Invest in crisis response for people living with psychiatric conditions

You may have missed the Nov. 25 Washington Post article, “Seattle psychiatric nurse reckons with the city’s most vulnerable residents,” featuring a psychiatric nurse working at the Downtown Emergency Service Center (DESC) trying to help some of the most vulnerable people in our community. 

It’s two stories in one, showing an intense level of suffering being experienced by people living with serious psychiatric conditions and the heavy toll that can take on the people attempting to relieve that suffering. And it’s vividly told, showing minute-by-minute examples of what inadequate support from the behavioral health crisis response system can look like.

More than a year ago I joined with numerous colleagues across the behavioral health treatment continuum to sound the alarm to government leaders about the state of the crisis response system and scarcity of appropriate community supports, using phrases like “people in crisis” and “workforce challenges” and “the under-resourced behavioral health system.” The stories chronicled in this article are the raw versions of what those phrases mean.

People living with psychiatric conditions are not inherently dangerous, but in all walks of life danger rises with desperation. If you can’t get the help you need for the symptoms you are experiencing and the pain you are suffering, you can deteriorate in ways that might include diminished ability to regulate your emotions. When that leads to risks of harm to yourself or other people, you need more intense help, and you need it now, not sometime after waiting weeks for an evaluation as described in the article. Same-day evaluation with immediate placement into treatment used to be the norm in responding to these severe situations, but now DESC and other community providers are often left without that essential backup support.

So with a picture this bleak, what’s the way out?

Last year, we and others proposed essentially the three-legged stool of a greatly enhanced crisis response system including the creation of places for people in crisis to receive immediate support, major support for the behavioral health workforce, and investment in the basic infrastructure everyone needs to have a healthy life, none more important than safe and affordable housing.

We applaud King County’s recent announcement of plans to ask voters next spring to approve a proposal to build many more crisis centers and to provide appropriate compensation and training to the behavioral health workforce. Without successful passage of this measure, the 46 beds at DESC’s Crisis Solutions Center will continue to be the only voluntary crisis care facility for all of King County’s 2.3 million people, and we will still lack any “walk-in” behavioral health crisis care centers to which people can self-refer. And without the proposal’s workforce stabilization components, there will continue to be high levels of burnout and turnover across the full range of behavioral health programs.

The state and federal governments should also provide resources to bolster this system. While enhancements to our crisis system’s capacity are urgently needed, solely building up the crisis response system is not sufficient to fully address the needs of people experiencing crises and front-line workers who are caring for them.

A whole lot of crisis can and will be prevented when we fully attend to the support systems and housing everyone needs. The Housing First philosophy means providing permanent supportive housing. Specialized rental housing with robust services has proved to help people with serious behavioral health conditions who have lived on the streets for many years. Likewise, Assertive Community Treatment programs, the most intensive type of outpatient psychiatric care, is proven to help people who otherwise would remain long-term in psychiatric hospitals. Specialized outreach and crisis response programs are needed for people with untreated psychiatric conditions currently experiencing homelessness. These outreach programs provide one-time or short-term follow-up care to people in active psychiatric crisis, engaging them in care options and offering support to make healthier decisions.

Especially in the current times when many normal supports have been weakened, these successful program types need to be shored up with a better-supported workforce and to be expanded to meet the full scale of community needs.

The state Legislature will be convening in January and has an opportunity to invest in behavioral health and affordable housing resources and the essential workforce that prevents people from experiencing a crisis and supports their recovery after a crisis.

There are reasons to be hopeful, at least in the long run. For one, there is an incredible behavioral health workforce, albeit a fractured and hurting one, to build on. At often great personal sacrifice, people continue to show up every day to carry out the proposition that people with psychiatric conditions deserve direct, personal care and can thrive when they get it. Likewise, people with these conditions want that help and care, and make use of it best when it’s consistently available and they aren’t fighting for survival. 

The pandemic exacerbated all of this for sure. As that recedes there should be some level of natural improvement. Investments to restore and build the system we need will get us through the current chaos and into a new era where everyone with psychiatric conditions can resume thriving and healthy lives