C is for What Constitutes a (mental health) Crisis?

When I am not seeing clients in my private practice, I work as a clinician in a mental health crisis clinic run by a community mental health agency. I ended up at the crisis clinic by serendipitous accident. I had applied for an internship with said local agency, completely oblivious to the very existence of the crisis center. I imagined that during my internship, I would be meeting with clients one-on-one several hours a week for the year. Instead, I got to do something quite different.

How does someone end up in the crisis clinic? Community members who may be experiencing a mental health crisis can come to us, free of charge, for up to five days at a time. In those five days, we provide a safe environment, connections to community resources such as housing, CD (chemical dependence) treatment, case management for ongoing mental health support, medication management/stabilization, appointments with primary care providers and dentists, connections to youth services. A good number of our clients are without stable housing. Many spend most nights on the streets or at the drop-in center. Few have jobs. Most struggle with addiction, and I think it’s safe to say the vast majority experienced a major trauma in their lives: abuse, neglect, death of a parent or sibling or child, sex trafficking, even torture.

Most of our referrals come from the local hospital’s emergency department; many referrals come from our own agency’s counselors and case managers who work with hundreds of clients with mental health issues such as schizophrenia and bipolar disorder. Other referrals come from a variety of community agencies: housing, doctor’s offices, domestic violence shelters, the county crisis line, other mental health agencies in town.

But, what constitutes a mental health crisis? How does someone end up with us? When someone is feeling suicidal and unable to keep themselves safe, they may get a bed with us. If a person has made an unsuccessful attempt on their life that hasn’t required hospitalization, they could end up with us. We might get a young man who is experiencing his first psychotic break and his family has no idea how to help him. We may take in a young woman who recently lost custody of her children and is feeling despondent. Often, we have clients who are coming off of meth or detoxing from alcohol and are psychotic enough that they cannot be left alone yet not so gravely disabled that they require involuntary hospitalization. Others have previously diagnosed mental health issues that are not being well managed by medications. Some have urges to throw themselves into traffic or in front of a train but are oriented sufficiently to be coherent and logical and thus not detainable.

Interestingly, but probably not surprisingly, homelessness does not constitute a mental health crisis. We are not a program that bridges people to housing. Homelessness is so pervasive and intractable, we’d be holding folks for years if they were waiting to be housed. Occasionally, if someone is at risk of severe decompensation if they were to return to the streets, we’ll keep them for a few extra nights in order to transition them into a supervised living situation.

Nor do we provide respite. People can’t come to stay with us in order to heal from surgery or to get a break from their intolerable living situations. We are not a hostel, though one time we had a client in who had managed to use crisis centers like ours as way stations in his travels across the country. Desperate times call for desperate measures, and given the current housing and homelessness crises, folks get creative in order to feel safe, to be fed, to sleep in a bed. Many know what to say to get the ER social workers to call us. And why not? Doesn’t everyone deserve to feel safe? To sleep with a roof over their head? To have a hot meal and a hot shower?

A lack of housing may not constitute a crisis sufficient to warrant a bed in a crisis center, but I’m sure it would feel like a crisis if I were the one on the outside of that door. And that is exactly why I continue to work with folks in crisis long after my internship has ended. I am all too aware that life is a precarious balance.


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