This section addresses the elements of clinical best practice that must be embedded throughout all components of an ideal crisis system.
The framework for this section is that the accountable entity ensures all providers are responsible for adopting and adhering to the identified best practice guidelines and ensuring that these guidelines are incorporated into training, supervision and clinical oversight, human resource and quality oversight, policies and procedures, evaluation criteria and supervision for all categories of staff ranging from physicians and other psychiatric care providers through all types of crisis workers including individuals providing peer support. In addition, the overall quality improvement activities undertaken by the accountable entity incorporate the expectation that these clinical practice guidelines define expected system performance and that lack of adherence to these practice guidelines (e.g., the crisis center refusing to evaluate someone based on their alcohol level) would trigger a quality oversight and review process.
Crisis systems have many customers: individuals in crisis who are often brought for help involuntarily, and their families and collaterals; law enforcement; and behavioral health and human service providers. All of these customers – especially the clients like Mr. Y – engage with crisis systems at a time of great stress and vulnerability. Therefore, the first rule of clinical practice development is to ensure that every customer is treated in a welcoming manner and that those who are most vulnerable and despairing are treated with respect, gentleness, safety and hope and, to the greatest extent possible, no one is re-traumatized by the crisis service’s actions. An ideal crisis system and the programs within it will only successfully welcome and treat community users if they focus on implementing the clinical practice standard known as customer service. Many of those standards are familiar to all of us. All of them should include awareness of the biases and discrimination that our customers might experience in their home communities, including racial bigotry and disrespect and disdain related to mental health challenges.
Common attributes of best practice customer service include timely and friendly service that welcomes every customer, attends to their needs and ensures quality, satisfaction and clear communication and collaboration and competent service based on the best available methods and doesn’t skimp or cut corners.
The same standards must hold true at an even higher standard for crisis services. The setting needs to welcome the most difficult to please individual customer – those like Mr. Y who are likely frightened, angry, reluctant, inattentive, lacking hope for a meaningful future and sometimes unaware of their service need.
The setting must also create a welcoming experience for individuals and families for whom the service was not initially built, such as those who are non-English speaking and/or represent a variety of cultures, including individuals who are immigrants or have unique needs, such as the LGBTQI and/or gender non-conforming population. The same approach must apply to frightened or angry families, overwhelmed law enforcement personnel, busy human service providers and all other partners. Creating a welcoming, hope-infused, trauma-informed and culturally affirming crisis system improves the likelihood of satisfied and well-served customers and a satisfied community. Diversity within the community and the presence of racism, micro-aggressions and differential treatment of communities’ members based upon race, language, housing status, prior contact with law enforcement and other differences may trigger biased assumptions by responders. The structure and set-up of crisis services can help diminish the impact of bias on those in crisis.
The accountable entity works with crisis system providers to establish policies requiring welcoming, hopeful, trauma informed practice and ensuring that all providers demonstrate continuous attention to implementing those practices in training, supervision, human resources and quality improvement. Specific markers include:
Employees set the tone, maintain the standards, invite the person in crisis into the service and ensure connection with community practices. As such, employees need to be well-suited to the work, familiar with crisis work and the needs of people with mental health and substance use issues in crisis, sufficiently and regularly well- trained, supervised, satisfied with their work, happy to be at work and consistently feel and show patience. Employees must be aware of their own biases and be willing to broaden their perspectives about culture and race and to learn from others.
Staff are provided with specific guidance and role-play practice - reinforced through supervision - on how to handle challenging situations with all types of customers, including customers from culturally diverse backgrounds, in a welcoming manner. Staff use real experiences to inform their role plays.
There are guidelines for communication with customers and within the team that requires never using disparaging or despairing language to describe individuals and families in crisis, even when they are not listening.
Systemic and provider-specific policies and procedures reflect the core principles of trauma-informed care, including:
Protect: Promote safety and trustworthiness, a calm environment that leads to better emotional regulation for all, transparent and direct communication and consistency and accountability.
Respect: Engage in choice and collaboration, use motivational engagement as a foundation, employ shared decision-making at every opportunity, encourage strength-based and empowering work, understand the context of client’s life and how their current coping was adaptive, incorporate collaboration and problem solving that includes system and supports and work toward goals and change.
Connect: Focus on relationships, particularly for clients who are pushing help away; ensure cohesion and shared mission and values; find out what happened, not what is wrong; work collaboratively; encourage care coordination and family engagement; and focus on accountability and responsibility, not shame and blame.
Redirect: Encourage skill-building and competence, teach strategies to cope with stressors and increase wellness, view setbacks or relapses as learning opportunities and include strength-based education and training for staff.
Cultural affirmation: Provide welcoming care that is kind, friendly, hopeful and open-minded; and that is also culturally affirming, understanding the relevance of culture of origin and culture of choice to individuals. Culture includes race, ethnicity, language, and sexuality, as well as the full range of individual/family/community affiliations (e.g., veterans’ organizations, 12 Step participation) and spiritual/religious practices.
Culturally affirming care recognizes the impact of:
Culturally affirming care requires practitioners to:
Intentional tracking of race/primary language/housing status and other markers of limited financial access to food/housing/transportation/employment.
Part of the continuum of services in an ideal crisis system includes opportunities for staff to learn how to utilize the collaborative network-based approach to psychiatric care. Open Dialogue was established in Finland in the 1980s for people with new onset psychosis. It involves providing immediate help including a treatment meeting with the individual, family, significant members of social network and professionals within 24 hours of a call to a crisis service. Open Dialogue employs listening and communication rather than relying specifically on hospitalization and medication as the initial intervention. Other key principles include gaining a social perspective, embracing uncertainty and creating a dialogue to create a shared understanding of the problem.
Open Dialogue has spread throughout much of Scandinavia and other European Nations and is currently utilized in various sites in the US. Although evidence of effectiveness is still emerging and a recent review suggested that the research support for this practice is significantly limited, there are many positive anecdotal reports from practitioners that reinforce Open Dialogue as a structured approach to a more in-depth implementation of the welcoming, trauma informed, hopeful, relational approach that was described in the previous section. For this reason, training front-line crisis responders in the use of Open Dialogue is an opportunity to introduce an approach that reinforces the positive culture of practice for the crisis system as a whole.
Measurable criteria for Open Dialogue in the ideal crisis system: The accountable entity ensures that front-line crisis practitioners like those in the crisis center have training in Open Dialogue and opportunities to practice Open Dialogue interventions as teams.
A comprehensive behavioral health crisis system with a complete continuum of services including ongoing family engagement with the definition of family expanded to include all significant members of the client’s natural support system is essential to any community. Families and collaterals, including current service providers, are the people who know the consumer best and will be the first to recognize both subtle progress and early signs of deterioration, making them best-suited to partner with crisis evaluation, intervention and follow-up. Further collaboration among family, consumers and providers helps to facilitate optimal recovery.
Unfortunately, many crisis systems do not provide crisis provider staff with practice guidelines, competencies and supervision for how to effectively engage families and other collaterals. Crisis providers are often over-trained to say “no” to communication with collaterals and under-trained to say “yes.” While families are typically the first to realize that a problem is developing, they may have limited knowledge about diagnosis, treatments, the behavior and the behavioral health system.
Consequently, they may not engage with the crisis system in what we might consider the most appropriate way, so they can be criticized and pushed away.
The same thing may happen to collateral behavioral health providers and other informants. They ask the crisis system for help too soon and they are criticized for “dumping.” They wait too long and they are criticized for waiting. All crisis staff need to be educated with practice guidelines for family and collateral engagement, have opportunities for supervised practice and know how and when to ask for help rather than saying “no.” Active engagement efforts and continued education are vital. Providers have an obligation to address needs of the family and collaterals to an equal extent as those of the client and practice in this area will reinforce the positive benefit.
The accountable entity ensures development of clinical practice guidelines for family and collateral engagement and requires all contracted crisis providers to implement those guidelines and competencies through training, supervision, human resource policies and quality improvement activities. Specific content includes:
All staff are trained to regard all families and collaterals as priority customers in crisis situations. Staff demonstrate competency in routine engagement of all available collaterals and know how to gather information even when the client limits disclosure. Disposition is never complete without full participation of collaterals and provision for their ongoing needs. Families should also receive ongoing supports following an acute crisis. This should include availability of:
Staff receive training around the importance of strength-based approach to family and collateral involvement and can communicate importance of family and collateral involvement to all involved.
Staff are expected to continually revisit initial denials of consent to emphasize the importance of family and collateral participation in discharge planning.
Staff are trained to not discharge clients with risky behavior or ideation back to families or housing providers without obtaining information from them on their perception of risk and their ability to have a safety plan.
All crisis staff are trained in how family and collateral involvement are viewed as necessary services that can be documented and, where appropriate, reimbursed.
Staff are trained to provide proactive engagement efforts that directly involve family members in treatment decisions as allowed by the consumer.
Staff have skills and access to resources for helping families remain engaged in care following the crisis, as well as helping families link to ongoing services. Staff have skills for providing continuing support to behavioral health providers and other human service providers who are working with a challenging or risky client.
Training provided by families. Families, who are often advocates participating in the community crisis collaborative, participate in both training families how to access the crisis system and training staff how to respond to families in crisis. Ideally, dialogue between families and staff is part of routine training.
Continuing improvement of response to families and collaterals. Staff have opportunities to connect with collateral providers outside of crisis situations to engage in constructive dialogue about how to be more responsive as well as how the referents can receive a more helpful response.
Mr. Y's family was not involved at the time of his initial crisis. This likely resulted in the loss of information which would have been important to Mr. Y's care. It also caused unnecessary worry and stress for his family and natural support system.
Successful crisis assessment and intervention requires involvement of collateral informants, particularly family members and close friends, in the crisis assessment and intervention process. Many crisis providers believe, incorrectly, that their ability to engage those collaterals is prevented by the Health Insurance Portability and Accountability Act (HIPAA) or state confidentiality regulations in the absence of a specific release by the client. For this reason, it is important for an ideal crisis system to provide clear guidelines to crisis providers about how to maximize involvement of family members and collaterals in the crisis intervention process.
The comprehensive crisis system defined in this report recommends an accountable entity responsible for oversight, contracting and quality monitoring that ensures the dissemination and implementation clinical practice guidelines for information sharing and collaboration with family members and other collaterals during the crisis episode. This includes:
All confidentiality regulations permit communication with collaterals without release when such communication is necessary for assessment and intervention in a potentially harmful crisis or life- threatening emergency, whether that emergency is for a medical event (e.g., syncopal episode, seizure) or for a behavioral event (e.g., acute psychosis, suicidal threat or behavior, violent threat or behavior). This understanding must be communicated to all crisis providers with the expectation that communication with collaterals is a rule, not an exception in such situations, and that absence of communication would be an adverse quality metric.
Individuals have the right to request restrictions on how a HIPAA-covered entity will use and disclose personal health information (PHI) about them for treatment. A covered entity is not required to agree to an individual’s request for restriction but is bound by any restrictions to which it agrees. (45 CFR 164.522[a]). When undertaken on behalf of a single consumer, treatment activities may include case management, care coordination and outreach programs.
Even in the absence of a life-threatening emergency, crisis providers can facilitate the receipt of information from collaterals, even without permission to disclose information to collaterals. This information is often vital in the crisis assessment and disposition.
Successful crisis resolution and disposition will rarely, if ever, involve the client being discharged to return home after a significant crisis without involving the people the person lives with in evaluating and participating in the discharge plan. If the client’s crisis has been visible to those they live with, such communication is essential to success. Complaints about discharges home without communication or about lack of communication to collaterals in general, are useful quality metrics for system and provider performance monitoring. This point of view remains a crucial component of the crisis network’s values – discharge is meant to facilitate crisis intervention and successful discharge is part of the work.
It is necessary for the crisis system to ensure that systemwide and provider-specific confidentiality regulations and mandatory confidentiality trainings include specific instructions about when it is permissible to share information with collaterals, as well as when it is not. Such training should provide guidance for how to share information appropriately, in accordance with the standards described in this section.
The confidentiality requirements specific to substance use disorder (SUD) treatment do not apply in the case of a medical emergency. “Patient identifying information may be disclosed to medical personnel to the extent necessary to meet a bona fide medical emergency in which the patient's prior informed consent cannot be obtained.” (42 CFR § 2.51) Most standard trainings only cover what is not allowable and fails to provide proper guidance and direction to crisis providers.
Crisis plans and psychiatric advance directives (PADs) are a simple and effective way to respect an individual’s dignity and autonomy and mitigate the severity of future crises. These plans may range in complexity from a formal legal document (e.g., advanced directive) to a handwritten wallet card. The common feature is that they capture the individual’s preferences and plans so they can be articulated at a later time when the person may be unable to communicate effectively or think rationally. A crisis plan can also include reminders of interventions or techniques that the individual can use to help manage their crisis and ask for help earlier.
The most compressive crisis plans are created during a period of wellness and kept on hand in case of a crisis. One of the best-known crisis planning tools is a Wellness Recovery Action Plan (WRAP). Developed by Mary Ellen Copeland of the Copeland Center for Wellness and Recovery, WRAP is a prevention and wellness self-management program taught in a multi-session group setting led by a trained facilitator. By the end of the program, participants have created their own crisis plan that includes items such as what interventions and medications they prefer and even designates a temporary proxy decision-maker. In many states, this plan can be converted to a legal document – a PAD. Information about the individual state statues governing PADs is available at the National Resource Center on Psychiatric Advance Directives (nrc-pad.org). Advocacy organizations such as NAMI often host local WRAP classes.
Creation of a crisis plan can itself be an effective intervention for preventing future crisis. The Stanley- Brown Safety Planning Intervention (suicidesafetyplan.com) is a quick and simple intervention in which a clinician or peer works with an individual to complete a 6-item worksheet that results in a plan the person can follow if they think a crisis is emerging. Elements include helpful coping strategies, helpful people or agencies to contact and strategies for making the environment safe. There is even a smartphone app so that the individual can refer to the plan when needed.
If a person arrives to a crisis facility without a pre-existing safety plan, then clinical or peer staff can work with the individual to create a focused crisis plan for use during their stay, or to prevent or mitigate future crises. Such a plan can help prevent the crisis from escalating to the point of restrictive interventions such as involuntary medication, seclusion, or restraint. A crisis plan might include information such as preference for specific types of staff (such as female) due to past trauma or that agitation can be prevented by allowing a child, or adult patient with developmental disabilities, to keep his or her favorite stuffed animal.
The accountable entity ensures that all crisis providers have policies and procedures regarding the development and utilization of PADs and crisis plans, as follows:
Even in an ideal crisis system, the primary responder to a mental health crisis will often be a law enforcement officer or other first responder. It is critical that uniform practice standards are applied for law enforcement officers, first responders and 911 call-takers. First responders need to know how to de-escalate crisis situations and, when appropriate, how to divert individuals with mental illnesses away from the criminal justice system or emergency medical system and into behavioral health crisis intervention.
A behavioral health crisis system should include law enforcement officers as first responders only when necessary and eliminate the need for law enforcement to be the routine first responder for situations that can be addressed safely by clinicians. In fact, having law enforcement respond can sometimes escalate the situation.
The first important practice guideline for first responders in an ideal system is to have a clear set of instructions for directing the vast majority of behavioral health crises to behavioral health crisis providers. While police officers with Crisis Intervention Team (CIT) training have done and continue to do a remarkable job dealing with individuals with mental illnesses, routinely using law enforcement officers as default first responders is not the ideal model. In an ideal system of care, behavioral health professionals would become the default first responders for the bulk of mental health crises, with CIT-trained law enforcement officers serving as backup for high-risk situations as needed.
Unless law enforcement involvement is critically important, a mental health crisis should be treated like a primary health emergency and medical (i.e., behavioral health) personnel should be the first responder to a mental health emergency. To do otherwise reinforces stigma by sending a message that an individual in mental health distress requires a law enforcement response. Additionally, a law enforcement response often requires that the individual be handcuffed for transportation to a crisis center, which is both embarrassing and traumatizing. These encounters make it more difficult and less likely for an individual with a mental health disorder to seek treatment and makes it harder to trace the trigger of the crisis and intervene – as the law enforcement intervention typically becomes another trigger. The second important practice guideline for first responders involves transportation. When appropriate, transportation for an involuntary examination should be by a behavioral health professional in a civilian vehicle or ambulance – not a marked police vehicle.
Finally, whether law enforcement officers are serving in a primary responder role or a backup role to a mental health professional, they need to be appropriately trained in best practice response techniques. Communities should adopt the CIT training model developed in Memphis, Tennessee. Known as the Memphis Model, the purpose of CIT training is to set a standard of excellence for law enforcement officers with respect to treatment of individuals with mental illnesses. CIT officers perform regular duty assignment as patrol officers and are also trained to respond to calls involving mental health crises. Officers receive 40 hours of specialized training in psychiatric diagnoses, suicide intervention, substance abuse issues, behavioral de-escalation techniques, trauma, the role of the family in the care of a person with mental illness, mental health and substance abuse laws and local resources for those in crisis. There are core elements of CIT training that should be included as best practice guidelines for first responders in an ideal system.
Training for 911 call-takers/dispatchers is also an essential part of an ideal and effective response to individuals in a mental health crisis. “The success of CIT depends on their familiarity with the CIT program, knowledge of how to recognize a CIT call involving a behavioral crisis event and the appropriate questions to ask in order to ascertain information from the call that will help the responding CIT Officer. Dispatchers should receive training courses (a minimum of 8-16 hours) in CIT and additional advanced in-service training.”(University of Memphis School of Urban Affairs and Public Policy, 2007)
With regard to the amount and extent of training, CIT International recommends that CIT officers serve in general patrol duties until called on to respond to mental health related calls and should not be part of a special unit that only responds to mental health calls. CIT officers should volunteer for the training and be selected based on maturity and experience in order to be eligible to become a CIT officer. They discourage training in the pre-service police academy and CIT training for the entire police force. CIT is a specialist model and should not be a generalist model where CIT training is mandated for all officers. Police officers who have not received specialized CIT training should receive the Mental Health First Aid (MHFA) for Public Safety 8-hour training course.
The comprehensive crisis system defined in this report recommends an accountable entity ensures that all first responders are trained in policies, procedures and practice guidelines related to the following material. Not all first responders need to receive 40 hours of CIT training, depending on their role and the frequency with which they encounter people experiencing behavioral health emergencies, but they do need at least eight hours of training and instruction about where to get immediate consultation in the field when needed.
Procedures for connecting rapidly with behavioral health crisis responders are clearly delineated and the role of the first responder in maintaining safety in the situation until the behavioral health first responders arrive is communicated.
Marked police vehicles, handcuffs, and other criminal justice devices should be avoided for routine transportation. Other modes of transportation and safe procedures for transportation without involving police should be identified.
CIT Officers and others whose first responder role frequently involves behavioral health emergencies should receive the full 40 hours of training in all CIT elements. CIT-trained officers should further have access to the core elements of expansion training, particularly if they are in a supervisory or team leader role.
1. Partnerships: Law Enforcement, Advocacy, Mental Health
2. Community Ownership: Planning, Implementation and Networking
3. Policies and Procedures
4. CIT: Officer, Dispatcher, Coordinator
5. Curriculum: CIT Training
6. Mental Health Receiving Facility: Emergency Services
7. Evaluation and Research
8. In-service Training
9. Recognition and Honors
10. Outreach: Developing CIT in Other Communities
Crisis staff of all disciplines and backgrounds should be competent in the basics of crisis engagement, assessment and intervention. Although staff may have extensive clinical experience in other settings, they may need training in adapting their skills to the unique features of crisis work. No one should assume competency without assessment, practice and supervision.
The accountable entity establishes and monitors the core competency requirements for all crisis providers, as follows:
Crisis organizations should have an annually-reviewed training and competency plan in place that:
He was not engaged, he was arrested.
Assessments should comply with state and federal regulations and include the following:
Need for emergent intervention. Determine if the person has acute medical or psychiatric needs that need immediate intervention (e.g., injury, unstable vital signs, severe agitation or psychosis, substance intoxication/withdrawal). For non-emergent medical needs, what is needed in the moment to help the person maintain comfort and stability during the behavioral health crisis intervention process (e.g., medications, medical equipment like insulin or needles, monitoring)?
Immediate initiation of information gathering. Assessment should not be delayed because the individual in crisis is too agitated/psychotic/intoxicated. In these cases, collect as much information as possible from collateral sources and chart review, along with an assessment of the individual’s mental status and find out why a more detailed assessment cannot be performed at this time. Attempts at reassessment should occur after appropriate intervention. Focus all assessments on addressing the most acute issues.
Co-occurring substance use. How have substances contributed to the crisis presentation? Was there a past recent period of sobriety? If so, what helped the person’s success and how can that be applied now? Are there signs and symptoms of acute substance intoxication and withdrawal?
Co-occurring cognitive impairment. Does the person have evidence of cognitive impairment? Is it longstanding, as intellectual and developmental disabilities (I/DD), or recent? For recent impairment, what is the best way to restore cognitive functioning? For persistent impairment, what is the best way to assess cognitive baseline and engage the person in accordance with their cognitive capacity? How will this impairment impact the crisis intervention and the follow-up to deal with this crisis and, if possible, future crises.
Why now. A narrative of the progression of the crisis with focus on identifying the most recent pre-crisis baseline and then determining the sequence of events that led to what precipitated the person to seek (or be brought to) services now.
Risk assessment. As discussed in detail elsewhere, an assessment of the risk of harm to self or others, including mental status exam, an inventory of static and dynamic risk and protective factors and access to firearms and other lethal means.
Level of current engagement. What is the individual’s most important request at the moment? How does this relate to their hopeful recovery goals? To what extent and for what issues is the person willing to receive help and what kind of help? If the person is unwilling to accept help, do they meet criteria for involuntary intervention? In all instances, what is the best way to engage the person in a collaborative plan?
Prior engagement with the behavioral health system. What has been tried? What worked and what didn’t? Why? Who is responsible for this individual’s care? Are there system/administrative barriers that need to be addressed? Was there a crisis intervention/prevention plan? Was the individual able to utilize this plan?
Community stressors and supports. Are there psychosocial factors (e.g., housing, transportation) that are contributing to the crisis? Are there supports that can be leveraged to help the person be successful after discharge?
Collateral information. Whenever possible, within the limits of client choice and privacy regulations, collect information from one or more collateral sources (e.g., family member, case manager) to gain a more complete picture.
Level of care assessment. All staff should have training in utilizing standard level of care assessment tools (e.g., Level of Care Utilization System [LOCUS and CALOCUS]) to make structured level of care determinations and to communicate in a common language to other crisis providers.
Intervention. Crisis intervention must be timely and match the person’s needs as identified in the assessment. Core competency for crisis intervention includes the following:
Emergent interventions. The ability to provide emergency interventions to address medical emergencies. It is not expected that all services be available in the crisis setting, but staff should be trained to recognize medical emergencies and protocols should be in place to ensure that emergency care is available. For example, a free-standing crisis center should require all staff to be certified in basic life support and have protocols for rapid transfer to an emergency room (ER).
Treatment of acute agitation. Acute agitation is a behavioral emergency and should be treated as such according to psychiatric practice guidelines such as those published by the American Association of Emergency Psychiatry. The first line intervention is verbal de-escalation, followed by appropriate pharmacotherapy. If a psychiatrist or other psychiatric care provider is not on-site 24/7, staff should be trained to recognize a behavioral emergency and protocols should be in place to ensure rapid intervention and transfer, if necessary.