Mental Health First Responders – Filling an Important Need for Americans with Suicidality
As the “second-leading cause of death among people ages 10-43” (Hedegaard, et al, 2018), suicide presents an ongoing public health concern in the United States. Naturally, the mental health community seeks to make psychiatric care as available as possible to individuals who are at risk of suicide. To this end, federal and state-sponsored public services such as twenty-four hour a day, seven day a week text message and telephone hotlines fill a critical need as the first line of defense in the fight against suicide.
However, at times extreme cases of suicidality require an in-person response from emergency services to ensure the safety of someone in crisis. Presently, this responsibility falls to local police departments. However, the increase in suicide rates in recent years and reports of the inadequacy of law enforcement’s response to mental health crises indicates a serious need to include mental health first-responders in emergency dispatch services.
The American Mental-Health Crisis
Suicide rates in the United States over the past two decades have been rising at an alarming rate. According to the National Center for Health Statistics, suicide rates in the nation have increased by thirty percent from 2000 to 2016. Furthermore, no state is immune to these increases (Hedegaard, et al, 2018). Some research suggests that risk of suicidality is connected to being single, unemployed, poor, retired, disabled, or from a family who has a history of suicide. One notable risk factor is having a history of hospitalization for psychiatric treatment (Qin, et al, 2013). Whatever the underpinnings of suicidal thoughts and behaviors are, the numbers are on the rise.
As a response to the suicide epidemic, the organization Vibrant Emotional Health created the National Suicide Prevention Lifeline (NSPL) in 2004. NSPL provides a 24/7 text chat and telephone hotline free of charge to individuals in immediate danger from suicide. NSPL has answered over twelve million, texts and chats since 2015 according to their 2019 overview (Vibrant Emotional Health, 2019).
In the US, suicide is the second-leading cause of death among people ages 10-43.
NSPL continues to improve in its effectiveness, particularly since the passing of the National Suicide Hotline Improvement Act of 2018. This act called for the coordination between the Federal Communications Commission (FCC), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Department of Health and Human Services and the Department of Veterans Affairs (VA). These Federal agencies were called upon to “examine the feasibility of designation a three-digit code (N11 dialing code) for a national suicide prevention and mental health crisis hotline system” and to analyze “the effectiveness of the National Suicide Prevention Lifeline (NSPL)” (National Suicide Hotline Improvement Act of 2018). Indeed, congress is giving attention to the needs of citizens in crisis. But are the systems currently employed by the government adequate and effective in their response to the growing need?
The Inadequacy of Law Enforcement First Responders
While hotline services such as NSPL are often able to deescalate mental health crises over the phone, at times they are compelled to contact local police departments so that emergency services can be dispatched to the caller’s location. However, anecdotal reports of the detrimental psychological effect that such visits have on individuals in crisis and the alarming incarceration rate of persons with mental illness indicate that the needs of individuals in psychological crisis are not adequately filled by police.
In one report, an individual with bipolar disorder tells of the effect that an emergency visit from armed police had on him. He states, "Still on the phone, bawling and panicked, I heard police officers pounding on the door. They demanded I let them in. My anxiety spiked. Shame consumed me. My suicidality worsened, and I felt deep self-loathing" (Barks, 2020). Additionally, according to research from 2016, persons with mental illness are "three times more likely to be in jail or prison than in a hospital receiving appropriate treatment" (Bailey et al, 2018, p.1). This results from law enforcement confusing symptoms of medical illness with unlawful behavior and treating at-risk citizens as criminals instead of as patients. Admittedly, at-risk individuals calling during an immediate healthcare emergency could also be involved in illegal activity such as the use of drugs. Therefore, the intense anxiety associated with suicidal ideation is exacerbated by the presence of police officers and the potential for arrest. Additionally, well-informed, and compassionate police officers could face a conflict of interest when called upon to prioritize rendering psychological assistance over enforcing the law.
In short, law enforcement cannot adequately meet the needs of individuals in need of immediate in-person crisis support.
Learning from Mental Health First Support Programs in Europe
But there is another solution. First responders with adequate training in mental health services could fill the need for in-person crisis response. Rather than sending police officers or Emergency Medical Technicians (EMT) who may not have any experience administering psychological support and de-escalating emotional crisis, NSPL hotline workers could collaborate with teams of specifically trained mental health first responders who would be exceedingly better qualified for the psychotherapeutic nuances of such an emergency.
Mobile mental health support teams are more effective than law enforcement wellness checks for at risk individuals.
Currently, some countries are beta testing just such a solution. One example is the Psykiatrisk akut mobilitet (PAM) in Stockholm, Sweden (Bouveng, et al., 2017). PAM is a psychiatric response team comprised of two psychiatric nurses and a paramedic. The team works with local police and ambulance services in Stockholm to coordinate emergency visits to patients who are at immediate risk of suicide. In one year alone, PAM received 1,580 requests for service. Notably, one-third of all calls required no further action after the crisis intervention team made their initial visit. The pilot program showed how beneficial a mental-health-informed crisis support program could be. It provides a worthy example for emergency service decision-makers to emulate in the United States.
A recent qualitative study supplies promising evidence of the efficacy of PAM (Lindstrom et al, 2020). Researchers conducted interviews with thirty patients who benefited from the mobile unit. The patients’ comments centered around three themes that speak to the power of the program: 1) patients actively participated in decisions about their medical care, 2) patients did not feel dismissed, ignored, or judged, and 3) mobile response personnel created a safe and caring environment. In regard to their control over treatment decisions, one interviewee stated, “I was involved in all decisions made…I was also involved in the decision to go to the hospital even though in the beginning I did not agree to visit.”
One patient expressed appreciation their for being treated with respect and without judgment by saying, “I was cheeky and a bit panicked, but I still thought they were doing quite well. They read well how I felt, they did not depress my mood, rather the opposite…so we could talk.” The expertise of PAM staff created a safe and caring environment for patients in crisis was. Another patient said about PAM staff, “they talked and asked general questions about anything, so that my mind was distracted…so you don’t have to think about what it’s like right now” (Lindstrom et al, 2020). No doubt, the staff’s psychological training contributed to the effectiveness of the mobile response team.
The above comments demonstrate the advantage of implementing mental health first response teams rather than relying on law enforcement. Police officers may not have a basic understanding of psychological disorders. And some may even hold implicit biases towards mental health patients. While having local law enforcement muscle available to crisis response teams when a patient in crisis poses a physical threat to self or others, mental health practitioners are much better suited for the frontline of suicide crisis response.
Another example of a mental health first responder program is the Street Triage team in the United Kingdom (Horspool et al., 2016). Street Triage is a “collaborative service between mental health workers and police which aims to improve the emergency response to individuals experiencing crisis” (Horspool, et al., 2016). The Street Triage team dispatches an emergency vehicle staffed with police and mental health professionals. As part of the Street Triage program, a mental health professional works in the police control room itself, and renders assistance to police officers at a moment’s notice when necessary. One marked benefit of the program was that the mental health workers had extensive knowledge of support services and therapeutic options available locally; many that police officers were unaware of. One Street Triage mental health professional said, “I worked within that team and understood the process. It was obviously probably much easier for us….I would be able to write up my notes and the plan and then…add on to the schedule for the next day that person to be called or contacted” (Hospool, et, al., 2016, Results, para. 11). The Street Triage pilot program demonstrates again the benefits and feasibility of a state-sponsored mental health first response service.
Implementing Mental Health First Response Teams in the United States
As seen in the above two examples, awareness is growing globally for the need for mental health first responders. If programs like PAM in Sweden and Street Triage in the UK are implemented in the United States, they result in a need for many more qualified crisis intervention workers. Ideally, future legislation will allocate government funding for this purpose. Police departments and emergency services will need to fill positions around the clock to respond promptly to dispatch requests from suicide prevention hotlines.
As these programs mature, a corresponding need for licensed social workers and psychiatric nurses will arise. It is also possible for EMT to receive Suicide First Aid training. Perhaps specific EMT-related job designations could be created to support these initiatives; called EMT-EMHP (EMT-Emergency Mental Health Practitioner). Regardless of how they are designed, mobile mental health response teams will result in an influx of new jobs in the fields of psychology, psychiatry, and social work.
The increase in suicide rates in the United States in recent years represents a significant public health crisis. And much research remains to be done to uncover the root causes of the increased rates of suicide in the United States. It is time to give serious consideration to implementing mental health first response teams for at-risk Americans.
References:
Bailey, K., Rising, S., Ray, B., Grommon, E., Lowder, E. & Sightes, E. (2018). Barriers and facilitators to implementing an urban co-responding police-mental health team. Health & Justice, 6(1), 1–12. https://doi-org.ezproxy.umgc.edu/10.1186/s40352-018-0079-0
Barks, B. (2020, August 14) Virginians need care – not cops – in a mental-health crisis. The Washington Post. Retrieved from: https://www.washingtonpost.com/opinions/local-opinions/virginians-need-care--not-cops--in-a-mental-health-crisis/2020/08/13/826066a2-dbe7-11ea-8051-d5f887d73381_story.html
Bouveng, O., Bengtsson, F. A., & Carlborg, A. (2017). First-year follow-up of the Psychiatric Emergency Response Team (PAM) in Stockholm County, Sweden: A descriptive study. International Journal of Mental Health, 46(2), 65–73. https://doi-org.ezproxy.umgc.edu/10.1080/00207411.2016.1264040
Hedegaard, H., et al. (2018). Suicide rates in the United States continue to increase. NCHS Data Brief No. 309. National Center for Health Statistics. Retrieved from www.cdc.gov/nchs/products/databriefs/db309.htm.
Horspool, K., Drabble, S. J., & O’Cathain, A. (2016). Implementing street triage: A qualitative study of collaboration between police and mental health services. BMC Psychiatry, 16. https://doi-org.ezproxy.umgc.edu/10.1186/s12888-016-1026-z
National Suicide Hotline Improvement Act of 2018, H.R. 2345 §§ 115-233 (2018).
Qin, P., Agerbo, E., & Mortensen, P. B. (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register–based study of all suicides in Denmark, 1981–1997. American journal of psychiatry, 160(4), 765-772.
Vibrant Emotional Health (2019). The national suicide prevention lifeline – the nation’s mental health public safety net. The National Suicide Prevention Lifeline. www.suicidepreventionlifeline.org
