Mobile Crisis Settings
David C. Lindy
Leila B. Laitman
Patrick J. Moynihan
Neil Pessin
CASE 1
Night after night John has been banging on the pipes in his apartment. Usually taciturn and solitary, for the past several weeks he has been increasingly hostile to neighbors he passes in the halls. He has been seen talking to himself and looking around suspiciously, and appears to be listening to something that is not there. When a woman who has known him since childhood asked if anything was wrong, John screamed at her to leave him alone. He refuses to seek help, and denies that he is banging on the pipes at night. Otherwise he keeps to himself, appears reasonably well nourished, and has not been overtly threatening to anyone.
CASE 2
Isabel, a 65-year-old woman with no history of mental illness, has been caring for her grandchildren and working as a housekeeper 2 days a week for years. When her daughter came to pick up the kids this evening, Isabel casually mentioned that they couldn’t go outside today because the men were filming her. In reply to her daughter’s further questioning, she said that the men had been filming her having sex with her husband and selling the films. She knew this because she heard people on the street talking about the films. She refused to acknowledge that there was anything wrong with her or to see her doctor, and told her daughter not to mention it again.
How can such patients receive assessment and treatment? Their situations are not frank emergencies, they do not meet the threshold for dangerousness to self or others typically required for involuntary interventions, and they are certainly not going to seek mental health services on their own. And yet the need for care is clearly present. Some cases reflect a deteriorating course that will soon become dangerous. Other cases relate to a chronic condition that, although ego-syntonic for the patient, has become intolerable for loved ones, neighbors, or the wider community. Mobile crisis services are designed to help with these difficult-to-reach cases.
Mobile crisis services, however, have not developed in a uniform manner within the mental health system, and mobile crisis team has never become a specific term in and of itself. Indeed, the exact nature of the crises requiring these services is highly variable. A Google search of the Internet for “mobile crisis” yields 12,800,000 English pages, most of which are descriptions of mobile crisis programs from within the United States and Canada. There are relatively few links for research articles, and no evidence of journals or professional societies dedicated specifically to mobile crisis. A search for “mobile crisis best practices” reveals nothing from the American literature, although there is a recent document, discussed further later in this chapter, from the United Kingdom (1). Of note, there appears to be no book chapter expressly devoted to mobile crisis services as a component of psychiatric emergency services. The inclusion of this chapter is a reflection of the field’s now general acceptance of mobile crisis services as basic to mental health emergency care. However, it must account for the great variability of the nature and functioning of mobile crisis services. Perhaps this state of affairs is best understood historically because mobile crisis stands at the crossroads of two major trends in psychiatric services, namely, where community mental health outreach intersects with emergency psychiatry.
HISTORY OF MOBILE CRISIS SERVICES
The history of mobile crisis services is intimately linked to the history of outreach in community mental health and to deinstitutionalization. The first mobile crisis service noted in the psychiatric literature operated in Amsterdam in the 1930s (2). Called the “psychiatric first-aid service,” it attempted to manage psychiatric crises in the community so that patients could avoid hospitalization (3). As with many innovations in models of psychiatric service delivery, the Amsterdam team was developed in response to a fiscal crisis, with city officials hoping to reduce costly hospital admissions. Yet, reading the paper 40 years after its publication, it is clear that the Amsterdam team was guided by a very contemporary vision of respect for psychiatric patients as human beings and the principle of least restrictive care.
The concept of psychiatric outreach then seems to go underground until the 1960s, when President John F. Kennedy signed the Community Mental Act of 1963 into law. As Kennedy proposed in his landmark speech to Congress on mental illness and mental retardation on February 5, 1963, this law was designed to free patients from “prolonged or permanent confinement in huge, unhappy mental hospitals where they were out of sight and forgotten” (4). However, the movement of seriously mentally ill patients into the community meant that there was a need to develop community-based mental health services.
The 1960s: History and Early Studies in Psychiatric Outreach
In the early days of the community mental health movement, there was a great deal of experimentation with alternatives to hospitalization (5). Alongside the development of community mental health clinics, home-based services were shown to be effective in maintaining psychotic patients in the community. Visiting nurses providing home-based antituberculosis treatment in Lexington, Kentucky, were trained to use home visits to deliver chlorpromazine to schizophrenic patients. A controlled study showed that the patients receiving this psychiatric home care had significantly lower hospitalization rates than patients seen in the clinic (4). Studies in Boston also showed the efficacy of home-based treatment for patients formerly treated with long-term hospitalization (6,7). Despite these positive findings, the 1960s saw the clinic model become the primary mode of providing public-sector psychiatric care (8). In addition, other alternative models, including residential treatment, group homes, and partial hospitalization, “competed” with psychiatric home care.
The 1980s and the Development of Mobile Crisis Services
Nonetheless, the nature of many psychiatric disorders required a service capacity for mobile care. Psychotic denial of illness, chronic and recurrent medication noncompliance, and a growing epidemic of comorbid substance abuse all contributed to a vicious cycle of expensive hospital recidivism for public-sector psychiatric patients. These problems were compounded by fragmented, complicated systems of care that were often unresponsive to the needs of the individual, as well as by poverty, social isolation, and stigma. Twenty years of struggle with these issues led to the rediscovery of psychiatric outreach in the 1980s. Assertive community treatment (9), intensive case management (10), and, in the United Kingdom, psychiatric home care (11) became well studied, if underutilized, standard models of outreach-oriented mental health care.
Mobile crisis services developed and expanded at this time. In the late 1970s, 20 (60%) of 33 federally funded community mental health centers’ emergency services included some form of mobile service (12). By 1995, 39 of all 50 states, the District of Columbia, and the U.S. territories (Guam, Puerto Rico) reported some form of mobile crisis services (N = 53, 74%) (13). Although most mobile crisis services at this time were publicly funded, they were oriented to a spectrum of missions and provided services in a wide variety of models and settings. To date, more recent national surveys do not appear in the literature.
History of Psychiatric Emergency Services
Emergency medical services in general hospitals only developed in the United States in the 1960s (14), and the development of psychiatric emergency services (PES) is more recent still (15). Deinstitutionalization, in addition to its impact on community-based services, created a dramatic increase in the number of psychiatric patients
presenting to emergency rooms (16,17). Like emergency medical services, the PES must also have a capacity to respond to psychiatric crises at the scene. Hence, mobile services have come to be seen as a crucial element of the PES.
presenting to emergency rooms (16,17). Like emergency medical services, the PES must also have a capacity to respond to psychiatric crises at the scene. Hence, mobile services have come to be seen as a crucial element of the PES.
Thus, mobile crisis services evolved from the blending of the two separate, but related, histories of community mental health outreach and psychiatric emergency services. Mobile crisis services therefore tend to be variations on a theme, devoted to providing care to psychiatric patients in trouble who are difficult to serve, but also lacking in uniformity and standardization of mission and practice.
VARIETY OF MOBILE CRISIS SERVICES
What Is a Crisis?
Mobile crisis teams (MCTs) can be defined as mental health services that operate on an outreach basis to assess, triage, and treat persons in the community experiencing mental health crises (18). But what is a “mental health crisis”? This crucial term is often vaguely defined. One definition of a psychiatric crisis is an emotionally significant event that creates a serious disruption of an individual’s baseline level of functioning, overwhelming usual methods of coping (19). Sometimes it is the system supporting a marginally compensated individual that becomes overwhelmed, with relatively little change in the patient’s baseline functioning. Thus, a complete mobile crisis evaluation must assess both the individual and his or her support system (20).
This raises the question of the difference between crisis and emergency, or what the difference is between psychiatric crises of an emergent versus urgent nature (21). Emergencies can be defined as events that are imminently catastrophic, unscheduled, and demand immediate attention and management. Psychiatric emergencies frequently result in hospitalization, although they can lead to hospital diversion. In contrast, urgent cases are less extreme, do not require 24-hour availability, can be seen less immediately, and often involve complex problems that require multiple visits. This distinction suggests a continuum between emergent and urgent psychiatric emergency services, with mobile crisis services belonging somewhere in between. This model allows for the location of mobile crisis services at a place on the continuum that is optimal for a particular community, or, perhaps even better, for an extended segment of the continuum along which mobile services can flexibly move as needed.
Goals of Mobile Crisis Teams
Mobile crisis services have three major goals: (a) providing crisis services in the patient’s natural environment, (b) bringing services to the difficult-to-reach patient, and (c) averting hospitalization when possible (18). Because many patients receiving mobile crisis services are the last people to actually want them, they must be engaged in a way that is respectful of the intrusive nature of the intervention. Seeing patients on their home turf allows them to retain some feeling of control. It also efficiently accesses other people who may be important in the patient’s life and in the management of the crisis. Because many of these patients refuse other offers of care, mobile outreach may be the only way to meet with them. Avoiding hospitalization is a goal that is usually shared by patient and mobile crisis team and can therefore become the basis for a more collaborative approach to resolving the crisis. If hospitalization is required, the mobile crisis team is well positioned to accomplish this goal in the safest, most clinically expedient way.
Three Basic Types of Mobile Crisis
To the best of our knowledge, there is no report in the literature providing comprehensive data as to the different types of mobile crisis teams currently operating in the United States. A national survey of mobile crisis services looked at the numbers of states that provided mobile services, but not the types of service (13). One suggestion is that there are three basic types of mobile crisis services: emergency teams, urgent teams, and mobile clinic teams (22). These three types of mobile crisis service reflect the spectrum of acuity and the wide range of interventions for which mobile crisis can be used.
Emergency teams operate on a 24-hour, 7-days-per-week basis and are prepared to be immediately available on-site (20,23,24). They are typically connected to a psychiatric emergency ser-vice, and have negotiated formal relationships with local police and emergency medical services. Emergency teams will often be involved with cases that require hospitalization. In contrast, urgent teams are designed to avert psychiatric hospitalizations
and resolve crises (25, 26, 27). Patients are seen on a scheduled basis, teams do not provide 24/7 coverage, and frank emergencies are referred to emergency services. Urgent teams make multiple visits as necessary and can initiate treatment, pending referral. Urgent cases can, of course, become emergencies, and personnel are prepared to handle such contingencies. In New York City, for example, mobile crisis personnel have been granted legal authority to order police to involuntarily transport patients who present a danger to self or others to emergency rooms for further evaluation. Many teams combine these models and are equipped to handle emergent, urgent, and routine cases.
and resolve crises (25, 26, 27). Patients are seen on a scheduled basis, teams do not provide 24/7 coverage, and frank emergencies are referred to emergency services. Urgent teams make multiple visits as necessary and can initiate treatment, pending referral. Urgent cases can, of course, become emergencies, and personnel are prepared to handle such contingencies. In New York City, for example, mobile crisis personnel have been granted legal authority to order police to involuntarily transport patients who present a danger to self or others to emergency rooms for further evaluation. Many teams combine these models and are equipped to handle emergent, urgent, and routine cases.
Mobile clinic teams are more oriented to brief, home-based, mental health treatment (28). They have sometimes been used as outreach components of clinic services. For example, a client being treated in a clinic is also seen by an outreach worker who conducts family therapy in the home (29). Home-based crisis intervention services are short-term, intensive, family-centered treatments designed to avert psychiatric hospitalization for at-risk children (30). In a similar vein, home treatment is sometimes used as an alternative to psychiatric hospitalization (31). These services are often called mobile crisis because they are designed to avoid hospitalization and use the patient’s natural environment.
Mobile Crisis Funding
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