Hello and welcome. I'm Dr. John Torres, the Director of Digital Psychiatry Division at Beth Israel Deaconess Medical Center and a member of the SMI Advisor Clinical Expert Team. I'm pleased that you're joining us today for an SMI Advisor webinar, Peer Support Engagement Skills on Mobile Crisis Teams. SMI Advisor, also known as Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'm very excited to introduce today's faculty for the webinar, Patrick Hendry. Patrick is Vice President of Peer Advocacy Support and Services for Mental Health America, where he provides national advocacy and develops new services for training peers and consumers within the behavioral health system. He has worked as an advocate and initiator of peer-run services for 27 years in a variety of leadership roles, including as a former director of MISTAC and a consultant for the National Council of Behavioral Health, University of South Florida, SAMHSA, the National Association of Mental Health Program Directors, among many other agencies. Patrick, of course, also serves as a member of the SMI's Clinical Expert Team. Patrick, thank you for leading today's webinar. Thanks, John. And so, as John mentioned, we're going to be talking about peer engagement skills on mobile crisis teams. I just want to point out that I have no conflicts of interest related to the subject matter of today's webinar. So, our learning objectives today are to describe engagement techniques utilized by peer specialists on mobile crisis teams, to assess the value of the inclusion of peer specialists on those teams, and to define the most productive role for peer specialists working with mobile crisis teams. Mobile crisis teams are a service that can provide an immediate response to a mental health crisis. And during a mental health crisis, emergency rooms can sometimes be very difficult to access and very slow and traumatic for the individual trying to receive services. The main objective of a mobile crisis service is to provide rapid response, access to individuals, and resolve crisis situations that involve children and adults who are presumed or known to have behavioral health disorders. There's a variety of ways in which these teams can be staffed. But recently, some teams have started deploying peer specialists as members. This webinar is a discussion of the role of peer specialists and can play, and specifically, the ability to engage with the individuals. Sorry, I'm having a very difficult time seeing these slides, who may be distrustful or afraid of engagement with clinical team members or law enforcement. A typical team is composed of professionals and paraprofessionals. So teams are generally made up of civilian responders. And traditionally, teams have consisted of a social worker and another clinical mental health provider. More recently, peer specialists are being added to these teams. And we'll talk about some examples of that in a few minutes. They are trained in crisis intervention techniques. And there's actually some specialized training now for peers to work in these environments. At least one member of the team has to be legally qualified to impose an involuntary hold for further assessment if necessary. Most teams are accompanied by law enforcement. The presence of law enforcement is necessary when the potential for violence exists or if there's an underlying criminal complaint. All civilian teams are able to provide more on-site stabilization services and spend longer times when they're not accompanied by law enforcement. So there's a trade-off of either being able to spend more time on scene or to have someone there in case there's a criminal complaint involved. Introducing an integrated mobile crisis service that involves both can improve collaboration and efficiency and getting people to treatment more quickly in a crisis. Mobile crisis teams intervene wherever the crisis is occurring, often working closely with police, crisis hotlines, and hospital emergency personnel. Mobile teams may provide pre-screening assessments or act as gatekeepers for inpatient hospitalization and can also connect an individual with community-based programs and other services. Many communities have specific hours for their mobile crisis teams. The most effective ones and the ones who have shown the best outcomes are the ones that are available 24-7. The setting can include homes, emergency departments, schools, and virtually any place within the community. In 2013 to 2015, the Montana Peer Network piloted a program with local law enforcement crisis intervention teams. So local law enforcement had gone through CIT training to provide alternative crisis services. These trained CIT officers would respond to crisis calls and evaluate if the individual needed inpatient services or could be discharged into the community. If they determined that inpatient services were not appropriate, they'd call on a peer response team that could immediately respond and help coordinate with community resources and stakeholders to reduce high-cost impacts of crisis on community systems. The peer response team would continue to meet with the individual weekly on one-on-one follow-ups, and they were able to build long-term supportive relationships. So the Montana Peer Network program sometimes followed people as long as six months or even in a few occasions, an ongoing relationship where they transitioned into the peer network's regular one-on-one peer support program. The program produced significant savings over traditional crisis response. In the first year, there were 96 referrals by CIT, and these resulted in 749 contacts. The savings were approximately $15,000, but that included the startup cost that exceeded $50,000. So in a relatively small number of contacts, they were able to save approximately $65,000. One of the things that we always have to be aware of whenever we're providing services, particularly in communities of diversity, is that culture can play a really important role in how we deal with crises. This can be true for both the individual in crisis and the individuals or team members that are providing the crisis intervention. Because culture can include many, many different factors, as we all know. It can be age and gender and sexual orientation, race, ethnicity, language, nationality, religion, and many, many other factors. A lot of different cultures within the United States react to or respond to services in different ways. In Florida, there was a mobile crisis team that provided services in a migrant labor town and had to work with multiple cultures, a Haitian culture, the local Seminole Native American culture, Hispanic migrant laborers, African American community, and then the more traditional white farmers who the people would be working for. In those cases, the teams had to actually have people who could speak to those cultures directly, particularly with the Native American tribes, where they were very reluctant to engage with somebody who was not very, very familiar with their culture. Because of the need for promptly responding to crises, culture and cultural identity are frequently neglected. Then this causes communication problems and sometimes even exacerbates crises. When possible, it's really, really desirable that the team reflects the diversity of the community it serves. For instance, in the community that I was speaking about in Florida, there was a drop-in center that was peer-run. Again, they had to function with all of these different communities. The only solution they were able to come up with was that they had to have somebody working on staff that represented each of those individual cultures in order to get participation. The same kind of problem arises in services, location-based services, as those with mobile crisis teams. Team members should always try to be aware of the differences among cultures, the attitudes about mental health and sensitivity to intervention techniques. The first steps that a team will generally take is to come into the situation and de-escalate any potentially combative or disruptive situation that might be going on. Then they begin to try to engage with the individual as they calm them down. The teams that are mixed teams using law enforcement have found that the de-escalation techniques taught through CIT are very effective because generally the law enforcement is the first organization on scene where they're doing mixed teams. Interventions can be really intimidating. The individual may be already agitated, probably are because they're in crisis, and they may be experiencing confused thinking. The presence of law enforcement can produce fear. Many people have had traumatic experiences that may have involved law enforcement in the past. Unfortunately, in many of our states, when people are taken in for a crisis hold, they are taken by police officers in a police car and frequently handcuffed. This just exacerbates the traumatic experience that the person is already going through. As I said, the person may have previously had bad experiences with crisis intervention. The addition of peer specialists to this team can be very beneficial. We'll talk about some of the engagement techniques that peers are able to use that are very calming and able to build trust more quickly. Another very first step or the main step that the team takes is to do an on-site evaluation and assessment and to come up with a satisfactory resolution. It depends on the assessment. De-escalation and engagement are important in order to evaluate and assess the situation. Anyway, what they're working towards is a resolution. The goal of the intervention is the best possible resolution for the individual and the community. You have to keep both of those issues in mind. Resolution can take a number of different forms. It might be possible to lessen the crisis by talking to the person and helping them to calm themselves and express their needs and desires. Also, connecting them to resources in the community. This could be a respite facility or a support group, peer support, traditional mental health services, connections to temporary housing in homeless situations. Connecting them to these resources can be, in a way, the best outcome for most people. Frequently, the crisis that people are experiencing are based on something that is currently going on in their life. If they can address that or be taken out of that stressful situation, often inpatient services are not necessary. Using all of this and connecting people back to family and friends, if that's appropriate, can lead to a safe resolution that lets the person stay in the community. This is the outcome that we really are all trying to achieve whenever we provide services, is for the individual to be able to stay in the community and receive the type of services that are most effective for them. The evaluating professional can decide that the individual meets state criteria and mandate an involuntary hold for further evaluation. In most states, that's generally about 72 hours. This may mean that they're taken to a freestanding crisis stabilization unit or a crisis unit within a hospital facility. Sometimes, we try to divert people to something that's a little bit of a step down, and that's a respite facility. There's an increasingly number of respite facilities being run by peers around the country, respite being a place where a person can go and stay overnight, and sometimes up to maybe as much as four or five days. It's a place where they are safe. There's no outside influences if they want to remain safe from anything that's going on in their lives outside of the respite facility. They have the availability of peer support or even professional support if needed. Now, if the professional decides that the individual doesn't meet criteria for a psychiatric hold, they can refer the person to behavioral health services in the community. When that happens, the person is free to return to their home or some other safe location. We found in many, many communities that one of the things that seems to work best, particularly when law enforcement is the ultimate group that will take the person to wherever services are going to be provided, is to have these one-stop locations where someone can go for a more relaxed, more informal type assessment to see if they need to be connected to a homeless shelter, to food banks, to peer support facilities like drop-in centers or clubhouses, to traditional mental health services, to whatever they need that will address the issues that are creating the crisis that they're dealing with. If the professional decides that the person doesn't meet criteria and there's illegal activity involved, then the individual might be arrested. So, a mobile crisis team is dedicated to decreasing unnecessary incarceration, decreasing emergency room usage and hospitalizations, providing services in the least restrictive environment, and providing safe, compassionate, and effective intervention during a crisis. Some studies recently have shown or suggest that mobile crisis services are not only effective in diverting people in crisis from hospitalization, but are also very effective at linking suicidal individuals discharged from emergency department to services, and better than hospitalizations at linking people in crisis to outpatient services. So, when you're in crisis, what does an individual need? Well, we know that people need safety and reassurance. And this is the first thing that a crisis team member tries to establish, is a feeling of safety. The person knows that they can talk to these people, that they will be respected, they will be listened to and responded to in an effective manner. Unless there's some sort of violent activity, generally law enforcement will step back and allow the team to proceed with an assessment and evaluation. And if there's a peer member to the team, they can begin to build a kind of a trusting relationship that can then continue on after the resolution of the crisis. We also need to know that people are presented with helpful attitudes and approaches. So, for instance, when someone is in crisis and perhaps it's been the result of an incident in their own living arrangements, then the crisis team can help people to try and figure out for themselves what's the best solution to that problem and to offer them a series of alternatives. And again, so we go back to respite or shelters or inpatient services, or perhaps going home with another family member, whatever it takes really to put that person not only into a safe and reassuring environment, but also that is something that they choose for themselves. And this is important because we know that when individuals have choice and are able to make choices with assistance or without assistance, they are far more likely to carry through with whatever path they've chosen. So, if it's, for instance, to go into a respite facility, they're more likely to stay there until the crisis is really resolved than if somebody sends them there and it's not a choice that they agree with. It's also incredibly important that all members of the team, including law enforcement, treat individuals with respect. This has been one of the problems. This is how the CIT movement began in the country was that two things were happening. One was that police generally in a situation, they deal with the situation through their very police-like presence. So, they are frequently in a uniform. They may be carrying a gun or a taser or both. They use command voices. And we know that frequently those kinds of symbols produce the opposite reaction for someone who is in crisis and perhaps experiencing confused thinking. So, for instance, in CIT, officers are trained to deescalate. And when they're working in concert with a mobile crisis team, that's even more effective. And people are treated in a respectful manner and not, you know, ordered about in a way that just exacerbates the crisis. We've seen in this country and really all over the world way too often where a crisis that could have been resolved in a more peaceful manner ends up in violence. And I know that some communities started in CIT. I know Memphis did. And Miami, for instance when they adopted the CIT programs for their officers and they involved peers in their training very deeply and the Memphis model does too. It was because they had had a number of deaths resulting from mental health crisis calls where the officers came on scene alone without a mobile crisis team at that point and without CIT training and trying to use that normal police presence and command authority, the person resulted in violent reaction and unfortunately was killed. We need to make sure that people receive support and support means whatever the individual needs. We know that we're trying to support people by providing mental health services but again especially in communities that have these one-stop centers where if law enforcement is transporting the person they transport them to a one-stop center where then they can be assessed in a calm and respectful atmosphere and generally in communities that utilize mobile crisis teams the mobile crisis team will continue with the person into that center so they come out with the best resolution for everybody. We also need people need to feel like they're protected and this is again another place where the peer engagement is extremely effective because as I said before many people have had negative experience during crises before and are fearful. They may be fearful of law enforcement. They may be fearful of dealing with authority figures and we're going to talk about that in a few minutes but they're fearful of the process and they're even fearful of perhaps being put into an inpatient setting involuntarily. The presence of a peer who can talk to them one-on-one and in the language that they understand and by sharing having the idea of shared experiences can produce a feeling of protection and kind of a safety issue that people often need very much during this time. The other thing that's really important and this is where mobile crisis teams and particularly those with peer involvement are really good is in is providing with people with time and space and options. What that means is you know traditionally when mental health calls 9-1-1 calls would come in and police officers would respond in communities without mobile crisis. Law enforcement generally tries to resolve the situation very very quickly and that can be of great importance because they may be needed in the community other situations. Mobile crisis allows people to take more time and we find that by engaging people especially through peer support and taking that extra time to talk through the situation with the person on site frequently what would have ended up in an arrest or an involuntary home ends up in a community resolution to the problem. By space we mean that people need to be respected. People don't frequently in crisis don't want to be crowded they don't want to be feel that they to feel that they are being pushed into a situation that's not of their choice and so it's always good if there's options available. Those options could be you know that if someone is highly agitated they may be given the option of you know let's calm down and talk about this but if the person continues to escalate in their agitation the options may become less and less and eventually end up with the person being put into a situation not of their choosing. Research literature on the emerging roles of peer specialists gives us examples where peers can serve on a team with traditional mental health and substance use providers. These include assertive community treatment teams. The ACT model calls for peer support. Peers are working in crisis stabilization units, mobile crisis teams and peer bridger programs where people are starting to work with people during hospitalization frequently even in crisis units and then following the individual into the community and we we find out that the more we engage peers in these processes the more likely people are to take ownership of self management of their own situation. The introduction of a peer specialist into an agency or a mobile crisis team requires substantial preparation because it's really important that the staff understands what the role of the peer specialist is and we'll get into the specifics of that role in a few minutes. Administrators need to educate the existing staff about the value of lived experience and the specialized training that peer specialists receive. The inclusion of peers helps build teams that are welcoming and respectful and helpful and they're accessible and they're safe. The services that provide assistance to people in crisis or in extreme states need to be provided in a way that they would prefer and this is what I was talking about before so that if you're if you're providing a person options and choices and they can kind of guide the way this is going to go instead of being forced to fit into a system that immediately reacts with a hold put on the person or an arrest because perhaps there's been you know some misdemeanor type activity people yelling in the street or being aggressive with people on the street. These things can frequently be resolved on the spot so that we don't have to go to one these more traumatizing type of resolutions but also far more expensive and have much worse outcomes for the person in the long run. And the inclusion of peers is also designed to reduce the risk of seeking help and by that I mean again that you know we we go back to this idea that people's previous experiences prior to peer support being part of mobile crisis or even prior to mobile crisis being available the experiences that people have undergone can be frequently traumatizing and this can have long-term effects on their outcomes and quality of life going forward. So when we try to actually step in to help someone but we're not open to communicating with them and trying to resolve the situation in the best possible way and we fall back on these models of either involuntary holds or police involvement and possible arrest when we when we start to do that people become afraid of seeking help and so they may be in crisis and they may move even more rapidly to self-harm or harming others whereas when they work with people who are respectful of them they're much more likely to reach out for help next time a crisis occurs. So peer support has really proved to be a very promising strategy for engagement and it's really promising in engaging people in their own health care. Peer support in almost any type of environment whether it's on during a crisis in the community or working one-on-one with a person working within a community mental health center or a peer-run setting like a drop-in center or perhaps in a clubhouse or whatever the situation is we find that having somebody that they can communicate with and and build a relationship of mutuality in other words that the two people have had similar experiences and can speak the same language and know that each other is being treated with respect then people are far more likely when they're given that option to decide which trajectory their services are going to take to begin to self-manage and research has also shown that self-management almost always results in better outcomes because people are far more likely when they are involved through shared decision making or peer support they're far more likely to stick with treatment and to receive the maximum benefit possible from that treatment. By using peer support systems gain a trained effective workforce that can help lead to outcomes that are important to the people receiving services so not just outcomes that are important to the system itself and that's that's the older system that has been changing over the last 30 years and a big part of that change has been brought about by the introduction of peers into traditional services and we've moved more away from a more rigid model of services to something that is person-centered and flexible based on the individual circumstances. Peer support team members can sensitize other staff to the needs of people receiving services this is extremely true you know talking about the changes that have taken place in all systems of mental health services peer support has probably been the largest change agent involved in moving towards what we call a recovery-oriented system of care and this is the same thing in crisis calls so as we as we move towards more of a recovery approach to people how can we help you what can we provide that will resolve the crisis that you're in right now in a way that you feel good you feel trusting and that you will be a part of that service even if it's a crisis hold and unfortunately even if it's incarceration we hope that in many communities we know that peer services are now being introduced into jails and even prisons and so if people can continue to have that peer connection whether it's in a crisis unit inpatient hospitalization or perhaps incarceration if they continue to have that that respectful mutual connection with a peer provider then people are going to do far better patient engagement increases quality of health care services and it improves outcomes for the individuals receiving services and it also you know going back it increases outcomes for the system and what we mean by that is that when people are more responsive to services they are then served in the least restrictive environment and their services are more effective this frees up assets in the community for people to benefit even more for more people to benefit from what's available so the more that we are able to produce good outcomes for people and keep people living in the community then the more access we have available for the people who need the more intensive type services so some studies have shown that individuals who have difficulties engaging in services or adhering to treatment have trouble trusting authority figures and and a lot of times this is you know due to previous experience but it may also be something that you know has come from their childhood and that they they've always had that this is where peer support services can dramatically differ from the other members of a mobile crisis team because the the peer does not present themselves as an authority figure they present themselves as a support as somebody who's there to be strictly there for the individual who understands what the individual is going through who perhaps has experienced something extremely similar to what the individual is experiencing peer support can improve engagement of individuals individually and relationally or organizationally by increasing involvement people in their own care so in other words you know the more we engage people the more comfortable they are in that engagement the more trust that they build in the system the more likely they are to then trust other members of a treatment team so some of the skills that peers utilize to engage people first is to demonstrate respect for the person and that needs to be done very quickly and this is something that all members of mobile crisis needs to do and also law enforcement is to treat people with respect and to make sure that the crisis is approached in a calm and evaluative way so that the people on the team are trying to understand what's actually going on for the individual and how they ended up in this situation peers present a calm and caring demeanor that promotes a feeling of safety and has a calming effect on the individual and and they can do this because most of us who have worked in these roles have had some kind of experience of our own in crisis and community and and we know how important it is to be presented with calm voices and calm demeanor in order for us to calm ourselves and peers are very good at doing that peers are available to the person for support throughout the intervention process so the peer is there throughout the entire intervention and frequently in many states where they utilize peers in mobile crisis the peer accompanies the person beyond the the mobile crisis team experience and so they may follow the person to the one-stop facility where they can reach a better resolution and find the kinds of services they need they may follow the person or contact the person's family if that's appropriate and make sure that the person is taken to a place where they feel safe it might be their home it might be other members of their family they demonstrate an understanding of the individual situation based on this shared concept of lived experience and they provide the person with an understanding of what's going on and what will be occurring and so by explaining the process to the person we reduce the number of surprises and when people know how this is going to go when they're being confronted in a way by law enforcement and mobile crisis members if they understand how that process is going to proceed it's they they feel much more safe during the situation peers are also really good at demonstrating patience and a willingness to continue to work towards the best possible outcome so some of the qualifications for peers who work on mobile crisis teams basic peer support training and 47 states either have certification of peer specialists or are in the process of developing them i think 45 maybe 46 states actually already have their certifications in place in fact just two weeks ago california passed legislation to create a certification which is is a bit funny because california has more peer specialists working than any other state the most populated state there's over 6 000 people working in peer specialist roles within the state of california but without certification but they still go through training peers who are going to work in these type of situations need additional trauma-informed training they need to use communication as an intervention and so they need special training to to do that and there's a training that has been developed by the pennsylvania peer support coalition that is exceptionally effective and has really shown through the it's for peers working in crisis situation including mobile crisis teams and it's really shown increased outcomes it's relatively new so research has not been fully conducted yet but the the outcomes that we're seeing in the statistical information that we're seeing is showing a real positive result pennsylvania is a state that has been very advanced in its use of peer support peers who are going to work in in mobile crisis teams need to go through de-escalation training similar to the training actually that the police use but also the trainings that are typically used in mental health CIT has a type of training called calm assess facilitate and this is the type of actions that a peer will take to you come upon the situation you first want to calm it then the team wants to assess what's really going on here and then everyone works together to facilitate a good outcome safety training and enhanced self-care training and it's very important that people do exhibit self-care the qualifications for peers or candidates for inclusion should have substantial peer support work experience the team leader should conduct a face-to-face interview in order to make sure that the person is a good fit for the team even conducting role plays can be useful in the selection process for peers on the team and the role of peer team members should be really clearly delineated and agreed to by all law enforcement accompanies mobile crisis team it's a common practice and we've spoken about a lot so we'll go into in great detail here but it's really highly desirable that CIT officers are involved as much as possible the peer team members really need to understand the role of law enforcement so that they are not interfering in something that is not part of their role everybody's role should be very clearly delineated and they should have had specialized training to make sure that they were a good fit not only with the clinical team members but law enforcement the role of peers on mobile crisis team is primarily one of support the peer specialist is there to support the efforts of the team produce a satisfactory outcome utilizing the unique qualifications of peer specialists peer staff members can assure the individual in crisis that they are safe that they're understood that they can ask questions about the process and receive clear explanations can trust that the team will work with them to produce the best possible outcomes and finally to make sure that the person is followed up on and it is if possible within that community given access to ongoing peer support so with that I'd like to thank you and we're going to open it up to questions you

Peer Support

Engagement Skills

Mobile Crisis Teams

SMI Advisor

Patrick Hendry

Peer Advocacy Support

Crisis Intervention Techniques

Cultural Sensitivity