Texas Officer Who Ended '66 UT Sniper Rampage Dies - ABC News

Texas Officer Who Ended '66 UT Sniper Rampage Dies - ABC News

Texas Officer Who Ended '66 UT Sniper Rampage Dies - ABC News

Texas Officer Who Ended '66 UT Sniper Rampage Dies - ABC News

At jail, a rising tide of suicide | The Columbian

At jail, a rising tide of suicide | The Columbian

an article about a jail taking steps to be safer for folks at wits end. The Sheriff is adding on-site psychiatry and additional on-site mental health care to the mix of facility changes. This article presents some positive steps toward curbing a negative, and all too common, problem. If only for practical reasons (of risk management for the jail/county) and not for the greater reason of respect for human life, these are steps to be encouraged.

Thinking about police shootings in the Autumn sun

Here in western north Carolina the clouds are scurrying off the dance floor and the sun is lighting up the autumn color. Glorious! The extension burst until spring's pastels. I do miss this time of year in this setting.

Because I can't enjoy anything without being a "negative nellie" (or whatever the masculine version of that phrase is)  I immediately starting ruminating on death and destruction....

An article in today's CNN headlines recalls the tragedy of a young man killed by campus police. Its hard times all around in south Alabama. Can this be used to change policy and training? There's a good question.

Unfortunately I have only more questions. Like, who tracks police shootings and what does the data show? I am interested in this topic because I wonder if there are ways to train officers to increase the compassion of their interactions with the public, even an aggressive and potentially dangerous public. This interest is not just about police; the general public has an anti-authority bent--it takes two to tango, they say.

Hell, if I could be "king of the world" I would like to reduce competition in favor of cooperation. Following the Buddha more couldn't hurt anyone, except those who want to destroy. But, alas, I'm just a guy.

A website with a law enforcement POV with a newsfeed for police involved shooting is PoliceOne. It looks like a good source for cops to support each other, find training & tips, and preview gear. Not quite what I was looking for, but interesting as a presentation of that POV. It reminds me to be sensitive to the complexities that law enforcement (and military) personnel attend to in the performance of their duties.

The data I'm interested in may not exist, if this story from 2001 remains relevant. "[A] provision in the 1994 Crime Control Act requiring the Attorney General to collect the data and publish an annual report on them, statistics on police shootings and use of nondeadly force continue to be piecemeal products of spotty collection, and are dependent on the cooperation of local police departments. No comprehensive accounting for all of the nation's 17,000 police department exists."

In a late 2011 news story there is the appearance of no change:

"The nation's leading law enforcement agency collects vast amounts of information on crime nationwide, but missing from this clearinghouse are statistics on where, how often, and under what circumstances police use deadly force. In fact, no one anywhere comprehensively tracks the most significant act police can do in the line of duty: take a life.

"We don't have a mandate to do that," said William Carr, an FBI spokesman in Washington, D.C. "It would take a request from Congress for us to collect that data.

Congress, it seems, hasn't asked."

Consider a report about a LAPD unit that investigates police shootings  "to insure that investigations of police shooting incidents are full, fair, objective, independent, and timely".

Title:Implementation and Possible Impacts of Operation Rollout
Author(s):C D Uchida; L W Sherman; J J Fyfe
Date Published:1981

Here's something I didn't expect to find: A map from the conservative Cato Institute noting entitled Botched Paramilitary Police Raids. The map shows incidents where law enforcement actions resulted in the injury (or death) of an innocent solely due to action based on incorrect information. I.e, raiding the wrong home looking for suspects. The map was created to accompany the report Overkill: The Rise of Paramilitary Police Raids," by Radley Balko.

The issue is sensitive. And important.

Auroraadvocate.com - Kaleidoscope: 'Moral treatment' was Athens asylum concept

Auroraadvocate.com - Kaleidoscope: 'Moral treatment' was Athens asylum concept

this news story presents some history of mental health treatment in 19th and 20th century America (specifically Ohio). The author enjoys learning about the history of old buildings and that led to this presentation about The Ridges at Ohio University -- once the Athens Lunatic Asylum.

The Thomas Kirkbride plan was based on the "moral treatment" model of psychiatry and advocated for by Dorethea Dix. Patients came to live at the facility's idyllic setting. They joined in the operation of the campus's self-sustaining farm-like methods.

[side note: the wikipedia article on Ms Dix is out-of-date. It mentions that the hospital in Raleigh NC named for the advocate is "scheduled to close in 2010". That event has now happened. Dorethea Dix Hospital was replaced by Central Region Hospital in Butner NC.]

I found the article a nice quick introduction to the history of mental health reforms in the US, as well as an interesting look at the why's and how's of some old buildings. Too often both these topics are neglected in this world of auto-refresh. Very refreshing distraction....

Outcomes and payment models in crisis intervention

Here are a few notes and reflections about some of the things I'm thinking about today.

Treating Complex PTSD

I started out today reading about complex PTSD and DESNOS (Cloitre et al 2011). [quick rabbit trail: The layers of the crisis intervention field are deep. Makes me wonder about the history of the field and how it would be constructed.] The purpose of the article is to present a model for treatment of complex PTSD based in best practices. The authors explore how to treat the problem and in what order. Task 1: is "patient safety, symptom stabilization, and improvement in basic life competencies"; Task 2: "the exploration of traumatic memories for the purposes of first reducing acute emotional distress resulting from the memories and then reappraising their meaning and integrating them into a coherent and positive identity." Education about trauma, mindfulness & meditation, and symptom management CBT (cognitive behavioral treatment) seemed to rank pretty high as useful interventions.

Payment for Services

From there I jumped to a discussion at Shrink Rap about the pros & cons of capitated fee structures versus fee-for-service. The commentators quickly began promoting the Canadian healthcare system and calling each other names. Result: no decision.

Since this an interesting and timely topic (and I can write what I want in this space) let me opine also.

Capping payments (e.g., per member/per month model) is designed to allow providers flexibility in treating patients. A real plus of this system is that it allows budgeting to be based in reality. When you know your income resources can be allocated. The risk for providers is in managing the patient load by balancing the number of patients and the amount of care provided. Too few patients is risky for returning unearned funds, too many patients is risky for resentment and burnout. One other downside is the disconnect between each of the three poles: patient, funder, and provider.

Fee-for-service is designed to control costs using market factors. This system allows folks to buy whatever services they think they want/can afford. One risk is that patient's are often rely on their provider(s) (and marketing companies) for recommendations about health related purchases. A real plus is theoretical flexibility in provider and service selection. This system is favored by those who want to be rewarded directly for the number (and quality) of the services they provide.

Obviously, each model has benefits based on point of view.

Reflection

Prominently, outcomes and evidence-supported (based?) treatments are themes relative to both discussions. For a behavioral health care system to be most useful a requirement that patients can judge providers equally while providers can rely on treatment models.

So, I'm working in a crisis stabilization unit/detox at a standalone psychiatric hospital and I'm in a doctoral program in counselor education. I keep turning over what I'm doing and how I'm going to graduate. The answer is to write up what I'm interested in; what I'm interested in is usually whatever I'm doing. In this case I am interested in evaluating my presentation materials: what material is best to present to patients in withdrawal/early recovery with a 7-10 day average length of stay?

This isn't what brought me to school, but is a familiar idea. And a good one to keep in my back pocket. The patients are post-crisis intervention, so part of the evaluation could include the relationship of initial assessment/presenting problem to the admitting diagnosis and the discharge plan. How is the patient better prepared to return back to their environment after the intervention?

The Shooter: how did that happen?

This post is a quick review of a news item I found while surfing the web. The topic concerns crisis workers greatly, not least because of the balance between the rights of people and protection of the community. Mental illness is often viewed with fear, specifically because of events like the one that prompted this article.

Shootings expose cracks in US mental health system

is an Associated Press article I viewed in the Fargo Inforum, an online news source. The article discusses some of the issues involved with persons with mental illness that go on to harm others. The basis for the article is an interview with the parents of a fellow who killed some co-workers and himself a week before.

Point 1: the families of persons with mental illness suffer as much as the person. This is a truism that goes unrecognized by many crisis interventionists. [In fact, that might be a good question for an attitudinal survey of crisis workers: "how important are family services?".] One support mentioned is a "free, 12-week course for loved ones of people with mental illness" in the Minneapolis area. The local NAMI chapter is very involved with the family.

The NAMI Information HelpLine is an information and referral service which can be reached by calling 1 (800) 950-NAMI (6264), Monday through Friday, 10 am- 6 pm, Eastern time.

Point 2: The history of forced treatment is contentious.

"A successful patients’ rights movement in the 1970s made it difficult — and illegal in some states — to force a person into treatment unless he or she was homicidal or suicidal. Dr. Darold Treffert, a Wisconsin psychiatrist, coined the phrase “dying with their rights on” in 1974, after collecting stories of people who didn't qualify for involuntary commitment and later killed themselves

In the years since, 41 states have added “need for treatment” standards to their laws that allow more individuals to be placed into court-ordered treatment programs. Minnesota is not among them."

Point 3: Recovery is possible. The article closes with presentation of two successful professionals that learned to manage their disease and are now living "normally".

HRSA and licensure portability

The topic of licensure portability has particular importance in telehealth, where the entire premise is to deliver services across distances from pockets of providers to underserved regions. Urban centers often contain an abundance of providers, especially those connected to universities and teaching hospitals. Surrounding rural areas often do not have ready access to specialists (my interest is in behavioral health, and not just psychiatry but psychology, addictions, and talk therapies as well).

[may be that there is a map showing urban centers and the rural area they serve...probably yes, I just don't have one yet.]

While looking through some emails and chasing a few links today I ran across this discussion on the Telehealth Resource Center site on the Legal & Regulatory page:

Under Licensure and Scope of Practice, several models for cross state licensure agreements are presented. They include:

• Licensure by endorsement;
• Mutual recognition;
• Reciprocity;
• Special purpose or limited licenses.

The Health Resources and Service Administration (HRSA) reported to Congress about the issues. HRSA has an online resource center under their rural health section specifically related to telehealth. The page includes a broken link to the The Licensure Portability Grant Program (LPGP).

"The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable."

The emerging role of telehealth/telemedicine/mHealth in bridging the gaps to universal access to physiological and psychological healthcare continues to present opportunities for research and advocacy. One that I'll keep following with expectation for the next part of my career.

National Licensure

FixLicensure.org is a website promoting national licensure for medical professionals (I hope that independent mental health providers would also be included).

These folks are working with Senator Tom Udall (D-NM) and have briefed congress on issues related to telehealth and provider mobility.

Sign their petition to show support for this important issue.

The argument is being framed around the lack of access for military personnel (active and veteran) to mental health care and the promise of telehealth as a solution. Since military providers are licensed in their home state and able to practice across the nation, and, can help soldiers remotely when both are in a military facility there does seem to be some opportunity for change.

Other folks argue that the licensure process goes beyond insuring all practitioners meet minimum quality standards and is more properly a gate-keeping function that discourages people from entering the field. Clearly, with licensed providers being disciplined for ethics and fraud the quality standards can not be insured through verification alone. With the workforce issues in behavioral health this function is questionable.

To even cross the bar to be licensed an applicant must have educational experience from an accredited university. Well, let me re-phrase that, "to get a job in North Carolina you must have graduated from an accredited university." And, to get a license you must have completed coursework equal to the CACREP standards.

I think that I would support national reciprocity. That would allow states to set home rules while allowing licensed professionals mobility. For instance, if your get licensed in NC in 2002 and apply for licensure in TN in 2012 you will have to meet the 2012 rules. The bar has been raised in the intervening 10 years.

to review my earlier notes on this topc.

The TAF crisis assessment instrument

James and Gilliland (2013) discuss their Triage Assessment Form for Crisis Intervention (TAF).

In class tonight we are being trained in the use of this evidence supported instrument. Its a little different from most of the tools I've used in the past. More like using the GAF in that we are trying to score with guidelines related to the score.

The TAF also breaks out various domains to guide the assessor. Looking at the affective, behavioral, and cognitive domains helps describe the situation.

TN LPC app in the mail.

After long delay (about a year, actually) my application for licensure as a professional counselor in Tennessee is finally in the mail.

The actual credential sought is the LPC-MHP. This is a full independent license. The process included earning the CCMHC.

Mississippi doesn't require licensure, oddly enough. Not sure about pursuing that one.

When healthcare resembles cheesecake

It seems that Obamacare has people talking in the mainstream media about healthcare innovation--this is GOOD. Discussions about funding and about service delivery can be found in the daily news. The question of “if healthcare delivery will change” is no longer seriously on the table.

Payors and providers are already doing business differently. This post will look at healthcare reform and the objections to the Affordable Care Act through the lens of Dr Atul Gawande and The Cheesecake Factory. His article, BigMed, was published in the New Yorker.

People do not seem to be talking as much about medical education, managing change for providers, or about the effects of accountability.

In the current fee-for-service model the goal is to deliver as many billable services as possible. In the emerging per-member/per-month (pmpm) model the goal is to use less money than is available. PMPM shifts the risk of over-spending from the payor to the provider. The initial goal is to deliver as many low-cost services as possible; the old model focuses on the delivery of expensive services to promote increased billing. The new model encourages outreach, screening, prevention, and care coordination for the most complex cases.

One of the new realities of healthcare finance is that profits will come from savings in service delivery. Not from delivering more services. A floor is established for patient care through the use of outcomes. Meet the outcomes under budget and pocket the difference.

Steve Denning, author of RADICAL MANAGEMENT: Rethinking leadership and innovation, wrote a rebuttal in How Not To Fix US Health Care: Copy The Cheesecake Factory. Denning opposes a view of healthcare as routine and reducible to discrete functions; many of us would agree. However, reality is that most care is routine and can be flow-charted.

This rebuttal is built on the assumption that competition will enforce efficiency. While this may be true in larger markets, it is less true in smaller markets where there is much less competition, and even functional monopoly. It also supposes that there is current accurate information about the competition available to inform consumers of their choices.

Denning gives us the following model to organize the healthcare umbrella:

"As Clayton Christensen and Jason Hwang pointed out in their book, The Innovator’s Prescription (2009), the first step in making some sense of the US health care system is to get clear on “what is the job to be done?” They distinguish three very different “jobs to be done” in health care organizations:

Solution shops, which are organizations structured to diagnose and solve unstructured problems. These require skilled experts who deploy expertise, intuition and analysis to diagnose and find solutions to complex problems. An example would be Gawande’s elderly woman who fainted and fell: the first task is to figure out what is her problem.

Value-adding processes: organizations which take things that are broken and turn them into higher value things. Both the problem and the solution are largely known. The challenge is to deliver the solution efficiently and effectively. Knee-replacement surgery would be an example where a value-adding process is appropriate: the problem and the solution are largely known.

Facilitated networks are arrangements in which people exchange things with each other. Chronic care of diseases like diabetes are best handled through community-based networks. It is known what needs to be done: it’s mainly about getting patients to do it."

One place where the factory model is being used in healthcare is in the use of hospitalists. “Back in the day...” primary care doctors admitted patients to the hospital and then managed care for their own patients; this on top of their outpatient duties. In order for physicians to have more control over their work schedules the position of hospitalist was created. Hospitalists admit patients for inpatient care and manage routine care, coordinating with specialists as necessary. Inpatient care is an example of Christensen and Hwang's value-added process.

This new system offers benefits for physicians. Greater flexibility in scheduling for all physicians in a community becomes possible when inpatient care is carved out. A career ladder is built as new physicians work off loans, gain experience, and consider where they want to practice.

While there are benefits for physicians, patients may have different experiences. Hospitalists are often early career professionals with little experience independently managing patient care. This can lead to uneven care, and mistakes do happen. Continuity between hospitalists may also suffer as each doctor continues to think of themselves as an independent practitioner, rather than part of a team. Adding a supervisor and a coordinator—a team leader—to the mix could add quality control and reduce patient dissatisfaction (I have a couple horror stories that would illustrate a lack of quality).

Dr Gawande introduces a career ladder. Everyone he talks with has worked themselves up the responsibility food chain, with presumably greater rewards of autonomy and pay. Too often new employees expect to start at the top. But even experienced workers entering new work sites or new careers start at the bottom. Even professionals, like physicians and mental health providers, land in this trap.

To support a career ladder mentoring and supervision are required. This equates to the quality control function of team leaders as described by Dr. Gawande.

Popular perception of professional education is out of step, often setting up unrealistic expectations by students and early career professionals. Graduate and professional schools might consider increasing transparency in how career progressions happen.

It seems to me that folks are dug-in around the issue of not changing the current system. Yet, I've heard few people, providers, patients, or payors, express satisfaction with what we have. With an eye to tweaking the hospitalist model in routine inpatient care by adding a seasoned physician as team ladder increasing quality of care, reducing costs, and promoting positive patient outcomes looks easy to achieve. Bring on the ideas from people who think about the systems they work with; this is where we can get to the outcomes of the Affordable Care Act without selling our soul to the bean-counters.

Instant Gratification: ED services and the future of healthcare

Sitting at my new desk, well actually an old kitchen table converted to a desk, in my new house, well actually its a rental, considering what to write that doesn't sound stupid or strays too far off topic. So much for not sounding stupid....

In my most recent life I was an emergency behavioral health assessor. In my new life I am a student who will be exposed to folks in a low-acuity hospital setting (its a hospital-based detox/crisis stabilization unit). This will help me flesh out understanding of the folks referred by assessors. This gap in my knowledge will be filled and will hopefully translate into better decision-making on the front end. Patients and their families will hate that; they want what the American medical system has taught them to want: instant gratification.

Which Way NC article about ED use and the Patient Protection and Affordable Care Act (ACA). I agree with Which Way NC's point that ED usage will increase as folks get less access to care and rationing leads to more crisis intervention services--by the way, clinicians hate this because they are trained to provide care to help people get better, not manage crises.

Check out this news: more funding cuts to the NC mental health system handed down from Raleigh. This link is from the Watauga Democrat in Boone, but it is happening across the state.

<blockquote>

"Across its service area, Smoky Mountain Center was dealt state cuts to several pots of funding, according to chief financial officer Lisa Slusher:

— $974,070 from its substance abuse block grant

— $1.67 million from its single-stream funding, which can be used for any age, disability or service

— $783,979 from its social services block grant, which provides for child mental health services and adult and child intellectual/developmental disabilities

— $48,000 for its drug treatment court in the northern region, which includes Watauga County

It also will operate with $113,574 less from county contributions."</blockquote>

Prepartion for Active Shooter Incidents

link to Here&Now radio piece on preparation by the general public for an active shooter incident.

quote from the Here&Now story on their website:

"These very concerns inspired the head of Boston University’s police force to tweet about a detailed, some would say disturbing, security video to more then 1,200 Twitter followers. The video was produced by the Houston, Tex. Mayor’s Office with a grant from the Department of Homeland Security, and is meant as a survival guide in the event of an active shooter." video created by Ready Houston TX with funding from the US Department of Homeland Security.

There is a whole Youtube RunHideFight channel with preparation videos.

"Ready is a national public service advertising (PSA) campaign designed to educate and empower Americans to prepare for and respond to emergencies including natural and man-made disasters"(source) This FEMA-funded resource is also available in other common languages used by those living in the United States.

Q1) is this use of Twitter/social media effective?

PS: FEMA Think Tank is an effort by FEMA to gather thoughts not just from emergency management professionals and policy wonks, but also from regular citizens. There are monthly topical teleconferences to join and an idea board where you can submit new ideas and comment/vote on other people's ideas. Pretty cool!

The quick view is that this is a new model for grant development that has been nixed by Congress in favor of the existing top-down model. I'll need to follow up on this at a later time. FEMA and emergency prep are a little outside my scope, but I do have some experience and continuing interest. If anyone actually reads this post and wants to develop my assumption, please feel free to comment and share your insight.

current news items

Here are a few things on my mind lately:

• We lost a deputy in the line of duty earlier this week. The community is feeling the loss with grief and pride.
• Since that event happened I've mentally reviewed many interactions with law enforcement officers.
• one question is to the effect CIT training/practice has on law enforcement attitudes toward behavioral health professionals. Experience points to a range from none to thinking a 40-hour class makes an officer a counselor.
• The role of technology in self-assessment and promoting mental health continue to advance. (link) "The National Center for Telehealth & Technology (T2), designs and builds applications employing emerging technologies in support of psychological health and traumatic brain injury recovery in the military. Equally important is our work toward eradicating stigma that can deter Service Members from seeking help."
• 
  

Professional credentialing across state lines.

It has been quite a busy week here in the ED. In fact, our slower ED had a unusual number of cases earlier this week. Luckily, the driving was minimized and response times did not suffer. Now down to one active bedfinding case, I've got a few minutes to write and think about professional development.

Last week I was in Memphis--that is a new world, for sure--and ducks are lining up for this new life adventure. The opportunity to learn how the crisis response system works in Tennessee and Mississippi has the potential to expand my horizons. So far, only minor differences are apparent. Temporary medical power of attorney and differences in terminology are the first ones to come to mind.

But, determining a job and a place to live add a sense of security; class schedule will get nailed down in the next week or so and the puzzle will have the major pieces in place. All the rest will be filling in details. Much relief: cool rain on a hot day, odor of flowers in Spring, a favorite restaurant at the end of a long day--all the good things.

Moving to a different state is hard enough. Add in moving professional status and the chores mount. Lessons in the utility of flexibility arrive daily. For instance, I am a Licensed Professional Counselor in NC and had planned to obtain licensure in TN. So, naturally, I prepared to obtain a TN counseling license. In the process earning a new credential: Certified Clinical Mental Health Counselor (CCMHC). Now, a job in MS leads me toward that licensure process. Once I leave NC I can no longer practice as a counselor until granted a license in the state where I work.

Federalism is alive and well. There are national certifications and state licenses, but there is no national license. Since 2009, all 50 states have a professional counseling licensing. However, each has different credentialing processes and requirements. And this is not a problem just for counselors: all the helping professions face the same problem.

The  American Association of State Counseling Boards (AASCB)is one organization working to solve the problem through the development of a National Credentials Registry. Such a project requires common standards as an initial step toward nationwide portability of licenses.

Two additional credentialing issues come to mind, and I want to quickly mention them. One is how to define a career ladder in the counseling professions (social work, counseling, marriage and family, chemical dependency, pastoral) in an era of cost-containment and insufficient workforces. All the specialties have practitioners with different amounts of education and experience, and with vaguely defined professional development ladders. Another issue is recognition for sub-specialty certification. For example, several certifications exist for crisis workers. None were linked from licensing boards and none have a national status.

As an afterthought: we will never have effective distance counseling programs until there is some nationally recognized credential.

Professional development is a task for us as individual counselors and for the field. Although the credentialing system is imperfect, work continues on ways to increase quality and fiscal efficiency, it is interesting to consider the issues and steps to take in helping folks live as best they can.

Supreme Court allows Affordable Care Act to stand by

There are several winners after today's Supreme Court decision that the Affordable Care Act is constitutional. [Here is a link to the majority opinion.] Among them are insurance carriers, rural hospitals, folks who can't afford insurance, and consumers of behavioral health services. Losers include those who can afford to self-insure and those with no intention of paying for services received. Other writers can spin this differently, but part of what I sense from those who oppose the law is a selfishness and very narrow in-group definition.

There are problems in this country related to basic fairness. Problems from those who think that everyone is trying to get something for nothing and those who are indeed seeking a free lunch.

My biggest concern about this law continues to be how it will be funded and implemented. Adding "accountability" will encourage reviewers to find problems with documentation--this will be called fraud, but could be as simple as not signing a note quickly enough. It will also stifle therapeutic innovation  and professional development in favor of "manualized treatment" and credentialing of lower level staff by state agencies.

Private insurance carriers and major hospital systems have begun to institute reforms touted in the law. This is because there are ways to streamline care while increasing quality and access. In many ways, the marketplace will solve problems when the environment changes and lead the way to a higher level of care. When politicians enter the business landscape things get complicated and lead to a lower level of care. I keep remembering a time I wanted to pay the IRS using a debit card; that experience showed me the worst of regulation and business--regulations designed to protect me combined with the convenience fee of the immediate service.

I expect the frontiers of healthcare reform to be in the expansion of "evidence-based treatments" by academic researchers--often supplementing eroding salaries with grant-funded projects and sales of programs--and crisis services. Reducing access to behavioral health services will continue to promote the use of crisis services.

Anyway, I hail the law and the increased access to healthcare it brings. My elation is tempered by experience in a rationed system. But...we'll see. The whole thing has to play out.

What is a "crisis hotline"?

An effective crisis response system is built from many pieces, each piece designed to provide an interrupt, or stop, where folks can breathe and disrupt the escalation of their crisis. The initial interrupt occurs at the point the person reaches out for formal assistance. (Technically, the first interrupt is when the person realizes they are overwhelmed, in crisis, and uses their personal resources and friends, sometimes called "natural supports", to resolve the crisis. While these informal efforts may not be recognized as deescalation attempts they are very important to management of the crisis.) One point of entry into the system is through the telephone crisis hotline.

“Crisis hotline” is the generic name given to services designed to provide immediate, usually, telephonic response for persons experiencing an acute crisis event. The hotline may serve various purposes, including Information and Referral (I&R) warmlines, telephonic crisis counseling, and dispatching mobile interventions and rescue efforts.

In some regions specialized services exist for specific populations and problems; in other regions calls may be answered by generalists who have experience in a wider variety of problems. One area I am familiar with has the 911 emergency response for medical/fire/law enforcement response, a dedicated domestic abuse response line, and a behavioral health line. They work together to route callers to the most appropriate responder.

Hotlines are staffed with trained persons who may be licensed mental health professionals, unlicensed mental health specialists, or peer supporters. In some states, Ohio, for instance, the term "counseling" may only be used by a licensed counselor. So, while the caller may not receive “counseling” services on the phone, they will be talking with a trained phone responder who may provide a suicide risk assessment, crisis intervention, and referral to community services as needed.

Albert Roberts, PhD created the 7-stage crisis intervention model in use by many crisis lines. The model's seven stages are:

1. plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment;
2. make psychological contact and rapidly establish the collaborative relationship;
3. identify the major problems, including crisis precipitants;
4. encourage an exploration of feelings and emotions;
5. generate and explore alternatives and new coping strategies;
6. restore functioning through implementation of an action plan;
7. plan follow-up and booster sessions.

Early crisis lines were organized in the 1950’s to provide suicide prevention services and have grown into networks of crisis centers able to respond to specific populations and circumstances nationwide. Suicide is now seen as a public health problem by policymakers and resources are available to strengthen a national network of suicide prevention call centers. "Many people trace official interest in the subject to a Senate resolution, introduced in 1997 by Senator Harry Reid, Democrat of Nevada, whose father killed himself, which proclaimed reducing suicide a national priority."

Mobile technologies offer challenges to rescuers and opportunities for folks to get help. As technology changes it is essential that crisis systems evolve. Call centers are learning to use social media, SMS/"texting", internet chat, and other technology to give folks options for confidential help with crisis intervention and de-escalation. Stop Teenage Suicide is an example. SAMHSA and Facebook teamed up in Dec 2011:

"The new service enables Facebook users to report a suicidal comment they see posted by a friend to Facebook using either the Report Suicidal Content link or the report links found throughout the site. The person who posted the suicidal comment will then immediately receive an e-mail from Facebook encouraging them to call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or to click on a link to begin a confidential chat session with a crisis worker."

Besides adding points of access for those in crisis, chat and texting extend the availability of staff resources. While Information and Referral (I&R) warmlines and runaway assistance centers can often operate on a limited-time schedule, acute crisis response hotlines must be available with 24-hour telephone service 7 days a week to provide counseling, guidance, emotional support, information and referral, and rescue interventions.

Mobile phones challenge emergency responders to locate suicidal callers due to the very advantage of cellphones: mobility. When you can't locate a caller, response time may be extended. Increasing the sensitivity of GPS tracking with smartphones offers promise but raises privacy concerns.

Examples

• 1-800-SUICIDE 1-800-784-243
• 1-800-273-TALK 1-800-273-8255
• 1-800-799-4TTY (4889) Deaf Hotline 
• 1-866-COP-2COP

An Online Crisis Network
The first online network with 100% of its volunteers trained and certified in crisis intervention.

Moody's promotes Obamacare

Today it was reported that Moody's Investors Service supports "Obamacare", the Patient Protection and Affordable Care Act, because it provides a greater income base for non-profit hospitals. They are not as happy about reductions in Medicare payments for physicians, also included in the law.


I have been casually following the progress of this law and public challenges it faces with several thoughts in mind.

1. It is a good thing for all persons to have insurance. The more people have insurance the more costs can be spread and, at least theoretically, that should lower retail healthcare. I say that knowing that prices always go up, never down. I am reminded of the premiums paid for organic foods.
2. In North Carolina, mental healthcare reform led to increased rationing and increased overhead due to increased "accountability" to enforce fraud laws and to use recoupments  to balance the budget. This created a very dicey environment for providers and additional layers of administration that were funded with lower reimbursements for services.
3. Reduced services (not access, it is a policy goal to increase access) has led to increased importance of the crisis and intake assessments in promoting good behavioral health and "recovery engagement". This is not the system I was trained for in graduate school; true for most providers, surely.
4. While the politicians wrangle over power and donations business (especially insurance carriers and hospitals) is adapting to the new model(s).

So, what does the changing system mean for crisis services?

Good question. One worth spending some time with. If crisis services continues to be where the money is spent, clearly training and technology must adapt.

Ranting About Documentation

Over the course of the past week or so I've been confronted by the question of what is enough when collecting information for a crisis assessment. These are the assessments conducted on the patient who presents in a behavioral health "crisis". The purpose of the assessment is to determine the most appropriate level of care and safety plan so the patient can be directed at the end of the session.

In general, this is a routine intervention. Get a little history to flesh out the presenting problem and make some recommendations for follow-up care.

It is a problem when the documentation does not support the diagnosis or justify the recommended level of care. At least that's the way my thinking has evolved.

Guiding Principle 1: Albert Roberts, PhD 7-stage crisis intervention model.

Guiding Principle 2: The patient's medical record describes the patient.

Guiding Principle 3: Recovery works best when the patient can see individual crisis events and treatment episodes as part of a continuum.

It offends my professional ego when these principles are violated/ignored/not attended to. Period. Breathe...1...2...3...4...5...better now....

But then I ask if I'm just being pretentious or overbearing or taking some other negative stance.

Probably.

And, I wonder, because I can't not argue with myself, what is the minimum of good documentation? Certainly there must be enough story to justify a diagnosis and medical necessity for the recommended level of care. I guess that can be done in 5 sentences or less.

But I doubt it. "When in doubt, get more history" one of my professors used to say. Should I say, "doubt is good?"

Yes, if it can be documented....

Problem Behaviors in the ED: “Hostage taking”

Sometimes patients are brought to the emergency department by law enforcement, or another authority, for a behavioral health evaluation and development of a safety plan. Behavioral health evaluations have the initial goal of determining risk for imminently dangerous behavior. Evaluations consist of two significant portions: a medical screening and a psychosocial history gathering. These evaluations contribute data to the risk assessment and are used to create the safety plan. Safety plans can take many forms depending upon the risks, resources, and circumstances of individual cases.

Most of these involuntary evaluations are managed without incident; but, sometimes the patient refuses to participate in the process. When a patient fails to cooperate with either assessment component they may be considered to be holding the process hostage.

Over the past few weeks several examples of hostage taking behavior have presented themselves in “my” ED. One fellow came in after a police standoff and refused to talk to anyone or give a urine sample to complete the medical screen, another was intoxicated and LOUD and kept several police officers busy until he went to sleep, a restless lady presenting a flight risk, and one older retired professor with behavior problems secondary to dementia. Each case presented different dimensions of the same idea: hostage-taking behaviors.

In the basic hostage situation one person takes control of another person and refuses to release them. The goal is to trade the captive for some good. When the behavioral health patient holds an ED hostage they are controlling the assessment process. It is not always clear what the patient’s goal is, but can usually be framed around the desire to dictate terms of release. There is often a narcissistic reach for power in action.

The patient that takes the assessment process hostage is holding a desperate position in a lose-lose game. Such a position is played from a place of powerlessness, where the patient is seeking control of their situation and/or emotions. Although they may not realize it, this patient is the most powerful person in the room.

One of the behavioral health worker’s tasks is to promote the patient’s feelings of power and channel that power into the development of the safety plan and, ultimately, into their taking control of their recovery.

What tools are available to respond to the hostage-taker?

Well, I fully believe in paying attention to the basics of patient care and behavior management. The stronger the foundation, the better plans can be built. Responding to hostage-taking behaviors is no exception. That means promote respect and dignity, practice effective communication, and observe positive behavior management strategies.

As a refresher, here is a reminder of what behavior is/isn’t (from [1])

BEHAVIOR IS:

• Any action that can be seen or heard
• Is observable
• Is measurable

BEHAVIOR IS NOT:

• Your reaction to the situation
• Your interpretation of the situation
• Your expansion of the situation

And the ABCs of behavior management:

A=Antecedent: The event occurring before a behavior.This event prompts that behavior.

B=Behavior: Response to the events that can be seen or heard.

C=Consequence: The event(s) that follow(s) the behavior.This effects whether the behavior will occur again.

• When the behavior is followed by a pleasant consequence, it is more likely to reoccur.
• When the behavior is followed by an unpleasant consequence, it is less likely to reoccur.

Regarding the importance of communication (from [2])

“Effective communication is an essential part of caring for patients. Yet there is evidence that in practice communication continues to be problematic.
The research base shows that: Poor communication can have serious consequences leading to complaints by patients and their relatives

Poor communication can leave patients feeling dissatisfied, frustrated, anxious and so uncertain that it affects their ability to comply with recommended treatments

Good communication can influence patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure as well as decrease reported pain and drug usage

Insufficient training in communication is a major factor contributing to stress, lack of job satisfaction and emotional burnout in healthcare professionals”

To set up an effective box to provide for safety of the patient and community in the ED setting a few things are necessary.

Remove the patient to the least stimulating area available, where they can be observed without being the focus for other visitors. This reduces attention and stimulation, promotes dignity, and creates a situation where the patient can deescalate safely.

Make the patient as comfortable as possible within the confines of the treatment environment. Emergency departments are not designed for comfort, they are designed for efficiency. But the offer of a pillow, warm blanket, decaf drink, and food can go a long way in developing rapport—and, ultimately, the safety plan.

The tincture of time will do the rest. There is no need to do much more. Nursing care is generally not required once the patient has been installed in a calm setting. If the patient is in custody they are confined to a small area and not a threat for wandering. Nature will do more to dictate when samples are obtained for the medical screen than anything that you can do.

The biggest mistake made in the ED setting, in my opinion, is to respond to challenging patient behaviors with a power struggle. Power struggles are demeaning to staff and patient. More importantly, they escalate the very behaviors that provide the challenge.

The flow of the emergency behavioral health assessment and safety planning process flow begins with recognition of the position of the patient. Powerlessness is the presenting cognitive position more often than not. In the search for power patients may resort to hostage taking behaviors. Effective management of these behaviors is built with empathy and respect by the ED staff for the patient and allowing time to work its magic in deescalating the patient’s emotional state.

RELAX, it’ll be all right….

Cites:

[1] Retrieved by rmcox on 2 june 2012 from http://www.bbbautism.com/behavior_management_strategies.htm

[2] Retrieved 01 june 2012 by rmcox from http://www.connected.nhs.uk/index.php?option=com_content&view=article&id=2&Itemid=2

Hopeful Solutions for Psychiatric Boarding

Hospital emergency rooms are frustrated by a bottleneck in achieving basic care for increasing numbers of patients presenting with behavioral health crises. Behavioral health specialist are often "on-call" and may take hours to arrive for an initial assessment and treatment planning visit. Then, patients may have to wait days for access to crisis stabilization services. EDs are not designed to provide prolonged episodes of care; "boarding" is the term use to describe the time spent by patients waiting for transfer. The problem of boarding persons with mental illness in community hospital emergency departments is nationwide.

This Bazelon Center report serves as a backgrounder on the issue.

Consider this example from Stanislaus County, California:

WARNING--this article uses stigmatizing language

One Problem:

"In the past five years, Emanuel Medical Center in Turlock has seen a dramatic increase in ER patients with a psychotic diagnosis, from 276 in 2007 to 681 in 2009. There were 591 visits last year.
The for-profit Doctors Medical Center in Modesto declined to release ER data on psychiatric visits, but said the caseload at its sister facility is telling. Last year, almost 4,300 people were treated at Doctors Behavioral Health Center and discharged, more than twice the number in 2007."

To rub salt in the wound, "Vartan said the behavioral center has operated at a loss since its parent company, Tenet Healthcare, purchased it from the county in 2007." [retrieved by rmcox on 25 may 2012 from published Sunday, May. 20, 2012]

One Opinion:

The Siamese-twin problem of boarding and poor behavioral health care has really escalated over the past 5 or 6 years. Reasons for this increase include:

1) economic problems for individuals and families increases stress-induced problems like anxiety and depression leading to increased suicidal behaviors and substance use problems overwhelm sufferer's coping skills;

2) economic problems for governments (primary payors for behavioral health emergency services) force cost-shifting and resource allocation choices. Local systems focus on immediate crisis services and reduce state-owned inpatient services;

3) healthcare policy "reforms" create service delivery systems built around early-20th century industrial concepts of "economic efficiency" and attempts to determine what works best (eg, evidence-based practices).

These three issue areas provide a number of critical incidents, like the one described in Medesto, CA.
Now, I'm not much of a market capitalist--too skeptical of the profit motive and the scarce resource concepts as motivators--but I am a big fan of communities solving their own problems. (I'll also go ahead and say that some resources should not be funded on a fee-for-service model. Healthcare is one of those resources.)

As government backs out of the innovation/solution side of the problem and into the accounting policy side local communities move into the vacated space. The excitement of change is the creative freedom that exists during chaotic times. This means that new forms of service delivery and new ways of thinking about patient care will rise from the compost of the old system.

One Answer:

One example of a locally created solution is presented in this example from Columbia SC scheduled to open in 2013:

"A renovated wing in the Palmetto Health Emergency Department hopes to increase quality of care for patients with mental illness." [cite: retrieved on 25 May 2012 by rmcox from  published 6:44 PM, May 14, 2012) will provide specialized care.

Because the needs of persons with acute mental illness are different from the needs of patients with acute physical complaints setting aside dedicated sections with dedicated staff if a good idea.

Behavioral health EDs are an innovation that is rapidly spreading from metropolitan areas to even modest sized cities. Services provided can include crisis stabilization, observation and assessment, and medication initiation. Most importantly, these services can be delivered away from the bright bustling atmosphere of the traditional emergency department.

There is hope for systemic change in how people with mental health crises can get help and access services. Not only are there new thoughts about how to do things, new coalitions of providers are talking about doing things in new ways. Exciting times!

Defining the field and chasing rabbits

Opportunity. Challenge. Developing a sense of humor. Being interesting. Creativity is a muscle that needs exercise. How much longer before I reach goal?...

While preparing for graduate school in the Fall (U of Memphis, counseling) I stepped up the development speed for a knowledge base, a library of information, about the field of emergency behavioral health. This project may be a gateway into a future career. One of the first questions I've had to struggle with is how to define the topic and the structures that will give the project it's shape.

The topic stretches into acute versus chronic treatments, victims of war and natural disaster, threats to individuals, families, organizations of all sizes. It is pretty clear that national economic crises are outside the scope, but what about the family struggling with developmental transitions? Should this be just about acute interventions and how to do them or should it include the all four phases from training and planning before the crisis through the post-vention and recovery phase?

Well, it should include "everything" that can be connected from a base definition. That much is clear. My personality would not let me do anything less.

There is the consideration of "crisis" vs "emergency" and the level of risk to health or property. But what is this thing, this construct, that so many people hang their hats on? Let's follow Flannery and Everly (2000) and start with the idea of psychological crisis.
A psychological crisis happens when a person or family is overwhelmed by some one, or series of multiple, stressful events that throw the person/family out of balance to the point that they cannot recover without assistance. Flannery and Everly refer to this phenomonon as the "crisis response" to the "critical incident" stressor.

This whole field is based on planning for, mitigating, responding to, and recovering from critical incidents. And, defining who, what, when, where, why and how crises happen. This blog will track rabbits and map the trails.

Mapping the Landscape: a Rationale to blog about Emergency Behavioral Health

Welcome to my latest blogging project. This blog will present my ideas about behavioral health crisis response as they develop. In the past I've used blogs to post news item and resources and to collect interesting items for presentation elsewhere; but not this time. Now I am collecting my thoughts after 13+ years of professional crisis response in preparation for a return to graduate school and the leap into the next phase of my career.

The field of emergency behavioral health is broad, making it very easy to get lost without a map. In this blog I will try to create such a map, a visualization or picture, of where the on the web the informational cities are located and what areas are ripe for development. The more I collect and organize my professional library the clearer the vision from the summit of the "big questions".

Over the years blogging has matured tremendously; my style and knowledge of blogging hasn't exactly kept up. To catch up I've surfed a little--according to Urban Dictionary "surf the web" is still a relevant phrase--and read that good writing is the key to getting and keeping readers. Marketing is how readers find what has been written.

So now I'm starting to lose focus from the topic/purpose of this post--staying focused is one of my "growing edges"--and getting caught playing with the language and not the idea. Cleanly stated: The purpose of this post is to talk a little about the challenges of maintaining a blog and what I hope to accomplish with this project.

I will have a job that allows me to travel (and collect commemorative stamp images like those issued through the Eastern National (EN) passport program and sought by the members of the National Park Travelers Club (NPTC)) and assist communities to serve their most vulnerable. All while living in serenity. Its a tall order. But, its time to direct my energies with my talents. For many years I've guided my career and personal choices with the mission "to give back to the community that gave so much to me" as I've adapted to compromise. Now I will take the hard steps to create my future. [time for a quick breather. that statement sets up so many challenges, I mean, opportunities.]

The most vulnerable include those who have used up all their resources to cope with life's challenges. A strong safety net is required for persons and families experiencing a behavioral health crisis or psychiatric emergency to return to normal functioning with as little disruption as necessary. This is the topic I will explore with this blog.

What have I accomplished tonight?

• defined my topic
• created a rationale post
• outlined my professional goal(s)
• reminded myself about the difficulty of practicing humility

What is left to accomplish?

•  outlining a structure for my posts
• linking to some guideline websites

1. Keep posts <250 words. (source)
2. Have interesting headlines. (source)
3. Use relevant keywords consistently and naturally to promote search engine optimization (SEO) and relevance for readers (should also force greater focus on topic organization). (source)

Lessons from previous blogging experiences:

1. post regularly with valuable content
2. this blog is not just a linkdump or collection of items. It is my job, as blogger, to connect the dots and show why the item is relevant.

Part structural guide, part lofty goal announcement, part focus statement: this post covers a lot of ground--and breaks most of the style guidelines just presented.... Thoughtful practice is important to increasing the subtly of our skills; reflection is required for thoughtful practice. Hopefully I can accomplish what this blog sets out to do...The Moon or Bust!