing demands in states. I think states really need to think about how do you sustain something that may have come in as a result of DOJ's involvement, but really brings positive results to the state. But to have it to continue, you need leadership, you need leadership to do that.
There were some good and some mixed things that came in with this. That is, good and bad. The one thing is that... there's crisis systems, and then there's all the ancillary services that I kind of alluded to. This is a massive shift in any state. It's not just a matter of putting a mobile crisis team in place. It's a matter of contracts and funding and regulations, and I think that that was very difficult, but it's absolutely important and essential for these systems to work, to get through the massive systems change needed to implement these things well.
I think I answered your question.
REGAN RUSH: Thank you, Steven, and I really appreciate your point about how the state really took the agreement and then used it to sort of continue as a catalyst for change, and focusing on areas that might not even have been spelled out or been obligations of the agreement. And the importance of leadership, and especially at the governor level.
I'm wondering if you have thoughts about the role of — that advocates can play, disability advocates can really play to kind of sustain that change. And I'm interested in your perspective, having been on the state side.
STEVEN DETTWYLER: Yes, the advocates need to be involved, for both of the things, for getting these things going in the first place, and for sustaining it. Delaware had a really strong partnership with both the Mental Health America and NAMI throughout. We had peers in the organization, but then the state backed out of it, in order for the peer system to be an independent advocate. These were all critical components for both the development — keeping our eyes on the prize, as it were, reminding us what we were doing, why we were doing it — and being an important partner at the table the entire time.
We also had really good partnership with the police, and by that I mean, the police understood that their role in this was not a police matter. It wasn't something that they were trained or expected to do, but it was something that they got involved with, with people in crisis, all the time, and it wasn't really what was needed in the state. And essentially the police needed to get out of what they were doing for a lot of the work they were doing. They were really good partners on this. Without them in partnership, people still would have been picked up under 911, they still would have been taken to emergency rooms, they still would have been hospitalized inappropriately. It was the partnership with the police and the advocacy groups that really helped us to get to the part where police's role was minimized, the humane part of the crisis diversion programs like our living room models were allowed to flourish, to really do what they could do. But all these different groups were essential for this to work well.
REGAN RUSH: Right, thank you, Steven. I'm going to also remind folks, just, if you have questions, we're sort of at the question part of the program. Please put them into the chat to Deena Fox. You can also raise your hand by using the reaction, hand-raise button on your Zoom, or you could also, I'm being told that a technical way to do this without pushing the little reaction button, you could do alt-Y for Windows programs to raise your hand. If you're calling in by phone, you can press star-9 to raise your hand. Or you can, if you're using a Mac, you can use option-Y to raise your hand and ask a question.
I'll go ahead and start, we already have some very good questions, and one is a follow-along, Steven, to what you just talked about, about the role of police. The question is: What is the right goal, CIT trained officers, or mobile crisis? And does CIT also train detectives and officers who are not sort of on the beat parole officers?
STEVEN DETTWYLER: I'll just start. Our goal was to absolutely minimize the role of police. Police are needed sometimes, but almost never, really, almost never. CIT is really important, I think, for police to understand situations, they're going to come into contact, whatever, aren't the state's role. The police are always going to be involved at some point for some people, so they'll need training. But the goal is really to completely minimize the need for police through other means, and we've talked about several of those.
REGAN RUSH: And another question that is a follow-up to that one is, is it realistic to expect a non-police response when there's a perception of a violent situation? And this questioner has indicated that they've called a mobile crisis and they just called the police, so the promise of non-police response is misleading at best.
STEVEN DETTWYLER: David?
REGAN RUSH: David, you want to take that one?
DAVID COVINGTON: Yeah, so, um, I want to push on this a little bit. I'd like to just even take Steven's comments and maybe just extend them. So we believe, first of all, law enforcement should be involved in any situation when there's overt criminal activity or imminent public safety threat. Hospitals should be involved when there's a medical emergency.
Our belief is that of the likely 26 million calls that go to 911 every year for mental health, substance use, and suicide, the overwhelming majority of them do not include those criteria. In fact, we've already looked at, with a group out of Atlanta, over 4 million calls to the city of Atlanta 911. And in fact, even apart from mental health calls, most calls to 911 are not meeting those criteria that we're talking about! It's very few. Car accidents are obviously the number one, with 18%. And there are very few related to what we're talking about.
Now, let's press on that for a moment with data. So we have, in our crisis recovery, our flagship program, we operate a dozen programs across ten states, but our flagship program in Peoria, which has been open for 25 years now, we get 13, 15, 20 law enforcement drop-offs a day. Now, they originated with either some sort of pickup order, a 911 call or some sort of engagement. I've asked our team — that's 5 or 6,000 visits a year — how often is the individual so violent or aggressive that we have to call law enforcement back, say this was an inappropriate referral and we need you to come back and help us out? The nurse manager on site said, David, I've only been here three or four years, and we've never done that once. Once or twice a year we may file charges against someone because of something beyond the pale, but even then we don't say, law enforcement, rush back here.
Another example, we have one of the most robust mobile crisis teams in the country, running 2,000 plus mobile crisis contacts per month, where law enforcement is the first responder and law enforcement passes off, it's about 5% of the time that those mobile teams say, you know what, we're going to need law enforcement in the scene. Sometimes there is a weapon or a history of violence so they're looking for law enforcement to clear the scene, and then they'll engage. Sometimes they want law enforcement on the scene, but they'll engage. And we've been doing this a decade across 159 counties. And it's the same thing. 3 to 5% of the time they're engaging with law enforcement. So if there's a medical emergency or overt threat to public safety, then we need to investigate and involve our partners. But we've got to grapple with the fact that that's about 95% of the time, that's not the case. Now, you can have both mobile teams and crisis facilities that don't want to move into this environment because, hey, this is hard work, I am not going to say it's easy. But the power that Lisa and Melody were talking about earlier, peers are very effective at engaging, collaborating, and we've got many examples where even our best medical and clinical people, which are really good, peers have had a sense of what's going on and been able to support it. And that de-escalation and engagement is going to be more effective from our trained peers and trained medical and clinical as opposed to the agitation and escalation that occurs automatically from seeing that firearm, the taser, the club, the uniform, etc. So it's a new paradigm, but we're seeing people across the country move into this space.
STEVEN DETTWYLER: If I can add, Regan, to something that David said, is SAMHSA just did a survey of all 59 states and territories that receive block grants about the states of their crisis systems, and there's enormous variation among the states. The person that asked the question initially was talking about what happened to them. There's no one response right now in the United States. There are 59 different responses. We're hoping with leadership from lots of places, and more federal money, that there will be more consistency, but really these are state-driven approaches. We know what the best practices are, but there's still enormous variation.
DAVID COVINGTON: But Steve, it's not complicated. Melody described a clinician and a peer coming into her home.
STEVEN DETTWYLER: Uh-huh.
DAVID COVINGTON: It was a team, and they brought two different skill sets, Melody, but one was really engaging and connecting, and one, you know, ideally, they're providing documentation support, etc. That's all we're really talking about. Go where the person is, a two-person team, a peer is involved, and that's it, and it's available 24/7 to anyone. So the variability will start to come out.
STEVEN DETTWYLER: Uh-huh, yeah.
DAVID COVINGTON: As we start thinking about what we're trying to achieve here.
DEENA FOX: I think, if I can jump in real quick, what I've heard with states when they're trying to develop these services, they often get some pushback on these same questions that are coming up now about, is this safe, can we as providers feel comfortable sending people into a crisis scene when we don't know if the situation will be dangerous or there may be some indicators. And what has, you know, of course, we provide this as the information and the statistics to support the fact that it is not, and also that over, you know, hopefully a short period of time, people can become more comfortable as they begin doing the actual response, and that it may be that there is a higher degree of coordination with law enforcement earlier on, until people realize and really become more comfortable with the experience of actually, this is not a dangerous situation, and I feel comfortable that my clinicians and my peer support specialists will know when it is that they actually do need that kind of support. So I think that there may be — and David, if you have specific strategies on the transition, but I think that there's probably a learning curve, and a confidence curve, has been my experience in talking to providers and states where we've been pressing for this approach.
DAVID COVINGTON: So, Deena, I think you're spot-on. There are two major challenges here: The mobile teams and the crisis facilities are where the rubber hits the road. And then it's not just law enforcement. We historically have taken the exact approach you've just described. Outliers change the entire thing, and then everyone with any potential that this could be violent or aggressive. And also, any potential that this could have a medical complication means that we send everyone shunted through a hospital emergency department. I can tell you that in 2004, our flagship program that I mentioned was one of the best in the country in terms of we did receive law enforcement drop-offs, but also, I'll be honest with you, a little bit of cherry-picking. There are states with whole crisis facilities that don't accept law enforcement drop-offs, and we did, but we didn't accept everyone. In 2014, in Arizona, it's now an expectation. And we were told by Aetna, David, you have about 5 minutes to fix this issue. And the concern was we didn't have the clinical nursing resources to support that work. So we leaned that that heavy. But in late 2014, we started accepting every single law enforcement drop off, again, 13 to 15 a day. And now it's 25,000 successive people that law enforcement came into contact with them, whatever, on the street, 911, pickup order, etc., they brought them directly to us, they didn't call, they didn't go in a web portal, they came to us because we were the closest in the count. There are two others in the county operated by different companies, but they do the same thing. They came up, knocked on the door, there's almost an airlock room that goes into the 23-hour temporary observation unit, not to admissions. The law enforcement officer is there 3 to 5 minutes, and then they're back on the street, they're gone. So there are individuals who in fact have medical complications, but now the law enforcement officer is gone, and we're owning that on our end. So all we've done is switch the order from everyone spending days at the ED to, quote-unquote get the medical clearance, to us identifying to the staff that there's someone who needs additional supports, and in the 1 or 2% of cases where that's the event, then we're going to get them to the care that they need outside. But the same thing relative to the reality of that the individuals are going to be aggressive or agitated. We actually do have people that, they have big feelings on sometimes the worst day of the year or their life. So safety is a constant issues for us, and we think we're one of the best in the world doing it, and we also don't have it mastered. We're actually piloting something called a CURU right now in a couple of our sites nationwide. We're always trying to learn. But the principles that work for us, the peer-first, peer-last that Lisa talked about — having wide open spaces, we actually believe that having the Plexiglass fishbowls that staff are behind are counterintuitive, it accelerates anxiety and agitation. Our staff are trained in restraint and individual support if necessary, but, Lisa, what's our — project Renew, the seclusion and restraint room was called our renew room, and we had a project for doubling down on further reducing those incidents, and we're making it every year that goes by. So this does work, and that's what we need to engage in together, and we're much more effective at it. The danger that's happening with law enforcement is, again, where you have a number of individuals who are harmed or killed in these incidents, the ADA concern, we're far more effective where those incidents are concerned. And it's a new paradigm.
MELODY WORSHAM: And David and everyone who is listening right now, I looked at the statistics yesterday that just in 2021, almost 200 people have been killed by police who live with mental illness, they were in mental health crisis and the police responded. There have been almost 200 people. 200 people! Because of their mental illness, they were allowed to be executed. And a lot of those people were contemplating suicide. And I just can't imagine someone who was thinking about taking their life, and a cop is aiming a gun saying "don't kill yourself or I'll kill you". It just doesn't make sense! It just doesn't make sense.
In my state, the only way to go to a state-run hospital is by police. You can't drive yourself up, you can't ask for help, you have to call the police. You don't have a choice in the matter. And they do treat you that way. We had a killing right here in my own town, you know, last year, a teenage boy, his grandmother called and said he's in mental health crisis, he was in mental health crisis, and he would not "obey" the cop's orders, so the police shot him right there on his grandmother's couch.
So I'm sick of hearing about this! And then when I hear people go, yeah, well, you know, YOU try showing up around mentally ill people without being armed, and I go, I do it every day. I work at a mental health place, I do it every day. I encounter people in crisis every day, and I do not have a gun or taser or billy club, and guess what, I've yet to be killed. I've yet to be killed. So this microcosm of people that we consider to be dangerous are making the rules for ALL the other people. And, you know, it just doesn't make sense. It's such a disturbing system, I, you know, and you wonder why people aren't asking for help, you wonder why people are just making it on their own, and it's this very thing we're talking about. We have to get away from this paradigm, and the only way to do that is a change of attitude, we have to get rid of the stigma. It has to be the belief system not just of our police or our legislators, it has to be our next-door neighbor who is voting for those legislators and insisting that police respond. We have to change the mind of our communities, and that's on the local level. For all the wonderful things SAMHSA does, you can't do it, it starts here in my neighborhood, in your town, in your municipal county. That's where it's got to start, and we have to stop thinking of mental illness as a crime and that we're all dangerous people. We have to get over that. It's such a big hurdle, but it's where it's got to be. We can't make laws and have all this change. Laws are not going to change this, attitudes, attitudes have to change.
DAVID COVINGTON: All of that, Melody, and I'll say, look, we're not minimizing that safety is not important, it's not people with mental illness, it's people. And when we go out into communities — there was a social worker killed in a home in Washington state about 20 years ago now, and Washington state went through a very powerful planning process to ensure things were safe. This wasn't mobile crisis, but it was a social worker in a home by herself. So the Washington State Safety Summit is an amazing report that we've used the last, oh, gosh, at least 15 years, guiding our principles in mobile crisis. That there's assessment up front. If there's a weapon in play, it is a law enforcement response, but we're still going, we're going, law enforcement is dealing with the weapon, and once the weapon is in — no longer in play, we're there. So it's a protocol around identifying past aggressiveness and issues of safety, and then tiering the response. What Melody is keying into is we tend to take a few interactions and leverage them into a broad approach. We're asking two questions in our facilities across the country constantly. We're asking our staff, did you feel safe today? Because the safety of our guests, all of them, and our staff, is paramount. We're constantly brainstorming new ways to make it safer and more effective, giving people the space they need, thinking of new ways of having respite rooms within our units, where we're constantly working on these things, and the environment itself. But the other thing we're doing, Melody, and Lisa, is Lisa is actually leading an effort with our peer staff who are asking random guests constantly, are you feeling cared about during your services and supports?
So those are the two tensions that we're constantly weaving back and forth together. And, look, there's whole states and multiple providers and metropolitan and rural areas that have been operating in this new way, and Melody, it's so great to hear that you had a mobile team in your home. That's the new standard, and we're seeing those cascade around the country.
MELODY WORSHAM: Well, and part of that model, you just pointed out, David, is very important. The reason why that social worker put her life in peril is that she was alone. Peer supporters do not work alone. We do not ever work alone. We always work in teams, it's part of our ethics, it's part of our values, and the mobile crisis teams. So there's not just a single person there. We need to come in a team, because I'm going to see things that my partner does not see, and she's going to see things that I don't see. And we try to make that peer team as close to relatable to the people that we're responding to, too. So it's not two 21-year-old white girls going out to see an octogenarian African-American veteran. We try to match it up as possible so they can relate as much as possible to the person coming out there, so we have an experience they can relate to to calm them down, you understand what time going through. But it's a team effort. We don't go by ourselves.
DAVID COVINGTON: And that Washington State Safety Summit was teams, and adequate clinical triage on the front end. It's also communication that the team has the ability to not even call, but just one button, without having to say anything, that they're communicating, I need some additional support. So those are the principles that — but the version for that is why we currently have a social worker saying I'll meet you at the hospital instead, and then we're often at a different stream altogether, and the water is going one direction, regardless of which way clinically that person is swimming, they are headed towards risk management, acute care. It's a really powerful thing you're doing, Melody.
REGAN RUSH: I want to jump in, because I think we're out of time. I wanted to thank, again, all the members of the panel. This has been an incredibly robust discussion. The questions that we got in were fantastic, and heavily related, a number of them about law enforcement issues and interest in peers and peer supports. I'm really happy to see everybody so engaged in this issue, and I just, I think that Melody's final point about the importance of change and really where it needs to happen, at that community level, coupled with Steven's point about what's required at the high level, and how those two obviously are correlated together, and how everybody really can be a positive influence in their own community to make these kind of changes and bring in good strong crisis services. It can be done, it has been done, and we must continue to do it. So, thank you so much. It was great spending this time with everybody.
LISA ST. GEORGE: Thank you!