Ten Things To Consider In Crisis Intervention

1.  Remember to keep yourself safe.
If you cannot maintain your own safety, you will not be able to help others. Always ensure your physical safety and be aware of your environment.  If you are in a workplace, is your area safe? You should never be in a position where the person in crisis is between you and your exit route. Do the doors swing outward for safe exit? Are there unsecured items in your interview room that could be used as weapons? It is important that safety be considered when designing a potential interview room or treatment area.

2.  Note any changes in behaviour.
We can all recognize when someone is raising their voice or behaving in a threatening way. It is   equally as important to check in with someone who is normally a talkative person and presenting subdued, quiet or withdrawn. It is best to have a colleague remain a distance away to call for assistance if needed. 

3.  Remember your physical positioning.
Be mindful of personal space. For various reasons including both culture and possible trauma in their past, the person in crisis may require greater personal space that you may be used to. Also remember to communicate at the same level. If the person is sitting, it is best to sit as well. It is difficult to build a trusting relationship if there is the perception of a power imbalance. 

4.  Be aware of tone of your voice.
If someone is yelling, it is not helpful to speak louder or in a commanding way. It is also not helpful to be patronizing. Either of these tones will cause someone to escalate. It is best to speak clearly and calmly.  Avoid commands like "just relax" or cliches like "everything will be ok."

5.  Be prepared to listen.
It is very important to allow the person who is struggling to be heard. In many cases, this is where the difference is made.  Allow the person to talk and ask for clarification if there is something that you do not understand. This will help you to assess the situation and will also communicate that you are listening carefully. Validating feelings is essential during a crisis.

6.  Ask the question.
Do not be afraid to ask if someone is suicidal. It is best to be direct and not to use jargon.  In many cases, the person may be waiting for you to ask the question. When they can share their feelings, plans etc. there may be some relief expressed as they are no longer hiding their feelings.  Ask if they have a plan. You may need to know this to dismantle the plan in an effort to keep the person safe.

7.  Stay with the person.
It is important to remain with the person in crisis until you have transferred care. In a serious situation, this may involve accompanying them to an Emergency Department. For a situation of less risk, ensure follow up with a professional and arrange for someone to stay with the person if possible. Arrange a follow up call for the next day.

8.  Be prepared.
It is important to remember that many workplaces do not have crisis trained staff. When a person in crisis comes to you for help, it may seem appropriate to provide a card with a phone number for a Crisis Line. You may feel that you have done all that you can do. However, when someone is in a crisis situation, they may perceive this in a different way. They may feel that you do not care. They may feel shut down and rejected which can lead to an increased risk to their safety.  Remember to give your time, and to listen! It is important to train staff not only in physical First Aid and CPR  but in how to manage a mental health crisis as well. There are excellent courses available to ensure that your staff are prepared.

9.  Be aware of self care.
If you are involved with front line crisis work, it is important to recognize that this can be difficult at times. Remember to attend debriefings and to take time for yourself as well. 

10.  Be flexible.
It is very important to be able to adapt quickly when working with persons in crisis. During the past few months, a working group has formed called SSRTC. We are a group focused on prevention and proactive approaches to mental health crisis. Follow us on twitter #SSRTC. We are collaborating to make a difference and creating innovative ways to reach those who are falling through the gaps of our current system. 

Mental Health and Homelessness

I was asked recently why so many of our homeless community are struggling with mental illness. Although there is a common perception that the mental illness leads to the homelessness, there is another side to this answer that needs to be discussed.

We are all aware of the increasing number of folks struggling with untreated mental illnesses who have fallen through cracks in our system. We see this everyday.  The folks we may not see are the less visible. Far too often, we may not assess the person who lost his job and is now living in a shelter because he cannot afford to pay rent. Many of the folks in our homeless community are there because of negative circumstances, loss of relationships, loss of family members, loss of home, income etc. When someone experiences loss and a significant change of circumstances feelings of sadness, fear and anxiety are common reactions.  In many cases this person can become very overwhelmed, feel depressed and have thoughts of suicide. This is referred to as an adjustment disorder or a situational crisis.  There can be a significant risk involved for this person's safety.

When someone is sleeping in a shelter or outside, their sleeping patterns become interrupted. Lack of sleep and poor nutrition can also lead to irritability and difficulty coping. In severe cases, sleep deprivation can even lead to a form of psychosis. Fortunately, this will improve quickly with a hospital admission and adequate rest.

As homelessness service providers, it is very important to look beyond the physical presentation and general health concerns. We cannot do a complete assessment without addressing their mental health and coping. For someone in a situational crisis, this may be a new experience and they will not offer the information to us. We need to ask the questions!

I would encourage all outreach providers to include a comprehensive mental health assessment with your intake and assessment. We have funding and resources to address the physical health needs but it is very important that we expand our current practice. There is no easy answer for what came first, the homelessness or the mental health struggles.

Falling Through Gaps

Ask anyone who has lived experience trying to manoeuvre our mental health system or those struggling within  it, there are gaps. People are falling through these gaps every single day. Our system is a maze and the greatest challenge for folks is learning how to get help.

For those who are able to attend a family doctor, they can connect with the system by referrals to specialists, psychiatrists, out patient programs etc. However, there are many who are quite vulnerable and at great risk.  They may live in poverty and have no means of transportation to get to appointments so may not follow through with treatment. Some persons may be homeless, sleeping outdoors and mistrustful of others. For these individuals, there are numerous barriers in attempting to get help. Success is possible though with outreach, trust building and establishing relationships. If we add outreach efforts into our system we can effectively help people navigate between agencies and services. We can also advocate for their individual needs and how to address these within the traditional healthcare system.

Even with the best efforts and collaboration though people can still fall through the gaps. There are times when we can be successful in getting a hospital admission for someone at risk. However, on discharge they may not meet the criteria for an Assertive Community Treatment Team if they do not have enough prior hospital admissions to qualify. We are left with community support through agencies that is less intensive and participation is voluntary. It is essential that outreach support be developed as part of voluntary programs as without this you will lose some people. These gaps in care lead to the revolving door syndrome that we experience all to often.

Those of us who understand the gaps also understand why we need solutions. It's time to look at some innovative approaches to care. It's time for some out of the box thinking. With so many slipping through our gaps, we can't ignore this.

What is Crisis Outreach?

So just what is crisis outreach and why does it work?  This really is a simple concept. The rationale for this type of service delivery seems obvious yet it continues to be overlooked.

I have been involved in crisis work for the past fifteen years and have taken many different types of training for managing all levels of risk. We tend to focus on  physical escalation and safe intervention. This is usually our most serious type of intervention when we may need to act as a team to keep the person safe and secure. In extreme cases, we may need to have police assistance for safety. However, if we can intervene prior to any physical acting out, we can manage an escalation during the verbal phase. This requires specific training and negotiation skills. Fortunately, most crisis situations can be safely managed at this level.

Alternatively, we could try to focus on prevention and relationship building. We could concentrate on being proactive rather than needing to be reactive. We could go into communities, engage with members, build trust, assess their needs and work collaboratively to safely manage their concerns. The alternative is for us to wait by a phone or in an office for persons in distress to reach out to us. In some cases, by the time someone may call a crisis line there can be a significant risk to their safety.  This could result in an involuntary apprehension and the person being taken to the emergency department. Even worse, some people who are feeling suicidal may never get the courage to call or come in for help.

With effective crisis outreach lives can be saved. When a trusting relationship is in place, self disclosure of suicidality may occur. Many potential crisis situations can be prevented with proper assessment, providing support and resources. Ongoing  monitoring by outreach can help to keep that person safe.  This is less stressful for those community members who are struggling with mental health concerns and situational stressors. For service providers, there is also the benefit of a reduction in crisis calls that would have required a multi-person response. There is a decreased risk of injury for both the community members and the responders.

In recent years, much of the focus on physical wellbeing has shifted toward prevention for maintaining optimal health. It's time to look at preventative measures for mental health as well. Crisis outreach is one method that will work...let's talk about it!

When The Street Is Your Home

     Tragedy struck our homeless community this past week as we learned of a horrific loss of life. A man without a home who had resorted to sleeping inside a metal structure and heating this with a propane heater burned to death. This is the worst kind of news that any of us working with our homeless community ever wants to hear. There is always risk involved with being outside in any severe weather and despite our best efforts, tragedy still occurs. During the past month, two other lives were lost from hypothermia.

     Most of us cannot comprehend the struggles faced by those who are existing day after day, night after night on our streets. These folks are facing stigma, judgement, and at times very little options or hope for a better solution.  In a city focused on cutting costs, the most vulnerable seem to feel the greatest loss. With funding cuts, agencies have been forced to reduce their outreach services.  We have less outreach workers and nurses on the streets and also less support to areas outside of the inner city. The deaths that have occurred so far this year have all been to the east and outside of the downtown core. 

     We continue to struggle for the implementation of adequate shelter beds. There are unique needs within our homeless community such as poor physical health, substance use, mental illness, service animals or pets etc. Those who work with and understand the needs of this community also know that there is a need to think outside of the box when providing shelter spaces. Currently, there are many people sleeping outside because of needs not accommodated by a traditional shelter system. When lives are being lost, we cannot afford to ignore this.

      There is also a need for a national housing strategy in Canada. If you would like to get involved or help us advocate for solutions to homelessness, please see this link. Thank you for helping us bring dignity for all...

http://www.dignityforall.ca/en/C400

     

     

Project Winter Survival 2013

     Saturday January 12, 2013 was kit packing day for the project. With the generous support of our sponsors, their employees and volunteers 3,000 survival kits were packed at Bargains Group at 890 Caledonia Rd. Toronto.  While packaging the completed kits into boxes, I found myself overwhelmed as I thought of how our homeless friends would feel to see this type of support. For folks who find themselves facing stigma, adversity, and judgement on a daily basis, I realized how grateful they would be to see such a tremendous response and the genuine caring that filled this warehouse. This was truly a remarkable day.

     One week later, on Saturday January 19, 2013 we gathered once more at the same location for distribution day. At this time 3,000 sleeping bags had also arrived to be distributed with the survival kits. Project Winter Survival 2013 was officially launched!  We had the honour of hearing from a very special guest speaker. Pete, who has lived experience, has faced homelessness and he shared his story with us. While we were discussing the generosity of our sponsors, Pete said "I never would have thought this many people cared."

      Temperatures are dropping sharply and the risks involved with sleeping rough will be increasing in the next few days. We are very fortunate to have this project in the Toronto area. As outreach workers we will continue to hand out these supplies to those who are out there struggling in a way that most of us cannot imagine.  Our goal is always to get someone inside and to safety. These survival kits and sleeping bags provide us with tools to help us communicate, gain trust, and continue to encourage people to come indoors. In the meantime, those sleeping rough will have some supplies to assist with their basic needs.

      Yesterday, we distributed some kits in the downtown area. We met two women who were sleeping outdoors as they were fearful of violence in the shelters. They were very grateful and thrilled with the hygiene products. We met a man who lives outdoors in a secluded location. He was still using his backpack from a survival kit he had been the previous year. We also met a man who reminded us that being treated with dignity is what is most important to him and that "we are all angels, but some have only one wing right now." He was grateful for that extra bit of support. I hope this will help him to feel more complete.

Homeless and their Best Friends

Over the past four years of street nursing, I have been noticing an increase in the number of pets, mostly dogs, that I am meeting.  Last year when on outreach in New York City with my friend Mark Horvath, we met some "travellers."  These are groups of teenagers and young adults who are homeless and travel together city to city. I was fascinated to learn their stories and meet their "service dogs." These dogs are for emotional and psychological support. Within the past few years, there has been great success with recovery from PTSD using service animals. My experience in New York City resonated with me as I suddenly realized why they choose to have their best friends with them when alone and out there doing their best to survive day to day.

Now some will say and we've all heard "Why would you have a pet if you can't afford to look after yourself?"  Well, I have been carrying dog treats in my backpack for a few years now and visit not only our homeless friends but their best friends as well.  As a dog owner, I fully understand the emotional attachment and unconditional love we receive from of our pets. However, now imagine yourself homeless, alone, afraid of being robbed at night and sleeping outside on cold concrete in a city where few people really seem to care. The attachment to your pet becomes even greater as does the importance of co-existing. I am finding that part of my assessments lately are not only that of our homeless community, but a well being check of their pet is necessary as well. I would not claim to be an expert in animal health, but can say that fortunately this far, nothing obvious has been found. As a crisis nurse, I also look at the underlying issues that someone may be experiencing and consider the importance of attachment and the emotional significance that their pets may provide.

Unfortunately, it is now January and winter is cold in Canada.  In general, we are facing a grave situation here with the availability of shelter beds and many are unable to secure a place for the night. We also have a situation where some folks cannot come into shelter because they would be forced to leave their best friend outside. We do have one shelter that allows pets but it is usually full.  The reality is that many are left with no option but to sleep rough. I am in no way advocating for someone to keep their pet out in the cold but realize why for some they choose to have their best friend with them.