Mental Health Crisis; Immediate and Intermediate Intervention Strategies

If you’re reading this, you’ve most likely been in this situation or came close to it where you’ve had to make a decision or did make a decision not realizing there was one to even be made; who do you call when someone is experiencing a mental health crisis? The answer is not always clear or defined and the results vary as much as the outcomes and together, we’re going to work through strategies to assist with obtaining the best possible outcomes and realistic barriers they present, be it with a child or adult.

1.      Identify The Crisis

The first step is to identify the crisis by placing them in a category which will change the situation by immediate crisis or intermediate crisis; is the individual at risk of causing harm to themselves or others?

If the individual is actively attempting to harm themselves or others, this will move to immediate crisis needs and your first step will be to assess what rationally makes sense in the situation; does the person have an item that can be used as a weapon? Are they actively using it as a weapon or threatening to?  Are you able to get the item without causing harm to yourself or others? Are you able to deescalate the situation by speaking to the individual? If talking doesn’t work, are you able to contact emergency services immediately? Does the individual suffer from hallucinations or delusions which may interfere with their logic in the moment? If you are unsure about any interventions, contacting emergency services before any personal intervention is likely the first step as the situation is extremely risky.

Your local emergency services will respond sooner and be more prepared to engage with intervention needs. When you call your local emergency services (911 in the U.S), you want to reaffirm the situation as a mental health crisis and reaffirm this multiple times with need for ambulatory service as the police will respond and unfortunately, the lack of training and handling of mental health crisis needs is often met by authoritative response and less empathy given fear and unknowns with an individual’s stability and the officers own safety.

From the moment you dial 911, even if the operator hasn’t answered, your call is being recorded so know everything you say and how you say it matters – if a situation turns worse, this recording assists in speaking exactly what you spoke.

You can find more information about 911 calls and requesting state records here.

Once services are dispatched, they will work on de-escalation and interventions to assist with the individuals ongoing needs, such as hospital transport once the individual can be safely transported voluntarily or if needing assists for involuntary transport due to the crisis. For the most part, individuals will deescalate when law enforcement is present as the individual is aware of their actions to some degree and will want to avoid the walls now presenting to their behavior; I see this more with aggressive behaviors that stem from power struggles and control.

There is a caveat here; once the person is calm, it doesn’t always mean hospital transport or admission.

Caregivers can consent for their adolescent to be taken for evaluation (don’t listen to any age of consent – state you are consenting which abrogates the adolescents consent by law) and adults can petition for a 302 evaluation and admission in Pennsylvania – anyone can petition for a 302 (doctors and police, even) and while there is a process for the 302 evaluation and admission, it can be used as well to persuade voluntary evaluation.

You can find your state laws and resources on involuntary commitment which covers information on mentalillnesspolicy.org.

This does not always mean positive outcomes and we’ll get into this later but for now, this is a general overview of the immediate crisis needs. A positive strategy is once immediate service needs have been activated for safety needs and intervention, you can reach out to crisis mental health services if they are available in your area and inform them of the situation – immediate crisis intervention needs and actions taken already and request services to assist or help with the situation once the immediate risk is addressed and in this sense, services can possibly assist the police with mental health support services.

If the situation is an intermediate crisis, you can focus on de-escalation and assessment.

2.      De-escalation and Assessment:

If the crisis is intermediate, meaning there is no immediate crisis with safety risks to others or the individual, you can work on de-escalation and assessment of needs.

Whenever you are caring for someone with mental health needs, it’s important to have planning and strategies in place whether crisis level needs are not common or non-existent up to this point; always be aware of your state laws and federal laws, as well as what services are available for you in your area in the event of a crisis developing.

You can find information about mobile and non-mobile crisis intervention services available to you on the National Suicide and Crisis Lifeline website here.

A barrier with mobile crisis centers I’ve ran into, and others reported to me, is constantly being informed of not having enough staff to come to the home or location during the crisis which makes the whole purpose of these services highly ineffective. I’ve stated this before and will again; these services are contracted and by contract – it could be to the lowest bidder. We had a service in place that was actually staffed and coming to the homes, and it was replaced by another service and now we hear low staffing issues repeatedly. Report these situations to your state and speak out as they need to be held accountable and services that can actually provide the service intended be put into place, it can only happen by reporting.

If you feel you need support during an intermediate crisis and do not feel it is at an immediate level, you can reach out to national and local crisis services for assistance. Create and keep a list of phone numbers and services available to you somewhere you can locate and acquire easily during a crisis as this will assist with having planning in place and resources available immediately. Services can speak and assist both you and the individual in crisis and help with finding solutions, as well as consult on potential immediate needs.

The goal is to deescalate an individual who is triggering which, unbeknownst to you even, you may already know some successful strategies.

A good strategy is to ask what emotional response is triggering and assess what emotion is at play.

Is the individual angry? Are they struggling for power or control? Were they denied something? Was there an argument before triggering? Why they are displaying anger most often answer what they are seeking in their display.

Is the individual sad? Are they more despondent or less responsive? Are they vocally stating desire to hurt themselves or wishes to not live? Have they stated plans to end their life? What behaviors have you seen throughout the past few days or time leading up to this point that are different from past behaviors which you can identify a difference?

Is the individual more manic? Has their behavior significantly increased, and they appear more random or highly energetic, sleep less, make irrational statements or grandiose proclamations with decisions to make intense life changes such as moving across the state or selling all their possessions to invest in something else out of seemingly nowhere?

Is the individual anxious? Are they stating high levels of fear or anxieties about a situation or feeling toward something? Is there any diagnosis with delusions or hallucinations in their history which may be affecting their thought process and ability to discern reality from their mental state?

Knowing what they are seeking will help you understand what they need to assist with finding a base.

If an individual is showing more anger or aggression associated, they likely want to feel in control or desire to have some power in the situation. This isn’t always easy to address as what the individual wants cannot always be accommodated and for children and adolescents, even more so depending on the parenting style and sometimes, you have to ask yourself if you yourself as a caregiver are not being fair and possibly need to negotiate your own terms (I see this often with caregivers who are not consistent with rules, agreements and follow through – you can’t give a child power in everything then expect to take it away without a fight).

  • Offer limited choices, such as would you like to have A or B.
  • Give specific time limits and choices, such as, “how about we take five minutes to collect ourselves so we’re both more prepared to talk and then come up with solutions we can both agree on.”
  • Use constructive language that assists with building a team view, such as “we,” and do not use defensive based language such as “you,” followed by “are,” or some statement that will signal a need to defend themselves or actions.
  • Use language to assist with defining their emotions and shaping it to less heightened vocabulary, such as “You seem angry, and I want to help you feel less frustrated. What can I do to help you feel less stressed?”
  • Control your own emotions and fight the urge to defend yourself and what they are stating no matter how much it upsets you; anger wants to confront, but you have to look beyond it to understand what they are really speaking. Pain and communication is not always clear – how one individual sees a situation is not defined and this is how they are seeing it, which may not be fully rational or understood. Now is not the moment to clarify, but your opportunity to support them by comforting them, such as “I’m sorry you feel that way, I didn’t know my actions came off this way or you were experiencing this as a result. Could we work together to find a solution and talk about this so we can both understand each other better?”.

Give the individual space to talk openly about their feelings, time to calm down and regulate their emotions (as well as yourself), and space as needed and requested with agreement to discuss the situation once everyone is in a better position to do so emotionally.

The situation is more difficult for depressed individuals as they will often decline services and this is where you as an individual may have to make a difficult decision to intervene against the individuals wishes which could cost trust in the relationship and unfortunately, you’ll have to make that call. But there are strategies here and linguistics to assist, as well as the ability to build a team support.

  • Attempt to onboard the individual by offering to be there with them through the process; it is one thing to state a service available to them and end it there and another to affirm, for instance, therapy available and intent to go to appointments with them. If you are going to offer a difference, then you have to be committed to being the difference.
  • Check in on the individual regularly and reach out to services for welfare checks if you are unable to make contact. You can find more information on welfare checks here.

Sometimes just knowing you are a support can make a difference to an individual experiencing depression and build a rapport in which they reach out to you in a crisis because they trust you and look to you as a source to help them get through their feelings.

  • Speak to other trusted supports with the individual and build a team to assist with potential interventions in which everyone can meet and speak to the individual about concerns with specific behaviors and offer support through any interventions mentioned, such as going to the hospital with the individual for an evaluation or attending appointments which different members of the group can take responsibility for assisting the individual with.
  • Use non-controlling language and suggestive wording to lead the situation, such as “I read about this one service that can help with information with similar situations, why don’t we call quick and just see what they say? It doesn’t hurt and we can see what it’s all about,” and dial the number. You onboarded them and placed them in we and complete the action before they have a chance to deny it which may upset them, but if services answer – they’ll likely let you lead to information and the individual may possibly continue this agreeable behavior because it satisfies a context.
  • Make plans with them and obtain a commitment which can extend to “a something,” more in place or something to look forward to, such as getting outside in the community be it for a walk or a restaurant they enjoy or even a new place you know they would like. End the meeting with a new plan in place and so on; keep funneling the behavior to a new behavior and commitment and transition this new behavior into new patterns.
  • Help them identify their pain with a rational reason rather than an emotional state with no reasoning and don’t underplay their feelings – validate them by verbalizing their pain and situations. For instance, if an individual is struggling financially, you could approach their feelings by rationalizing the situation into a base for them; “I feel like you’re in a hard situation and it makes sense given the issues between paying for everything (list specifics if you know them) and it never seems to let up, anyone (inclusive) in a similar situation would feel the same – this just means we need to find solutions (potential resolution). Why don’t we look for services available to help?” And start looking for those solutions as there are a large number of services likely available and help the individual become active in that solution versus immobilized by the emotion a situation is presenting.
  • Do not make it about yourself. Repeat; DO NOT MAKE IT ABOUT YOU. What worked for you or how you would go about it is not always how the individual feels or needs, nor are they with the same privileges you may have had to succeed. The only place your experience has in the situation is if offering understanding in a way those who have experienced the situation can fully speak and stating it to show some basis of feelings shared, often with the barriers and realistic difficulties that knowledge creates and giving advice on how to navigate those barriers. It’s not about you so be mindful of yourself and what something means for them.
  • Observe the individual’s environment and physical factors; have they randomly sold or given away personal items? Have they suddenly stopped general behaviors with cleaning? Is their personal hygiene less cared for? Are you noticing marks or scars on their body? These are tells and they can represent different factors and degrees so observing and knowing them can help shape the level of intervention that may be needed. Even positively seeming behaviors can be a tell, such as an individual who has been depressed and following a general pattern of behavior in which they are not taking care of themselves hygienically nor keeping their living environment organized and in order, suddenly cleaning everything, giving items away, and appearing suspiciously happy all of a sudden may just have a plan to commit suicide. Behavior patterns do not just change in an instant unless there is an intense emotion that is overriding it and while some can be momentary bursts leading to actions, do not overlook it.

If someone similarly is experiencing high levels of energy and making irrational statements, they could be experiencing mania, and it is important to implement similar strategies such as building a team and reaching out to services.

Linguistic communication has an important function in all areas, and you’ll want to mold it to the emotion being displayed – if someone if experiencing mania, they are likely sure of their idea and have concocted this grand plan with some sediment or root. You telling them the plan is irrational is not going to work – that is simple and in a way, disrespectful to them. Realistically, as a support, we are not in place to be their therapist nor trained to work with this behavior like that of a specialist with years of training to address this. If the person is identifiably stating alerting statements with plans or choices, you should reach out to mental health services for advice and support available in your area for long term aid and speak to the person on their level which means using language that validates what the emotion is creating which might not always be rational, but it is real. When Mike states, in an extreme example, he decided to sell his home and head to Vegas to get rich at the casinos, don’t confront the irrationality but assist in defining it and assessing the level of actual thought and planning put into it; “Man…the casinos tend to have a winning hand (doubt on the choice – not Mike, don’t trigger defense which can reinforce the idea). I have seen some profitable cases with investments (new idea, possible new focus if doubt cast), and leaving for Vegas? We’ll miss you (emotional inclusion to other connections). How do you plan to go about selling your home? Have you consulted with anyone yet (more doubt placed, assess level of plan)?” This is just a general idea and mostly, the goal is to review and assess on their level of planning and commitment to the idea and place doubt on the idea and not reinforce their idea by triggering them into a defensive state and hopefully cast enough to place them in review verse active while working on potential services to onboard and potential emergency evaluation needs if the situation calls for it.

The same for anxious behavior and identifying the situation, you’ll want to assess the individual’s history as those with certain diagnoses can be more susceptible to hallucinations and delusions which substantially change the situation. While they may not be in immediate crisis, it could easily turn into an immediate crisis if they cannot distinguish between their mental state and reality and you may be in a situation which you have to, again, make a choice based on what you are seeing. In this situation, contacting mental health services available in your area while the situation is intermediate could assist with counsel and potential evaluations to help determine the individual’s level of need.

For individuals with general anxiety and other associated anxieties, you’ll want to assess the environment and current triggering – is the area triggering them? An individual? A sound? An animal? Most likely, it is something along these lines and you want to identify what that is and get the individual away from whatever is triggering them.

Grounding is a positive strategy here, as well, with verbally talking them through the situation and identifying the environment or factors outside themselves or part of themselves to help them focus on these aspects versus the escalating chemical reactions they are currently having. Breathing techniques are helpful here, as well.  I am going to put a link to grounding and breathing techniques here for those unaware to assist with information and there are certainly more resources available and other strategies to try – every individual is different and it’s important to know what works for the person.

A number of grounding techniques.

Breathing exercises with videos.

3.      Follow Through:

A person with a diagnosis is not necessarily an ongoing intermediate need for intervention but the difference often likely comes down to how they are managing their diagnosis and services in place – a person with a diagnosis or even multiple diagnoses or comorbid conditions relating that is involved with services actively has treatment and crisis planning in place, often with services that they meet with regularly that monitor and track risks. A person under the same conditions that isn’t actively working with services is left with only their active life supports which may be large, one person or even none and there are certainly variances here, but the purpose of this post is to arm you with simple distinctions and how to assist, which leads to the next point which is follow through.

Once the crisis is identified, deescalated, and assessed – you’ll move to follow through which is more of the end result and solution.

An immediate crisis will likely lead to hospital intervention services with an evaluation to determine if the person is clinically a threat to themselves or others, which sounds great on paper but I am going to have to pop that bubble right now for you. Yes, there it goes off into the atmosphere with my hopes and dreams for a rational system.

Here is the problem – emergency rooms are focused on medical emergencies in which they are equipped to handle medical emergencies and mental health crisis is a subset of this, not the main course. Not every county has a psychiatric hospital and they are overfull which is where you’ll hear the term that they are trying to “find beds,” and the individual is often placed in the psychiatric unit which is not a long term treatment facility.

This is easier for adults to be self-committing as they can actively state their need and desire which advances placement when a bed opens in a state institute.

For children, I have seen a teen with a long mental health history and services in place go into the emergency room after being found as a runaway with scars up and down their arms from self-cutting and being found and taken in due to police activity in which the teen was in a fight with another individual. Believe it or not, the mother had to push for a hospital evaluation and at one point, they were searching for available beds and couldn’t find any, so they discharged the teen stating they were stable because, by all definitions, they were at that moment.

For children, I have seen this repeatedly – the child could of just went on a killing spree and they’ll discharge from the hospital because, in that moment, they are stable and there were no beds available.

You will have to fight tooth and nail depending on what’s available to you.

You can reach out to psychiatric hospitals directly and inquire about intakes which has some success if you have time, such as in intermediate crisis, as again – beds may be full but you can call and check in everyday on availability.

I had a case in which the local psychiatric hospital staff stated need to visit the emergency department first to assess for health needs and confirm on these factors which, after, the individual would be referred to them which is and was untrue in this case; the emergency room would just mean sitting for hours for the individual to be sent home. I told this staff they were incorrect, called back on a different shift and spoke to different staff and got the answers I needed, and eventually scheduled an evaluation for intake. Remember, who you speak to makes a difference and sometimes you have to hang up and call back to speak to someone else or request to speak to someone else. If something feels illogical, it usually is and you need to follow your hunch.

Why go through the situation repeatedly just to have the individual sent home? Data. Document and track everything to assist because if you are experiencing similar situations, you want data to raise hell with when addressing the issue. If you didn’t complete the actions, they never happened which means the crisis never occurred on paper.

States have a program called Assertive Community Treatment (ACT) which is an intensive level of care for adults and there is ACT programming for teens in Pennsylvania – these services are a multi-disciplinary team that is mobile, meaning they come to the home and all work together for intensive level cases. Again, great on paper but part of qualifying is at least three psychiatric admissions in a year or two in which the individual was hospitalized for a period of thirty days and/or with other co-occurring needs such as substance abuse or treatment needs at high levels.

Say this with me now – at least three psychiatric hospitalizations in a year and two readmissions with thirty-day stays.

Well…now…clearly there is a problem when hospitals are sending individuals home and I’ve stated as much to my county representative when I needed remind the person my client couldn’t get actual hospitalization intake due to this. You’ll seriously want to hit your head off the wall at some point as you speak to statements more often following guidelines and regulations, but not the actual scenario taking place. So, there is this amazing program that likely would benefit high level cases but they cannot obtain it because hospitals discharge due to no beds being available and Mary will have to have another breakdown and hope the next emergency room visit comes with an available bed so they can be processed and treated somewhere.

That is real and hopefully, not true across the United States but for some – you will face this and again, track and fight back by arming yourself with knowledge and advocacies.

For more intermediate crises, you can start by onboarding services such as case management and intake at a mental health provider for therapy and potential medication management. This builds data and monitoring with treatment planning in place. There are waitlists, but if the crisis is not immediately needing resolution, there is more time to work with.

Different services can provide different referrals for higher levels of needs, such as residential treatment centers and partial hospitalization programs. I have a breakdown of all terminology and information compiled on another post to assist here, as well, which you can find here.

Referrals are important and can make the difference in long term care needs or immediate needs if services are onboarded by reaching out and discussing risks and current levels of concern, especially if emergency services are not as assistive with resolutions.

Your follow-through will depend more on short term and long-term solutions and what makes sense; if immediate, you’ll want to escalate due to obvious concerns and risks and intermediate is more able to monitor and have time for onboarding services.

Once onboarded, the individual will begin working on treatment and stepdown planning which puts in place the follow-through to ongoing needs the individual may have with assistance to those needs actively.

How you get to that route is generally based on strategies and they don’t have to be overcomplicated, just focused and with awareness on what is available to you where you live and how those services are supposed to function on paper and realistically, how they may end up functioning, so you’re prepared with solutions.

You can find additional resources and information available online or by calling your state human services department which can assist with service information and guidance, as well as your county MH/ID service provider.

Below, you can find links to two national services I have always found helpful and full of resources which may be helpful for you, as well.


4 responses to “Mental Health Crisis; Immediate and Intermediate Intervention Strategies”

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