STEPS TO FOLLOW DURING A CRISIS- NAMI-(National Alliance for the Mentally Ill)Maine -Family Resource Guidebook-
Be aware of early warning signs: changes in sleep patterns, dress, and friends; suspiciousness/paranoia, isolation, aggression. Donât let signs escalate. Get help immediately. (See Four-Phase Crisis Plan.)
If a full blown crisis starts, ensure the safety of all parties. Be patient and reassuring. If youâre calm, the ill person will remain calmer. Do not assume an authoritative role or argue. Treat the ill person with respect (even if he/she threatens you). Instead, be firm in your attitude and set boundaries for good behavior. Remember, the person is scared and having great difficulty in dealing with his/her emotions and thoughts.
Pre-Crisis Directive. Prepare a folder that includes the patientâs:
Name, address, phone number (and caregiverâs)
Diagnosis, psychiatric history medication dosages
General medical history (diabetes, heart problemsâvery important!)
Treatment preferences: i.e., patientâs choice of hospital, doctor, type of restraint (if necessary), choice to use ECT (if necessary)
A phone list of: the crisis team, doctors, emergency room, police, ambulance service, and any other services you may need
Call your local crisis team/physician/psychiatrist. The caregiver must discuss symptoms with Evaluators and decide what do.
The crisis worker may deal with the situation at patientâs home.
The worker may meet the ill person and caregiver(s) at the emergency room. (Two caregivers should always accompany the patient to hospital.)
It may be possible for the ill person to stay a day or two at a crisis center and not be hospitalized.
If suicide or violent behavior is involved, involuntary hospitalization may be necessary. The police and/or ambulance may be the best choice to transport the ill person to a hospital.
At admittance, patient should sign a Confidentiality Release Form to enable caregiver to: discuss treatment; give medical history, and help with release plan.
CRISIS
Crisis Intervention
In the last twenty-five years, the course of care for persons with serious brain disorders has changed dramatically. De-institutionalization and modern medications have re-shaped traditional treatment plans. Focus has rightfully shifted from that of lifelong hospitalization and "patienthood" to one of recovery and community reintegration.
Sixty-five percent of the individuals discharged from psychiatric hospitals now receive primary care and support from their families; so it is likely at some time the family caregivers will experience a crisis situation with their ill family member. Both parties need to learn how to recognize that a crisis might be coming, what actions can be taken, and what supports can be put into place.
A full-blown crisis situation can result because no prior planning has been done. Seldom if ever does a person suddenly lose total control. Studies show that 70% of people with mental illness can pick up on their own early warning signs of crisis; 96% of their loved ones can identify those same signs. Both parties must know what to look for.
Learn to trust your instincts! It is during the early stages that a full-blown crisis can sometimes be averted. If you sense deterioration in a relativeâs mental condition, try to discuss with that person how he is feeling:
Are the appropriate medications still being taken?
Are recent events or activities too stressing?
Are sleep patterns changing?
Is there ritualistic preoccupation with certain activities?
Are unpredictable outbursts, unusual agitation, or paranoia a problem?
Controlling a Potentially Explosive Situation
If the ill individual is in danger of self injury, if behavior is frightening, or if the ill person is threatening people, it is important to take immediate action: call a crisis center. Remember, the patient is probably terrified and your primary task is to help the patient regain some control. Accept the fact that the patient is in an "altered reality state."
It is imperative that you remain calm. If you are alone, call a friend or a relative to remain with you until professional help arrives. Below is a "what to do" list to use during a full-blown crisis.
(See Emergency Evaluation and the Law, this chapter; also Voluntary/Involuntary Hospitalization, Hospitalization
1. Donât argue with the ill person that what he/she is seeing, hearing, or feeling is unreal. Assure the person that you understand what his/her are experiencing is real to him/her and you want to help.
2. Donât threaten. It may be interpreted as a power play and increase fear or encourage assaultive behavior.
3. Donât argue with other family members as to how to treat the situation. This creates more confusion.
4. Donât touch or have continuous eye contact with the patient. Donât turn your back on him/her
5. Comply with reasonable, safe requests from the patient. This provides the patient with an opportunity to regain some of the control.
6. Donât block the doorway (However, try to keep yourself between the patient and an exit.)
7. Remember, do call the police if the person is violent. Most important, explain to police the details of the situation before they arrive so they will be prepared: i.e., how long the crisis has gone on; is the person suicidal; how has the person been violent; are there guns in the house; does the patient have a weapon of any kind.
8. Most importantly, understand that this illness is not your fault, nor is it the fault of the person in crisis. Mental illness is a biochemical disorder of the brain. It must be treated with the same attitude as a physical illness.
Four-Phase Crisis Planning
An out-of -control situation results because there has been no prior planning done. A "person-centered" crisis plan based on a four phase model is presented here.
Traditionally, most mental health services are "agency centered." Each agency-home health care (with psychiatrist/nurse/social worker), crisis service (with clinician, crisis support persons), mental health agency (with more psychiatrists, therapist, community support worker), and school (teacher, Special Education, social worker, principal) have set up their own plan. The more agencies, the more plans. Imagine trying to understand which agency has what plan? Who in each plan is responsible for what tasks? When should the parent and ill person use which plan? Now, add to this problems in communication, comprehension, memory, stress tolerance especially when you are in the midst of a psychiatric crisis!
The result is confusion and chaos for families and patients who are already exhausted. All too often the ill person is labeled difficult or non-compliant, among other things, because he/she didnât follow everyoneâs plan correctly. In reality, it is probably not the person who has failed but all the confusing plans.
This is why we present a "person-centered" plan: a plan designed around the patientâs needs and strengths and involving any agency or provider who can best support the particular needs of the person. It encompasses all the different degrees of full-blown crisis situation.
Phase One: Prevention
We have already mentioned a few early symptom indicators for a psychiatric crisis. In addition, families and people with mental illness can learn to recognize trouble spots and stressors in the environment. Identifying and planning for those difficult periods is the starting point in any comprehensive crisis plan.
Holiday gatherings are a perfect example. Loads of people, too much noise, old memories, excitement and confusion sensory overload! It is a lot for anyone to handle but especially difficult for those who may already have problems processing external stimuli.
Begin the planning by openly discussing the upcoming holiday with your ill family member. First, does he/she want to attend the event at all? If not what, if any alternative plan needs to be put into place? Do not argue with his/her decision. It is after all that persons emotions in question. He/she has a right to decide what he/she can or cannot handle.
If the family member chooses to attend, what supports might he/she need? A quiet spot to escape to if things get too overwhelming? A plan to leave if necessary? If he/she leaves, will someone need to go with him/her? Who?
Identifying the potential stressors will cut down on everyoneâs worries, including the ill individual. Arguing and anxiety and the usual "what ifs" are mostly eliminated. The entire family, including children and grandparents, should understand the plan is show how identified problems will be solved, show identified problems will be solved, and what job is whose. Problems are prevented even before the "stressor" holiday begins.
Phase Two: Intervention
Learning to intervene in the early stages can be the next step in effective crisis planning. Both family and the ill person must learn to recognize what are considered to be "universal warning signs" of a possible relapse. Example: feeling tense or agitated; thinking that they are being talked about or laughed at; trouble sleeping; trouble concentrating.
They should also begin to look for and recognize more "personal signs" in each individual. Example: Kind of dress (disheveled)? Is hair combed? How do eyes look (fixed, vacant)? What is eaten (not amounts)? Choice of, or changes in peer groups.
Input from anyone who has close contact may be helpful at this point. This is where the plan really starts to formalize. Other team members - friends, clergy, support people, crisis workers, teachers, therapists, doctors, case managers-- may recognize other signs and can be brought into the process. In addition to the person with the mental illness, family annd friends, it is imperative to have those professionals at the planning table as you begin to put the intervention plan on paper.
Involved providers may have access to funding for services and support that you may need to put this plan together. You will also need them all to "buy into" the plan.
Once the team is assembled and warning signs (symptoms) have been identified, they need to be put in order of occurrence. Reaching consensus on this list may take time. Work on it. It will be time well spent. Example: The first thing we notice is "uncombed hair" then...and thenâ¦etc.
The next step is to have the ill person decide what service, support, or intervention may be wanted as each sign starts to appear. Example
First sign: stops combing hair is early sign of depression. What might help at this point? Physical activityâ¦"Get me out of the house." Thus, intervention
1.Family will encourage outside activities (list agreed activities)
2. Family will provide outside activities list
3. Family will encourage calls to friends.
4. Family will call friends (i.e. friends must be contacted if they are not yet involved in the planning process. They must know what role they will play and agree to be involved before their name is on the list.)
5. When the plan gets to the place where a provider agency will be involved, several things must be planned ahead. What service? Who will provide it? How will it be funded? Who will be the contact person? What will the mechanism be to put it into action?
All of this must be documented. All involved providers must be informed. Each must agree to the plan, sign their agreement and receive a copy of what they have agreed to.
The same process will continue for each serious warning sign until a "bottom line" behavior/symptom pattern emerges. At this point, the plan moves into the next phase.
Phase Three: Crisis Management
Crisis management will likely take the most time, the most collaboration/cooperation and it can involve the most people. It is also the most critical and can literally save someoneâs life. Make sure you have plenty of time to plan and all the relevant participants are at the planning table.
Example result: When Johnny is in Crisisâ¦
1. Little sister will go to her room, lock her door, pack a bag, wait 10 minutes and then call her support person (name/phone written down and confirmed ahead).
2. The support person will wait 15 minutes. Unless he/she hears otherwise, he/she/they will come through the back door and take little sister to their home until mom calls. At that time the support person will bring little sister home again.
3. Older brother will put the dog in the cellar. He then goes to his room, and a parent will keep him informed.
4. To assure safety, Dad will keep Johnny within eyesight. Mom will call the crisis line.
In the chaos of a full-blown crisis situation remember even the simplest information can be difficult to communicate.
Have an information sheet with the following written on it:
Crisis service number
Local hospital number
Local police number
Your psychiatristâs number
YOUR name address, telephone number.
Names and numbers of a support person, case manager, therapist or counselor
Next, in a folder ready to go, have your family memberâs name, age, mental health diagnosis history, "other" medical diagnosis, medication(s) and dosage and information on the treating psychiatrist and family physician. Itâs best to have several copies of this information on hand. It can be given to mental health workers, ambulance personnel, police and emergency room staff to avoid repeating information.
When speaking with the crisis worker, be calm. Focus on why your family member is not safe and describe his/her behavior specifically. Donât describe how your sonâs behavior is impacting your husband and you.This is an unclear picture of his decompensation. A clear presentation gives specific information about diagnosis and actions. You may begin by saying: "My son is a danger to himself and has been talking about suicide; he is also having disorganized and paranoid thought."
The crisis worker will want to speak with the parents and hopefully be able to speak with Johnny if possible. Then they may meet Johnny and his parents at the nearest emergency room or come to the house and evaluate Johnnyâs behavior personally.
At whatever location, the crisis worker will de-escalate the situation, contract for safety, and arrange for follow-up within a prearranged time frame. The worker(s) may arrange in-home one-on-one support for the night if Johnny is evaluated safe enough to remain in the home.
A good preplan also includes preferences and decisions concerning the following:
If it is decided that the ill person must undergo voluntary or involuntary admission to a hospital:
Who is the best choice for transporting Johnny to a hospital, the parents, an ambulance, the police, or friends? How can you plan for these options in advance?
If parents transport Johnny, will they need help getting Johnny safely from the car to the hospital?
If parents need to arrange for child care for other family members, what are the options: parents, in-laws, siblings, neighbors?
If the police, ambulance, and ER staff are involved, their roles must be clearly predetermined, written into the plan, agreed to and signed by their appropriate representative.
Hospital care: List the hospitals in order of preference. Include the patientâs preferred form of restraint and/or medication for sedation (when and if necessary). Always consider the worst case scenario given past experience with the patient, and create needs-based interventions.
Phase Four: Recovery
Now that the crisis is over and your family member is safe, either at home or in an alternative setting, everyone needs to recuperate. It is okay to cry, to feel angry, stressed out, relieved and a whole host of confusing feelings. Take the day off take the phone off the hook, and do something special for yourself.
Next, understand and accept that what you did was necessary. Acting to keep your relative safe is the highest form of love, even when it may involve force and hospitalization. Your relative may be angry at you for calling the police or the crisis team, but at least he/she will still be around to express it.
Your ill family member will also need time to recover from this crisis episode. At no other time is this member and the rest of the family so totally "out of sync." Each is suffering from post-crisis slump. Families must back off. Lower their expectations of the patient. Recognize that you are dealing with a biological illness which strains your loved oneâs physical and psychological systems to the maximum. It may take weeks or months for a good recovery.
The final step in recovery is for the team to meet and evaluate the pan. How did it go? What worked? What didnât? This should be a blame-free time when team members cannot blame each other for mistakes. Focus on how to make needed improvements and evaluate the plan.
Conclusion
In summary, the crisis plan is not a tool to be used for power or control, nor is it intended as punishment. It should never be used as a threat. It is not a "quick fix". A crisis plan is a management strategy to help keep your ill family member safe. It is like a job description: you know what your responsibility is and what your co-workers responsibilities are before you begin. The plan should be in written form, outlining what steps would be done by whom.
The purpose is to teach new coping skills to those involved, help prevent a full-blown crisis, and pre-plan all necessary supports and interventions. It must be flexible enough to be used in a home setting, in the community, at school, at the grocery store-- wherever the crisis may occur. Thorough, proactive planning clearly organizes the chaos of crisis.
Emergency Evaluation and the Law
If the ill person meets the criteria for dangerousness the crisis worker will arrange for a physician or a psychiatrist to confirm the assessment and contact the local sheriffâs department to transport the ill person to a hospital for further evaluation and possible admission.
At the hospital, the person will again be evaluated, this time by a psychiatrist or other mental health professional, using similar criteria as used earlier. If the evaluation indicates the ill person meets criteria for involuntary hospitalization, the person will be retained at the emergency room until an involuntary hospital bed can be found and a "blue paper" processed.
At any time during this rather complex process, if the ill person is found (by doctors or the court) to not meet the specific criteria for involuntary commitment, he/she may be returned to the community, and referred to voluntary outpatient treatment. A person can be held for 72 hours under the blue paper until a court hearing can determine continued commitment or immediate discharge.
For a mentally ill person in crisis and refusing treatment, but not in immediate danger of hurting him/herself or others, it is possible to petition the Family Court for a "non emergency involuntary hospitalization." Relatives, friends, family doctors or mental health workers may execute a petition declaring that they feel the person should be committed and the reasons for their opinions. If your family member has been part of a community service providerâs treatment program, the therapist or caseworker may be asked to testify at the hearing.
The most common means of getting a person in crisis admitted to a hospital is by calling a doctor for an assessment and referral. However, if the ill person refuses to go to the hospital, the next option is to call the community crisis team (emergency services). If from conversation with the caller the crisis team determines that an on site evaluation is justified, they will arrange to meet the ill person at a general hospital emergency room at your home, or any other safe community location. Often your family member will voluntary accept treatment eliminating the involuntary admission process.
The purpose of the hearing is to determine whether the ill person meets the criteria stated above. The person must be mentally ill by clinical standards and meet the criteria of dangerousness to self or others. (See also Hospitalization)
HOSPITALIZATION
Hospitals may be needed for emergencies (be sure to keep the number for emergency crisis services available), for voluntary hospitalization, or for involuntary hospitalization and/or commitment. If the choice is private care rather than through the community mental health program, there are several things to consider.
Private insurance may cover a short hospitalization. Check carefully to see how much of the cost is covered; most policies have very limited coverage for mental health or psychiatric illness. Check with your insurance company about continuing your sonâs or daughterâs coverage after the age when coverage generally stops (usually 19, if the person is not attending college); it may be possible to continue coverage past that age on a parentâs policy.
Medicaid may cover hospitalization expenses if there is no private insurance coverage. Personnel from the community service provider and/or the Department of Human Services may be able to assist you with an application for Medicaid.
Some Community Mental Health Centers have an alternative arrangement for individuals in crisis, such as "crisis beds" which are used to provide care in the acute episode while avoiding hospitalization.
Admission Procedure
Voluntary Hospitalization
If a person needs to be hospitalized, voluntary admission is always the preferable route. If the person with a mental illness can participate in the hospitalization, the outlook is much brighter. When payment is made by an HMO (Health Maintenance Organization), insurance, or by the family or patient, the admission process is usually straightforward and decisions concerning need are determined by the patientâs doctor and the admitting staff.
Hospitals have individual arrangements regarding admitting patients covered by Medicaid and/or Medicare. The admissions staff at each hospital will advise voluntary patients and/or their families about patient eligibility and unique restrictions or procedures.
Involuntary Hospitalization
The involuntary hospitalization of a person with mental illness is a complex process designed to provide treatment in the least restrictive environment and to protect the civil liberties of persons with mental illness. Sometimes families are witnesses to the serious and rapid deterioration of a family member, and become fearful that the ill person may die, or never really recover. Our instinct is to protect our ill family member by getting them the medical help they need before decompensating and becoming seriously psychotic.
Balancing the need for treatment of a very ill person with oneâs civil rights is one of the greatest challenges of our law. Equally, one of the greatest challenges a family may ever face is having a family member committed with dignity and love and without destroying family relationships and the self-esteem of the ill person.
Commitment is not easy, but it often must be attempted. There are times when a family member has no other choice but to proceed with the process.
Application
The statues allow that a law enforcement officer, health officer or other person may make application when they believe that a person is mentally ill and dangerous, i.e. poses a likelihood of serious harm. This person also states the grounds for this belief.
Next a licensed physician or psychologist, stating he/she has examined the person and, in his/her opinion, the person is mentally ill and poses a likelihood of harm, must certify this observation.
The application and certificate (a "blue paper") must then be endorsed by a judge or complaint justice, who authorizes that the person thought to be mentally ill may be taken into custody and transported to the facility designated in the application.
Judicial Procedure and Commitment
Application is made by the head of the hospital upon the certification of yet another physician or psychologist. Once filed with the court, release or discharge can only be made by petition from the head of the hospital or guardian, parent, spouse or next of kin and granted by the court.
The hearing must be held no later than 15 days from the date of the application. The court causes notice of hearing to be sent to the proposed patientâs next of kin. For good cause, a continuance of up to 10 days may be granted.
The court orders an examination by two examiners, either licensed physicians or licensed psychologists. The patient has the right to choose one of the examiners. If the reports of the two examiners are to the effect that the person is not mentally ill or does not pose the likelihood of serious harm, the court orders discharge without a hearing.
The person shall have the opportunity to be represented by counsel.
Judicial Hearing
The hearing is conducted in as informal a manner as possible. The person, the applicant, and others required to be present have the opportunity to testify and cross-examine. The State is represented by the Attorney Generalâs Office.
It must be proven that the person is mentally ill and that his/her recent actions and behavior poses likelihood of serious harm. It must also be proven that inpatient hospitalization is the best means for treatment and that the hospital, through its treatment plan, has the ability and means to treat. The patient maintains the right to refuse treatment even after commitment. This procedure does not determine the personâs competency.
Commitment
Upon making the finding, the court may order commitment up to 4 months in the first instance and not to exceed one year in subsequent hearings.
Hospital Treatment Program
As soon as possible after admission to a hospital or treatment program, family members should make an appointment with the treatment team to discuss the following:
What is the diagnosis? Please explain.
What is the treatment plan?
What are the specific symptoms about which are you most concerned? What do they indicate? How are you monitoring them?
What medication is the patient getting? Is the response what was hoped for? What side effects should be watched for?
Has the doctor or nurse discussed with the patient the diagnosis, medications, and the treatment plan?
How often can we meet to discuss progress?
What is the aftercare plan when the patient is released from the hospital?
The patient must give consent before a staff person can release any information, including the personâs presence in the hospital. Ask to have your relative sign an authorization for release of information. If your relative does not want certain information released, the form can specify which information may be released.
Release Plan
Before leaving the hospital, your ill relative and family should expect:
Assistance securing appropriate housing such as group homes, supervised apartments, independent living, and community care homes.
Assistance in applying for appropriate public benefits such as general assistance, medical assistance and Social Security income.
Assistance in the orderly transfer to community based mental health services, such as timely psychiatric medication reviews, supportive counseling, and a case management system of coordinated care and treatment which provides a network or services through an identified program and staff.
After Hospitalization
Serious mental illness is a long term condition; families should plan ahead even if they are fortunate enough to have to deal with only one or two episodes. Families who have lived with mental illness for a long time often describe how carried away they were at the time of the first episode, and how they sometimes imprudently committed themselves to expensive treatment in expectation of a cure that was never to be realized.
Remember, the most expensive care is not necessarily the best! Money will not buy back the health of your loved ones. Private care is not necessarily better than public. What most patients do need is continued medical therapy, a safe, stable place to live, a chance to develop or relearn social skills, and someone who cares about them. The best place to look for comprehensive services over a long period of time is through the local community mental health provider. If such services do not seem to be available to your family member, contact your local affiliate or NAMI Maine. The members may be able to help you.
Day Treatment and Partial Hospitalization Programs
Day treatments are a component of the community resources for people with mental illness. Clients who have progressed along the road to recovery work within a group format to increase their understanding of their illness and improve their skills. The programs are staffed during the day and sometimes in the evening hours. Day treatment provides education on topics which include mental illness, medication and its side effects, money management, nutrition, leisure and social skills, job seeking, interpersonal communication, and self-esteem.
Partial Hospital programs provide a more supportive and structured environment for clients who are experiencing a period of instability. These programs offer more intensive psychotherapy groups as well as skill-building techniques. Itâs called partial hospitalization because it is offered by hospital staff, on hospital ground, but participants do not reside at the hospital
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Be aware of early warning signs: changes in sleep patterns, dress, and friends; suspiciousness/paranoia, isolation, aggression. Donât let signs escalate. Get help immediately. (See Four-Phase Crisis Plan.)
If a full blown crisis starts, ensure the safety of all parties. Be patient and reassuring. If youâre calm, the ill person will remain calmer. Do not assume an authoritative role or argue. Treat the ill person with respect (even if he/she threatens you). Instead, be firm in your attitude and set boundaries for good behavior. Remember, the person is scared and having great difficulty in dealing with his/her emotions and thoughts.
Pre-Crisis Directive. Prepare a folder that includes the patientâs:
Name, address, phone number (and caregiverâs)
Diagnosis, psychiatric history medication dosages
General medical history (diabetes, heart problemsâvery important!)
Treatment preferences: i.e., patientâs choice of hospital, doctor, type of restraint (if necessary), choice to use ECT (if necessary)
A phone list of: the crisis team, doctors, emergency room, police, ambulance service, and any other services you may need
Call your local crisis team/physician/psychiatrist. The caregiver must discuss symptoms with Evaluators and decide what do.
The crisis worker may deal with the situation at patientâs home.
The worker may meet the ill person and caregiver(s) at the emergency room. (Two caregivers should always accompany the patient to hospital.)
It may be possible for the ill person to stay a day or two at a crisis center and not be hospitalized.
If suicide or violent behavior is involved, involuntary hospitalization may be necessary. The police and/or ambulance may be the best choice to transport the ill person to a hospital.
At admittance, patient should sign a Confidentiality Release Form to enable caregiver to: discuss treatment; give medical history, and help with release plan.
CRISIS
Crisis Intervention
In the last twenty-five years, the course of care for persons with serious brain disorders has changed dramatically. De-institutionalization and modern medications have re-shaped traditional treatment plans. Focus has rightfully shifted from that of lifelong hospitalization and "patienthood" to one of recovery and community reintegration.
Sixty-five percent of the individuals discharged from psychiatric hospitals now receive primary care and support from their families; so it is likely at some time the family caregivers will experience a crisis situation with their ill family member. Both parties need to learn how to recognize that a crisis might be coming, what actions can be taken, and what supports can be put into place.
A full-blown crisis situation can result because no prior planning has been done. Seldom if ever does a person suddenly lose total control. Studies show that 70% of people with mental illness can pick up on their own early warning signs of crisis; 96% of their loved ones can identify those same signs. Both parties must know what to look for.
Learn to trust your instincts! It is during the early stages that a full-blown crisis can sometimes be averted. If you sense deterioration in a relativeâs mental condition, try to discuss with that person how he is feeling:
Are the appropriate medications still being taken?
Are recent events or activities too stressing?
Are sleep patterns changing?
Is there ritualistic preoccupation with certain activities?
Are unpredictable outbursts, unusual agitation, or paranoia a problem?
Controlling a Potentially Explosive Situation
If the ill individual is in danger of self injury, if behavior is frightening, or if the ill person is threatening people, it is important to take immediate action: call a crisis center. Remember, the patient is probably terrified and your primary task is to help the patient regain some control. Accept the fact that the patient is in an "altered reality state."
It is imperative that you remain calm. If you are alone, call a friend or a relative to remain with you until professional help arrives. Below is a "what to do" list to use during a full-blown crisis.
(See Emergency Evaluation and the Law, this chapter; also Voluntary/Involuntary Hospitalization, Hospitalization
1. Donât argue with the ill person that what he/she is seeing, hearing, or feeling is unreal. Assure the person that you understand what his/her are experiencing is real to him/her and you want to help.
2. Donât threaten. It may be interpreted as a power play and increase fear or encourage assaultive behavior.
3. Donât argue with other family members as to how to treat the situation. This creates more confusion.
4. Donât touch or have continuous eye contact with the patient. Donât turn your back on him/her
5. Comply with reasonable, safe requests from the patient. This provides the patient with an opportunity to regain some of the control.
6. Donât block the doorway (However, try to keep yourself between the patient and an exit.)
7. Remember, do call the police if the person is violent. Most important, explain to police the details of the situation before they arrive so they will be prepared: i.e., how long the crisis has gone on; is the person suicidal; how has the person been violent; are there guns in the house; does the patient have a weapon of any kind.
8. Most importantly, understand that this illness is not your fault, nor is it the fault of the person in crisis. Mental illness is a biochemical disorder of the brain. It must be treated with the same attitude as a physical illness.
Four-Phase Crisis Planning
An out-of -control situation results because there has been no prior planning done. A "person-centered" crisis plan based on a four phase model is presented here.
Traditionally, most mental health services are "agency centered." Each agency-home health care (with psychiatrist/nurse/social worker), crisis service (with clinician, crisis support persons), mental health agency (with more psychiatrists, therapist, community support worker), and school (teacher, Special Education, social worker, principal) have set up their own plan. The more agencies, the more plans. Imagine trying to understand which agency has what plan? Who in each plan is responsible for what tasks? When should the parent and ill person use which plan? Now, add to this problems in communication, comprehension, memory, stress tolerance especially when you are in the midst of a psychiatric crisis!
The result is confusion and chaos for families and patients who are already exhausted. All too often the ill person is labeled difficult or non-compliant, among other things, because he/she didnât follow everyoneâs plan correctly. In reality, it is probably not the person who has failed but all the confusing plans.
This is why we present a "person-centered" plan: a plan designed around the patientâs needs and strengths and involving any agency or provider who can best support the particular needs of the person. It encompasses all the different degrees of full-blown crisis situation.
Phase One: Prevention
We have already mentioned a few early symptom indicators for a psychiatric crisis. In addition, families and people with mental illness can learn to recognize trouble spots and stressors in the environment. Identifying and planning for those difficult periods is the starting point in any comprehensive crisis plan.
Holiday gatherings are a perfect example. Loads of people, too much noise, old memories, excitement and confusion sensory overload! It is a lot for anyone to handle but especially difficult for those who may already have problems processing external stimuli.
Begin the planning by openly discussing the upcoming holiday with your ill family member. First, does he/she want to attend the event at all? If not what, if any alternative plan needs to be put into place? Do not argue with his/her decision. It is after all that persons emotions in question. He/she has a right to decide what he/she can or cannot handle.
If the family member chooses to attend, what supports might he/she need? A quiet spot to escape to if things get too overwhelming? A plan to leave if necessary? If he/she leaves, will someone need to go with him/her? Who?
Identifying the potential stressors will cut down on everyoneâs worries, including the ill individual. Arguing and anxiety and the usual "what ifs" are mostly eliminated. The entire family, including children and grandparents, should understand the plan is show how identified problems will be solved, show identified problems will be solved, and what job is whose. Problems are prevented even before the "stressor" holiday begins.
Phase Two: Intervention
Learning to intervene in the early stages can be the next step in effective crisis planning. Both family and the ill person must learn to recognize what are considered to be "universal warning signs" of a possible relapse. Example: feeling tense or agitated; thinking that they are being talked about or laughed at; trouble sleeping; trouble concentrating.
They should also begin to look for and recognize more "personal signs" in each individual. Example: Kind of dress (disheveled)? Is hair combed? How do eyes look (fixed, vacant)? What is eaten (not amounts)? Choice of, or changes in peer groups.
Input from anyone who has close contact may be helpful at this point. This is where the plan really starts to formalize. Other team members - friends, clergy, support people, crisis workers, teachers, therapists, doctors, case managers-- may recognize other signs and can be brought into the process. In addition to the person with the mental illness, family annd friends, it is imperative to have those professionals at the planning table as you begin to put the intervention plan on paper.
Involved providers may have access to funding for services and support that you may need to put this plan together. You will also need them all to "buy into" the plan.
Once the team is assembled and warning signs (symptoms) have been identified, they need to be put in order of occurrence. Reaching consensus on this list may take time. Work on it. It will be time well spent. Example: The first thing we notice is "uncombed hair" then...and thenâ¦etc.
The next step is to have the ill person decide what service, support, or intervention may be wanted as each sign starts to appear. Example
First sign: stops combing hair is early sign of depression. What might help at this point? Physical activityâ¦"Get me out of the house." Thus, intervention
1.Family will encourage outside activities (list agreed activities)
2. Family will provide outside activities list
3. Family will encourage calls to friends.
4. Family will call friends (i.e. friends must be contacted if they are not yet involved in the planning process. They must know what role they will play and agree to be involved before their name is on the list.)
5. When the plan gets to the place where a provider agency will be involved, several things must be planned ahead. What service? Who will provide it? How will it be funded? Who will be the contact person? What will the mechanism be to put it into action?
All of this must be documented. All involved providers must be informed. Each must agree to the plan, sign their agreement and receive a copy of what they have agreed to.
The same process will continue for each serious warning sign until a "bottom line" behavior/symptom pattern emerges. At this point, the plan moves into the next phase.
Phase Three: Crisis Management
Crisis management will likely take the most time, the most collaboration/cooperation and it can involve the most people. It is also the most critical and can literally save someoneâs life. Make sure you have plenty of time to plan and all the relevant participants are at the planning table.
Example result: When Johnny is in Crisisâ¦
1. Little sister will go to her room, lock her door, pack a bag, wait 10 minutes and then call her support person (name/phone written down and confirmed ahead).
2. The support person will wait 15 minutes. Unless he/she hears otherwise, he/she/they will come through the back door and take little sister to their home until mom calls. At that time the support person will bring little sister home again.
3. Older brother will put the dog in the cellar. He then goes to his room, and a parent will keep him informed.
4. To assure safety, Dad will keep Johnny within eyesight. Mom will call the crisis line.
In the chaos of a full-blown crisis situation remember even the simplest information can be difficult to communicate.
Have an information sheet with the following written on it:
Crisis service number
Local hospital number
Local police number
Your psychiatristâs number
YOUR name address, telephone number.
Names and numbers of a support person, case manager, therapist or counselor
Next, in a folder ready to go, have your family memberâs name, age, mental health diagnosis history, "other" medical diagnosis, medication(s) and dosage and information on the treating psychiatrist and family physician. Itâs best to have several copies of this information on hand. It can be given to mental health workers, ambulance personnel, police and emergency room staff to avoid repeating information.
When speaking with the crisis worker, be calm. Focus on why your family member is not safe and describe his/her behavior specifically. Donât describe how your sonâs behavior is impacting your husband and you.This is an unclear picture of his decompensation. A clear presentation gives specific information about diagnosis and actions. You may begin by saying: "My son is a danger to himself and has been talking about suicide; he is also having disorganized and paranoid thought."
The crisis worker will want to speak with the parents and hopefully be able to speak with Johnny if possible. Then they may meet Johnny and his parents at the nearest emergency room or come to the house and evaluate Johnnyâs behavior personally.
At whatever location, the crisis worker will de-escalate the situation, contract for safety, and arrange for follow-up within a prearranged time frame. The worker(s) may arrange in-home one-on-one support for the night if Johnny is evaluated safe enough to remain in the home.
A good preplan also includes preferences and decisions concerning the following:
If it is decided that the ill person must undergo voluntary or involuntary admission to a hospital:
Who is the best choice for transporting Johnny to a hospital, the parents, an ambulance, the police, or friends? How can you plan for these options in advance?
If parents transport Johnny, will they need help getting Johnny safely from the car to the hospital?
If parents need to arrange for child care for other family members, what are the options: parents, in-laws, siblings, neighbors?
If the police, ambulance, and ER staff are involved, their roles must be clearly predetermined, written into the plan, agreed to and signed by their appropriate representative.
Hospital care: List the hospitals in order of preference. Include the patientâs preferred form of restraint and/or medication for sedation (when and if necessary). Always consider the worst case scenario given past experience with the patient, and create needs-based interventions.
Phase Four: Recovery
Now that the crisis is over and your family member is safe, either at home or in an alternative setting, everyone needs to recuperate. It is okay to cry, to feel angry, stressed out, relieved and a whole host of confusing feelings. Take the day off take the phone off the hook, and do something special for yourself.
Next, understand and accept that what you did was necessary. Acting to keep your relative safe is the highest form of love, even when it may involve force and hospitalization. Your relative may be angry at you for calling the police or the crisis team, but at least he/she will still be around to express it.
Your ill family member will also need time to recover from this crisis episode. At no other time is this member and the rest of the family so totally "out of sync." Each is suffering from post-crisis slump. Families must back off. Lower their expectations of the patient. Recognize that you are dealing with a biological illness which strains your loved oneâs physical and psychological systems to the maximum. It may take weeks or months for a good recovery.
The final step in recovery is for the team to meet and evaluate the pan. How did it go? What worked? What didnât? This should be a blame-free time when team members cannot blame each other for mistakes. Focus on how to make needed improvements and evaluate the plan.
Conclusion
In summary, the crisis plan is not a tool to be used for power or control, nor is it intended as punishment. It should never be used as a threat. It is not a "quick fix". A crisis plan is a management strategy to help keep your ill family member safe. It is like a job description: you know what your responsibility is and what your co-workers responsibilities are before you begin. The plan should be in written form, outlining what steps would be done by whom.
The purpose is to teach new coping skills to those involved, help prevent a full-blown crisis, and pre-plan all necessary supports and interventions. It must be flexible enough to be used in a home setting, in the community, at school, at the grocery store-- wherever the crisis may occur. Thorough, proactive planning clearly organizes the chaos of crisis.
Emergency Evaluation and the Law
If the ill person meets the criteria for dangerousness the crisis worker will arrange for a physician or a psychiatrist to confirm the assessment and contact the local sheriffâs department to transport the ill person to a hospital for further evaluation and possible admission.
At the hospital, the person will again be evaluated, this time by a psychiatrist or other mental health professional, using similar criteria as used earlier. If the evaluation indicates the ill person meets criteria for involuntary hospitalization, the person will be retained at the emergency room until an involuntary hospital bed can be found and a "blue paper" processed.
At any time during this rather complex process, if the ill person is found (by doctors or the court) to not meet the specific criteria for involuntary commitment, he/she may be returned to the community, and referred to voluntary outpatient treatment. A person can be held for 72 hours under the blue paper until a court hearing can determine continued commitment or immediate discharge.
For a mentally ill person in crisis and refusing treatment, but not in immediate danger of hurting him/herself or others, it is possible to petition the Family Court for a "non emergency involuntary hospitalization." Relatives, friends, family doctors or mental health workers may execute a petition declaring that they feel the person should be committed and the reasons for their opinions. If your family member has been part of a community service providerâs treatment program, the therapist or caseworker may be asked to testify at the hearing.
The most common means of getting a person in crisis admitted to a hospital is by calling a doctor for an assessment and referral. However, if the ill person refuses to go to the hospital, the next option is to call the community crisis team (emergency services). If from conversation with the caller the crisis team determines that an on site evaluation is justified, they will arrange to meet the ill person at a general hospital emergency room at your home, or any other safe community location. Often your family member will voluntary accept treatment eliminating the involuntary admission process.
The purpose of the hearing is to determine whether the ill person meets the criteria stated above. The person must be mentally ill by clinical standards and meet the criteria of dangerousness to self or others. (See also Hospitalization)
HOSPITALIZATION
Hospitals may be needed for emergencies (be sure to keep the number for emergency crisis services available), for voluntary hospitalization, or for involuntary hospitalization and/or commitment. If the choice is private care rather than through the community mental health program, there are several things to consider.
Private insurance may cover a short hospitalization. Check carefully to see how much of the cost is covered; most policies have very limited coverage for mental health or psychiatric illness. Check with your insurance company about continuing your sonâs or daughterâs coverage after the age when coverage generally stops (usually 19, if the person is not attending college); it may be possible to continue coverage past that age on a parentâs policy.
Medicaid may cover hospitalization expenses if there is no private insurance coverage. Personnel from the community service provider and/or the Department of Human Services may be able to assist you with an application for Medicaid.
Some Community Mental Health Centers have an alternative arrangement for individuals in crisis, such as "crisis beds" which are used to provide care in the acute episode while avoiding hospitalization.
Admission Procedure
Voluntary Hospitalization
If a person needs to be hospitalized, voluntary admission is always the preferable route. If the person with a mental illness can participate in the hospitalization, the outlook is much brighter. When payment is made by an HMO (Health Maintenance Organization), insurance, or by the family or patient, the admission process is usually straightforward and decisions concerning need are determined by the patientâs doctor and the admitting staff.
Hospitals have individual arrangements regarding admitting patients covered by Medicaid and/or Medicare. The admissions staff at each hospital will advise voluntary patients and/or their families about patient eligibility and unique restrictions or procedures.
Involuntary Hospitalization
The involuntary hospitalization of a person with mental illness is a complex process designed to provide treatment in the least restrictive environment and to protect the civil liberties of persons with mental illness. Sometimes families are witnesses to the serious and rapid deterioration of a family member, and become fearful that the ill person may die, or never really recover. Our instinct is to protect our ill family member by getting them the medical help they need before decompensating and becoming seriously psychotic.
Balancing the need for treatment of a very ill person with oneâs civil rights is one of the greatest challenges of our law. Equally, one of the greatest challenges a family may ever face is having a family member committed with dignity and love and without destroying family relationships and the self-esteem of the ill person.
Commitment is not easy, but it often must be attempted. There are times when a family member has no other choice but to proceed with the process.
Application
The statues allow that a law enforcement officer, health officer or other person may make application when they believe that a person is mentally ill and dangerous, i.e. poses a likelihood of serious harm. This person also states the grounds for this belief.
Next a licensed physician or psychologist, stating he/she has examined the person and, in his/her opinion, the person is mentally ill and poses a likelihood of harm, must certify this observation.
The application and certificate (a "blue paper") must then be endorsed by a judge or complaint justice, who authorizes that the person thought to be mentally ill may be taken into custody and transported to the facility designated in the application.
Judicial Procedure and Commitment
Application is made by the head of the hospital upon the certification of yet another physician or psychologist. Once filed with the court, release or discharge can only be made by petition from the head of the hospital or guardian, parent, spouse or next of kin and granted by the court.
The hearing must be held no later than 15 days from the date of the application. The court causes notice of hearing to be sent to the proposed patientâs next of kin. For good cause, a continuance of up to 10 days may be granted.
The court orders an examination by two examiners, either licensed physicians or licensed psychologists. The patient has the right to choose one of the examiners. If the reports of the two examiners are to the effect that the person is not mentally ill or does not pose the likelihood of serious harm, the court orders discharge without a hearing.
The person shall have the opportunity to be represented by counsel.
Judicial Hearing
The hearing is conducted in as informal a manner as possible. The person, the applicant, and others required to be present have the opportunity to testify and cross-examine. The State is represented by the Attorney Generalâs Office.
It must be proven that the person is mentally ill and that his/her recent actions and behavior poses likelihood of serious harm. It must also be proven that inpatient hospitalization is the best means for treatment and that the hospital, through its treatment plan, has the ability and means to treat. The patient maintains the right to refuse treatment even after commitment. This procedure does not determine the personâs competency.
Commitment
Upon making the finding, the court may order commitment up to 4 months in the first instance and not to exceed one year in subsequent hearings.
Hospital Treatment Program
As soon as possible after admission to a hospital or treatment program, family members should make an appointment with the treatment team to discuss the following:
What is the diagnosis? Please explain.
What is the treatment plan?
What are the specific symptoms about which are you most concerned? What do they indicate? How are you monitoring them?
What medication is the patient getting? Is the response what was hoped for? What side effects should be watched for?
Has the doctor or nurse discussed with the patient the diagnosis, medications, and the treatment plan?
How often can we meet to discuss progress?
What is the aftercare plan when the patient is released from the hospital?
The patient must give consent before a staff person can release any information, including the personâs presence in the hospital. Ask to have your relative sign an authorization for release of information. If your relative does not want certain information released, the form can specify which information may be released.
Release Plan
Before leaving the hospital, your ill relative and family should expect:
Assistance securing appropriate housing such as group homes, supervised apartments, independent living, and community care homes.
Assistance in applying for appropriate public benefits such as general assistance, medical assistance and Social Security income.
Assistance in the orderly transfer to community based mental health services, such as timely psychiatric medication reviews, supportive counseling, and a case management system of coordinated care and treatment which provides a network or services through an identified program and staff.
After Hospitalization
Serious mental illness is a long term condition; families should plan ahead even if they are fortunate enough to have to deal with only one or two episodes. Families who have lived with mental illness for a long time often describe how carried away they were at the time of the first episode, and how they sometimes imprudently committed themselves to expensive treatment in expectation of a cure that was never to be realized.
Remember, the most expensive care is not necessarily the best! Money will not buy back the health of your loved ones. Private care is not necessarily better than public. What most patients do need is continued medical therapy, a safe, stable place to live, a chance to develop or relearn social skills, and someone who cares about them. The best place to look for comprehensive services over a long period of time is through the local community mental health provider. If such services do not seem to be available to your family member, contact your local affiliate or NAMI Maine. The members may be able to help you.
Day Treatment and Partial Hospitalization Programs
Day treatments are a component of the community resources for people with mental illness. Clients who have progressed along the road to recovery work within a group format to increase their understanding of their illness and improve their skills. The programs are staffed during the day and sometimes in the evening hours. Day treatment provides education on topics which include mental illness, medication and its side effects, money management, nutrition, leisure and social skills, job seeking, interpersonal communication, and self-esteem.
Partial Hospital programs provide a more supportive and structured environment for clients who are experiencing a period of instability. These programs offer more intensive psychotherapy groups as well as skill-building techniques. Itâs called partial hospitalization because it is offered by hospital staff, on hospital ground, but participants do not reside at the hospital
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