Psychiatric Crises in the Emergency Room
Continuing our series on Fixing Mental Healthcare in America. An interview with Kesy Yoon, LMHC and James McMahill, LMFT, two Modern Therapists with work experience in the United States hospital mental health system. Curt and Katie talk with Kesy and James about their perspective on the emergency room as an entry point (and revolving door) for mental health treatment. We look at the bureaucracy, the funding issues, and the difficulty in providing adequate care in these settings. We also discuss the ideal of a psychiatric ER, to improve mental health treatment for those in crisis.
It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.
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Interview with Kesy Yoon, LMHC and James McMahill, LMFT
Kesy Yoon, LMHC: As a Licensed Mental Health Counselor (LMHC), I am dedicated to helping my clients understand who they are and how they fit into the world around them. Over the past six years, I have worked in a variety of mental health settings with individuals from all walks of life. Currently, I work with clients struggling with anxiety, perfectionism, trauma, and major life transitions. Over the course of my career, I have developed a specialty in working with the Asian American Pacific Islander (AAPI) 1st generation population. My work in this area is informed by my own personal experience with navigating the differences between an American upbringing and traditional Asian values. I enjoy working with AAPI clients to identify solutions to improve quality of life while honoring important cultural values and needs. Therapy is dynamic and my style is centered upon empowerment and hope. I show up as a human first, therapist second. As a counselor, I believe that every individual is a unique and complicated being; therefore, I do not have one uniform approach. I draw inspiration from several evidence-based modalities such as EMDR, Solution Focused Therapy and Cognitive Behavioral Therapy. I am also trained in the EMDR modality and I am currently in the process of EMDR Certification.
James McMahill, LMFT: I am an LMFT in CA and MN specializing in crisis care for those struggling with psychosis, severe depression, PTSD and suicidality. The majority of my clinical experience has been in crisis work and includes all ages, from children and adolescents in inpatient, TAY and adults in county outpatient clinics, and as a member of a Geri Psyche urgent response team. While in San Diego, I was the Program Director for Heartland Wellness Recovery Center, a county outpatient program serving SPMI clients in East County, San Diego. Currently, I am a team member for a CRT (Crisis Response Team) in Carver County, MN, and spend much of my clinical time in Emergency Rooms or responding to community or Law Enforcement mental health crises. I may also be commonly found co moderating Therapists in Private Practice (TIPP) on Facebook, with my wife Namrata.
In this episode we talk about:
- Continuing our special series on Fixing Mental Healthcare in America
- How emergency rooms become a part of the mental health system
- The role of emergency rooms as the first door for folks with a mental health crisis
- It can be a catchall and revolving door for some with longer term mental health concerns
- The challenges and overwhelm when someone comes into the ER
- The goals that emergency rooms can have when someone comes in with a psychiatric crisis
- The differences in ERs (whether they have psychiatric facilities or whether they transfer to other facilities)
- The challenges in placing clients in psychiatric inpatient care
- The revolving door – developing relationships and losing hope
- Potential legislation changes that could increase time for care
- Conflicting goals at different levels of the hospital and the hot potato syndrome
- Training of the emergency room staff, medical staff, law enforcement, fire services
- The criminogenic interpretation of behavior that can hinder law enforcement and seeing a patient as someone needing help
- The importance of patience in managing psychiatric crises
- Interacting with Law Enforcement in these situations
- Responses to the “mental health” being touted as the solution for mass shootings
- Challenges with reimbursement and insurance coverage
- Some solutions for smoother processes during psychiatric emergencies, ideas for ideal planning and training
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Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
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Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
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Curt Widhalm 00:00
This episode of the Modern Therapist’s Survival Guide is brought to you by Healthcasters.
Katie Vernoy 00:04
The health casters is a podcasting course and community designed for therapists in private practice and therapists turned coaches and consultants that supported the successful launch of over 270 podcasts. Learn more about the health casters at sellingthecouch.com/jointhehealthcasters and enter the promo code therapy reimagined at checkout for $100 off the listed price.
Curt Widhalm 00:26
Listen at the end of the episode for more information about healthcasters.
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe and practice as human beings to support you as a whole person and a therapist. Here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 00:45
Welcome back modern therapists This is the modern therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is part three of our special series fixing mental health care in America. And if you have not yet listened to parts one and two, please go back and listen to those and we’ll include links to those in our show notes over at mtsgpodcast.com. When we look at mental health care in America, part of what Katie and I were looking at is the various ways that people needing mental health services interact with all the various systems and today’s episode we’re focusing on psychiatric emergencies and the ways that clients, patients, people in general in psychiatric emergency situations and up in the emergency room. And so our guest today, once again, interviewed separately spliced together so our guests are James with me Hill, who works in Minnesota and Casey Yoon, who formerly worked in an emergency room in Los Angeles, California. We are joined by James McMahill, Licensed Marriage and Family Therapist.
James McMahill 02:04
Currently I’m in Crisis Response Team in Carver county in Minnesota, what’s up Western suburb just right outside of the Twin Cities,
Katie Vernoy 02:11
how do emergency rooms end up being a part of the mental health system
James McMahill 02:17
I have such as arranged experience from having conversations like these about emergency rooms or about law enforcement, you know, because each system is such a fingerprint from one another one er is so distinctly different from another er my experience when I was a director of an outpatient program in San Diego is so different from what I experienced on a day to day basis in the Midwest, for the most part of what I experienced as a clinician, it is a it’s essentially a holding place for someone who has usually come in for a medical issue. And then is witnessed by the attending MD or nurse to also be endorsing an issue that’s synonymous with a mental health concern. And in the two ers in particular that I work with, they have become so used to referring out to the crisis team that even if someone is coming in and stating that they’re experiencing depression or anxiety in any way, generally will lead to a mental health assessment by the crisis team. Once that’s completed, and we’ve made a recommendation, then the ER becomes much more of a complicated place, because then they’re kind of, particularly if we’re recommending an inpatient like treatment program, then the client is just kind of hanging out we are until we are able to secure a program for their ongoing mental health care. And so there’s this kind of tension following a disposition between the crisis teams and other hospitals who have short term residential or short term behavioral health units, and the two ers that we serve and who do not have behavioral health units in trying to get them to an appropriate level of care kind of as soon as possible. Because the ER is always concerned about how many beds are available, who’s coming in what the tenor and the mood of the unit is. And so it’s kind of a holding place for that moment.
Curt Widhalm 04:12
We’re also joined by Kesy Yoon lpcc, talking about some of the experiences of working in emergency departments when it comes to mental health. So thank you very much for joining us and spending some time tell us how mergency rooms work as part of the mental health system.
Kesy Yoon 04:30
My experience, the emergency room is often the first kind of net or door into a line of resources for mental health in the community. It can be kind of the first step that patients and their families or people take when someone’s having a mental health crisis. But on the other hand, I’ve also seen the ER function as a dead catch all net for individuals whom the system doesn’t know what to do with. And so sometimes it’s the first door that First kind of introduction to mental health and resources. But then it also becomes kind of this catch all, though, the person that’s in transition or can’t utilize their resources or in between resources, they also begin to use the emergency room as well.
Curt Widhalm 05:16
So what do you see when it comes to? There’s somebody brought in by law enforcement, it’s typically under a 5150 type situation. Walk me through what that might look like, if we were observing this from somebody entering the door, working through the emergency department staffing, tell the psych staff gets there. What is this experience like for somebody going through this kind of a crisis?
Kesy Yoon 05:43
That’s a great question. I have often wondered that how alarming it must be depending on what symptoms have been presented. But there was a lot of noise and a lot of chaos when you come into the ER, depending on the day, but most of the time, that’s what’s going on. So you’re coming in, usually, with law enforcement or fire, you’re coming to the double doors, you’re not coming to the waiting room, you’re not being triage the traditional way. You’re coming in, and everyone’s looking at you, right, because the tension is shifting. It’s just busy. And on top of that, you know, you’re getting rushed through triage. And I think things are happening so fast. And I’ve often wondered how it must feel to be someone who’s experiencing a mental health crises, to then be to be in a situation, it’s difficult for a person who’s not experiencing a mental health crisis.
Katie Vernoy 06:31
I was thinking that exactly. And even if somebody is coming in with some sort of an injury or a severe illness, they might also be having a mental health crisis as well. But when the primary symptoms are psychosis, or suicidality, or homicide, ality, like, it seems like it would be hugely disorienting,
Kesy Yoon 06:49
yes. And then your, your triage, you’re put into a bed, and they tell you a bunch of commands, you know, change into a gown, they go for shoes, your stuff is taken away, and then you’re maybe left alone. And then the doctor takes however much time to come see you. They’re asking you a bunch of questions. And then sometimes you might get visited by a social worker, if you’re lucky, you’ll get a kind nurse who has some idea of what you’re going through. And then after all of that, all the questions, all the stuff, all your stuff has been taken away, you’re essentially told that you’re on this 5150 dennis is quiet, you know, the only people that come in to check in US shift change. If you’re in restraints, maybe someone comes every 15 minutes to check on you, and then kneels and then you’re just waiting, like, after all of that barrage of communication, then it’s just quiet for however, the rest of the time you’re in the ER.
Katie Vernoy 07:43
So that sounds really overwhelming. I could especially imagine for folks who are having psychosis or other psychotic symptoms, like it would just seem like, especially I just your stuff getting taken, you know, like, Yeah, wow, you know, just such a, I don’t even though the right word, just very evolved a very vulnerable time. Right. You’re, you’re rushed in, you’ve got all this stuff happening. What is the goal? I mean, obviously, there’s an assessment to get to the 5050. But what’s the stated goal for the next 72 hours? For these folks?
Kesy Yoon 08:19
I think it depends on the hospital. So if you’re a designated LPS facility, which means essentially, you have a locked inpatient unit, your goal is to wait until a bed becomes available, if you meet the criteria, which is you know, this whole other broad maze of things. If you’re not at an LPs designated hospital that hasn’t locked psychiatric unit, then you’re waiting to be transferred. And even those kind of progress updates are very few and far between. But I just wonder about that, too. Right? You come in or your stuff is taken, you’re told that you’re waiting for a bed somewhere else? I mean, what if you have no idea where you even are, right? You wandered somewhere in a psychotic, just mess, and then now you’re kind of coming to and then they’re telling you Oh, we’re going to ship you to some hospital that’s 40 miles away, you don’t know anyone. So just wait for that you can deal with
Curt Widhalm 09:10
on this piece about trying to get people placed when somebody has entered into an emergency room. There’s a whole bunch of different departments who are either responding on the emergency side waiting for psychiatric to come in? What’s the turnaround to getting somebody into one of these programs that you’re talking about?
James McMahill 09:30
I mean, that really waxes and wanes? It depends on kind of that bell curve of utilization. You know, usually as you approach the weekend, the ability to get someone into a short term bhcu goes, maybe it goes way, way down, it’s a lot more difficult. So it really just depends on what’s going on out in the system. You know, we have a database that shows all the available hospitals, all the available programs and all of the available beds. And so once we’ve made that determination, a recommendation for an inpatient program and the attending physician agrees with that decision. Then it still rests on the crisis team to do quote unquote, a bed search, which is to page the different programs within the region to try to find someone availability, we will do our behavioral health assessment in that moment. And until we get that completed in a way that’s representative about what’s going on with the client and his best way as possible, the clients just going to be kind of hanging out there in the ER, and then we make that presentation of the behavioral health assessment, to the different programs to review, then it is completely up to the whims in the mood of the different behavioral health units that we are sending that packet to for review, to determine whether or not facing that that client would be a good fit, or not a good fit. And so there’s this odd kind of back and forth between, oh, my goodness, you know, this person has got a lot of severe issues versus and this isn’t as big of a problem for me as maybe some of the other clinicians have, do I try to write this in a scalable way? So we don’t get the person who’s reviewing the client to be like, no, we’re not, we’re not going to be taken someone who’s physically aggressive and struggling with schizophrenia, or any kind of psychosis. So it is really difficult to kind of find that balance between Okay, we’ve we’ve addressed the emergency situation, we’ve got backing by the attending physician. And now our job is essentially to find a place that will accept that client. And that’s completely based upon our write up, it’s based upon our ability to communicate with the behavioral health unit in a friendly and charismatic way to kind of get them in the mood to like to, to accept the client, and also just what the complications of the system are at that time.
Katie Vernoy 11:46
What has been your experience with the kind of revolving door I think all of us have kind of heard about the ER being used, both for medical, but it also sounds like mental health crises, like that’s where care happens. You know, the people just that revolving door, this is the catch all the lending? Yeah. For folks. What has been your experience of that? What does that actually look like?
Kesy Yoon 12:06
I think it depends on the relationship with the client has with the staff, to be honest, you know, I think there’s some clients who utilize the revolving door of the ER, and it’s almost like, it’s a homecoming every month, like, oh, they’re back. Like, they know the system, right? That’s the kind of client that’s not going to complain, they’re gonna give up their possessions willingly, they’ll do all the labs, they get it, you know, but some clients are more difficult, more aggressive. And it just, it almost becomes not this mentality of Oh, we can treat them like crap, because they they come here all the time, you know, versus the kind of clown comes in, and they get treated a little bit better, because they might treat the staff better. For me, it’s difficult because it almost compels this sense of defeat, like, they’re back again, I thought they got connected with services. So I’m torn. There’s some clients where I did, it’s almost like you don’t mind when they come back, because they know how to operate and you almost enjoy seeing them and catching up with them, right. But there’s also a large majority where it’s difficult, and it’s difficult not to become resentful and think, Oh, well, this patient’s just abusing the system and abusing our resources. It’s not that you don’t want to help. But I think when certain clients come in every month, you assume that they either don’t want the help, or yet you assume they don’t want the hope. And so you don’t advocate for them, really, you’re just trying to, you’re waiting for them also to get transferred upstairs, because you just think to yourself, oh, you’ll be back anyways, you’re not really going to change, you’re not really going to get help or seek treatment.
James McMahill 13:42
Yeah, absolutely. I think that that’s a much larger issue, or at least it was for me in Southern California than it is in Minnesota. It really impacts those who are unable to advocate for themselves who are homeless, who are untreated, in a much different way than it does the western suburbs of Minnesota, there isn’t a ton of homelessness in the suburbs of Minnesota, the response of those who would be picking folks up and doing emergency transports, for example. It’s just a lot different depending on what kind of er system that you’re working with. So when I was in San Diego, it was a much bigger issue. We had folks who would be picked up by perks or who would be picked up by law enforcement on a weekly basis to the point where they would become regulars in the ER and regulars in the short term, bH USD in the area. And that in itself also creates kind of this interesting relationship because when when people become known in ers and their high acuity, but also like presenting with the high degree of affability there’s almost a lower bar for those folks to be admitted into the ER and there’s this kind of friendship relationship. Oh, so and so was here again, come on in Yeah, don’t worry about it get up all taken care of. And yet there’s nothing after that, really, for those folks who unpaired to long term services, regardless if that’s because just voluntarily they feel better once they get out of the ER, and they’ve had their immediate needs met, and they don’t want to engage in any kind of outpatient programming or act level programming. And so I know that there’s a lot of discussion, a lot of work going on right now with quote, unquote, involuntary outpatient programs or mandated outpatient programs, particularly in Southern California. I don’t see that as much in Minnesota, as I did in Southern California.
Curt Widhalm 15:38
In an earlier part of this series, Senator Henry stern was talking about expanding the 50 to 50 part of the law and being able to hold some of these clients longer and beyond freedom and freedom of being able to essentially add a week a couple of weeks that would have assuming under his system would be reimbursed for the hospital. With more time and some of this treatment, do you think that that would help to alleviate some of the revolving door aspects that we see that if so much of this priority seems to be patch them up and ship them off? Right, right. What is treatment in these situations, some of these repeat customers that you’ve seen, just in some of your experience? Is there just that little bit more of stability that would alter their lives?
Kesy Yoon 16:32
Yeah, I think the time, I definitely think it would help with stability and stabilizing the symptoms, or maybe just getting the right mix of medications for certain patients. And then they could also be watching monitor, see if they have side effects. I think the other part too, is that it gives a chance for the case manager or the discharge planner, to try and work out Bible placement for some of these folks, you know, I think it’s difficult to try to find someone a place to live, if they’re only in the hospital for let’s just say 72 hour whole three days to to have them interviewed assessed by someone from a home and then for them to be accepted. Yes, I know, it’s there waiting, essentially, in the inpatient unit. But at least they have some time, you know, it’s not so hurried, and the case manager can really work on, let’s find his personal home that they’re not going to get kicked out of, or that we can hopefully pay for rent for a little bit longer than a week or so.
Curt Widhalm 17:29
There can be a bunch of different goals, depending on who’s working within the mental health system, you kind of have a hot potato syndrome of this particular client is too difficult where for estimate our program or funding goals, this can happen between administration and treatment. How do you in your experience, how have you seen this kind of stuff played out?
James McMahill 17:55
It’s a constant battle against the idea of Yes, I see that they need help. But no, this isn’t the appropriate place for them to get that. And so you see that across modalities, you see that across presentations, you see that across programs, who have identified as having a specific scope. I know I experienced that on a daily basis as a administrator of an outpatient program when dealing with someone who, at the time we were wrangling with the idea of is this person substance primary, or is this person mental health primary? And so there was often kind of that passing back and forth between programs of Yes, I understand. But that person doesn’t feel appropriate to our program. From an emergency room standpoint, some similar things go on, but it’s much more about the folks who are providing services in that moment, the nurses, the doctors, the the aides, the watchers, who are concerned with what someone who is potentially coming to their bhcu, or how that person who will disrupt their familiar or how that person will disrupt their system. And so the folks who are high acuity, the folks who are really struggling, and really the most vulnerable are those who end up spending the most time in the least therapeutic of spaces. Because we often have such a hard time finding them, or finding a program was like, Yeah, absolutely. We are well equipped to deal with that. And we can absolutely provide them with services. I mean, I don’t get that response. When I’m when I’m letting folks know that person is really struggling. They, they’ve been sober from methamphetamine after a year on and they’re struggling hallucinations and paranoia and school aggression. Like I know immediately, that I’m more than likely going to have a very difficult time finding that person services and meanwhile, they’re languishing in the ER in a in a box room. And so that’s really the tension. That’s where the hot potato for me lies in the ER of who is willing to accept this person and serve this person and give them the help they need.
Curt Widhalm 20:00
So when you’re talking about this cross training between emergency staff and psych staff, and part of this even gets into the training of the people who are bringing people in, like law enforcement or ambulance, paramedic type services, what kinds of training inadequacies from the sake perspective? Are you hoping that some of these other services would be able to have or what do you see as deficits that they have when they are working with patients who are coming in under these kinds of circumstances?
Kesy Yoon 20:31
I saw that quite a lot. Unfortunately. You know, I think it’s one of those things where again, it’s it’s very much about how do we not take responsibility for this person, this human being that we’re bringing into the emergency room for law enforcement, if they’re not criminal enough, or if it’s not just if it doesn’t fit into the standard or protocol for them to take them into their custody, they got to bring them into the ER. And then for fire, I mean, fire is even more broad. Right. So the Natalie’s I saw a lot. We’re just a very loose interpretation of LPs, and that’s the lanterman Petris short, I always forget the what it stands for, but just very loose interpretation of what it means to be danger to yourself or danger, others gravely disabled, that’s a, I mean, you can take all kinds of license with that, right. And I think with fire, it was also difficult, because I think oftentimes, the intention is good, like, if we give them to an ER, then they’re going to get set up, they’ll at least have a bed, they’ll have some meals, and then the ER will take care of it. But, you know, there were so many times, even with fire, where even just bringing someone’s wheelchair, that will be forgotten. I don’t know if that’s necessarily a deficiency in training, but the ER doesn’t have an abundance of wheelchairs at them they could give to this patient once they’re discharged. Right? So I think, even things like that, how do we see a patient as a whole person who has a life outside of the ER? And yes, who may need help. But that doesn’t necessarily mean the right should be taken away? And then they’re just left on the street, essentially, afterwards?
Katie Vernoy 22:09
How does the lack of substantial Mental Health Training by law enforcement, fire etc. So the the lack of knowledge and training for the folks that typically work with you, how does that affect clients?
James McMahill 22:24
I alluded to that image of impatience. And I think that that is what occurs the most when I’m dealing with law enforcement or emergency responders who are untrained in issues of mental health, because part of what law enforcement goes through on a daily basis is to address a criminal genic narrative, right. And it’s really easy to get lost in the the who, what, where when of that narrative. And so I often see on train law enforcement trying to apply that same structure to a mental health emergency. And that doesn’t mix well with someone who’s having an incongruent, internalized process to what it is that they’re also trying to communicate their words or with their actions. And so when that messaging is mixed, or is affected or impacted by what experiences someone’s going through, there’s that impatience and there’s that tension. And there’s a dismissal that says, Well, what you’re talking about is not a big deal, right? Or there’s that immediate kind of sense of, we’ve got bigger fish to fry. And so Meanwhile, I am seeing someone who is potentially responding to stimuli, who is exhibiting severe negative symptoms who might be having a dissociative event because of the trauma history. And it’s so it’s difficult to have to have a conversation with someone who hasn’t had training in that regard. Like, hey, there’s more going on here, than what’s on the surface. And I think we need to kind of slow the pace down and really explore what it is that’s going on. And so it’s that time and impatience thing that really, I think creates a rift between the practitioners who are out there as first responders and law enforcement or fire who are out there trying to do the same thing.
Curt Widhalm 24:11
So not only is there needs differences, but to this bottleneck that you’re talking about. It’s there’s policy implications into creating this bottleneck and California where Katie and I are a lot more familiar with things. You bring up George Floyd, you’re talking about this much more intertwined relationship between law enforcement and mental health where you’re practicing now, with the current environment, the current changes, the defunding the police sort of discussions, how do you see that being implemented with the kinds of systems that you’re interacting with now and is there really as much of a push for that where you’re working compared to some of the experiences that we’re seeing here? California.
James McMahill 25:01
I was stunned at the difference in working with law enforcement in the suburbs of Minnesota. As I was working in East County, San Diego, my outpatient clinic was in El Cajon, California. And to be frank, that police department was fairly well known for a quick temper and quick decisions and a lot of impatience. You know, even when they were coming into the clinic on those rare occasions that we did need to call law enforcement and perked was not available. I had some really poor experiences with law enforcement. And so I don’t know what the current climate is back in Southern California. But you know, when I came here, and I don’t know whether or not this has been a change due to what happened in Minneapolis, but I started a couple of months before the George florid murder. And since then there has been kind of a combination of things is one, law enforcement. And again, depending on what officer you’re dealing with, depending on what deputy you’re dealing with, or Sheriff you’re dealing with Sergeant you’re dealing with, and, and depending on what their mood or what their experiences it has been on that day. But overall, the amount of collaboration and the amount of requests for me to come out and participate in a law enforcement event with someone that’s struggling with mental health is way above what I experienced in Southern California, we’re getting calls quite often to come out. And you know, all arrive on scene and and the the officers deputies will kind of tell me what the situation is. And they’re always kind of waiting to see whether or not this is something that I can take care of on my own and give them the clear or whether or not I will stick around because there’s concerns about violence. But there is a surprising level of patience that I’m seeing in dealing with law enforcement in Minnesota. And for me that patience has always been the most crucial element in those those crisis bubbles, right? Because if you have an increased amount of tension with law enforcement, and you can feel the resentment about having to be there in that moment, it makes for a really difficult situation. And it’s very rarely results in a positive outcome for the client or positive outcome for the therapist, or for law enforcement. But there have been a couple of episodes here where where law enforcement was willing to work for hours with a client’s trying to figure out levels of safety trying to figure out levels of cooperation. And I’ve yet to have a situation devolve into something worse than it was when I had arrived. You know, I’ve I’ve had positive outcomes with law enforcement in in Minnesota. Now. There’s a lot of problems here. That is not to say that that’s not the case. Obviously, that’s the case. I mean, so far in my personal experience, of working with law enforcement, as it pertains to them wanting us to join and potentially give them space to remove themselves from a mental health situation. I’ve had pretty positive experiences. Now whether or not that’s driven by altruism or driven by their desire to depart.
Katie Vernoy 28:13
There’s a number of times, especially if there’s mass shootings or other things, whether it’s this public outcry for more funding for mental health programs. Sure. And it’s usually during some sort of a tragedy. What are your thoughts on those, those outcries?
James McMahill 28:30
You know, usually, the expectations for me in those times is to fully understand that in that, in that month in that bubble, whatever that is, is that there’s going to be the least amount of potential progress on actual mental health change than any other time, because it is used as such a such a red herring argument by folks who are looking for a distraction away from something but they don’t want to talk about someone, you know, if someone wants to make sure that they don’t have to talk about gun control, they’ll say this isn’t a gun issue. This is a mental health issue, and yet have very little desire to actually change anything within the mental health world. And then on the flip side of that, you have folks who may actually care about there being fundamental changes in mental health. But there needs to be this prioritization to having a conversation about gun control. And so they’re kind of stuck in this space of saying, Well, yes, I mean, we should talk about mental health. But let’s not get away from the issue that that dude in 30 seconds just mowed down 20 people with an assault rifle. And so I always cringe in that moment, because I know that there’s going to be the least amount of productive conversation about mental health, as of any time outside of that window of a tragedy like that.
Curt Widhalm 29:50
Part of the administration process is around this LPs designation of hospitals and you’ve had an experience For a hospital kind of walk this line that contributes to some of this placement process, especially for longer term treatment, from your perspective of working in these kinds of departments, there’s some of these admin kind of decisions that then end up affecting even some of these clients ability to reliably even have the emergency room be part of their safety plan. Give us a little peek behind the scenes, as far as what you’ve seen is some of these kinds of policy level decisions that affects even just the accessibility of care for people going through situations where they need to end up in the emergency room for psychiatric reasons.
Kesy Yoon 30:44
I wish I could be a fly on the wall and those meetings. In my experience, the first three years I worked in the ER, we worked with an inpatient unit that was opiates as needed, so it was locked. So if a patient did come in on a hold, there was almost an immediate transfer, or at least pending bed placement upstairs. So they had somewhere where they could really be stabilized and treated by psychiatric staff. Somewhere in between that time, I’m not quite sure all i knows there were very many audits, because when your LPs, Department of Mental Health, obviously there, they want to make sure things are running, they want to keep people accountable. But it would be it seemed like a very big burden of responsibility on the psychiatric staff. I felt like it was every quarter there the audited because we were designated. There was that reason, there was also a higher number of patients with admin days when we were locked, because we’re waiting for higher levels of placement. And afterwards, we decided to forego the placement, the LPS designation, and we became a strictly volunteer voluntary psychiatric hospital, we still had beds, but we could no longer take patients that were on 5150 holds unless psychiatrists came to the ER, discharged the hole and then had the patient sign voluntary. And I think that made it it’s hard to say because then at that point that the 5050 patients were either wait, they waited the 72 hours, er, and then they just got discharged with some paperwork, or we transfer them to a locked unit, where I don’t know how long they would stay there. But it did become difficult because it’s almost, it almost feels as though there’s very little you can do at that point. If someone comes in, you either transfer them or you wait, and then you discharge them or they go upstairs, you almost want them to sign voluntarily. But sometimes if they don’t have the cognitive abilities to understand what’s going on, or they’re in such a state where they can’t sign voluntarily, then you’re just either again, waiting it out or waiting to transfer them, which can be difficult.
Katie Vernoy 32:48
So due to the bureaucratic, not, you know, nightmare, as well as it sounds like some of the really hard requirements, this smoother system, have they come into the ER we have a place for them became this weird convoluted, maybe we can take them but right somehow they have to not be eligible for 5150. Right?
Kesy Yoon 33:20
Yes, they can’t be too acute. They have to be acute enough where there’s criteria. So you know, they’re suicidal enough or homicidal enough or psychotic enough, but not so much worse than their video on picking material because then we have to call a pet team from a different hospital,
Katie Vernoy 33:37
or then that’s when they end up like 40 miles away
Kesy Yoon 33:40
not knowing anyone. Yes, yes, exactly. And the hospital pays for those contracts as well. with certain lock it once you’re an unlocked hospital, you can pay for contracts with locked hospitals, so that they will then take your patients, especially the ones that are uninsured, you know, with County Medical.
Katie Vernoy 34:01
Yeah, it just seems like it becomes these silos again, when it was integrated in the hospital when you first started, right?
Curt Widhalm 34:11
This whole reimbursement aspects, like you’re talking about medical or uninsured people, but even for some of the insured people, what are some of the difficulties as far as a program of getting reimbursed, that essentially even contributes to this whole fiasco?
Kesy Yoon 34:30
I think one of the difficulties I experienced in emergency room was the emergency room is technically outpatient. So then to have a psychiatrists, let’s say from the inpatient unit, come in and do a consultation every 24 hours for a 72 hour hold, you know, depending on the psychiatry so it was difficult to get them to come down there because it’s an outpatient service. And I want to say it gets a little confusing with billing and then how do they get reimbursed as an inpatient provider for an hour patient’s service, which is also some of the barriers I experienced when we were in meetings about creating a psychiatric emergency room, because our hospital was in talks about that for a while. But I think again, there was just too much red tape, bureaucracy stuff. And a psychiatric emergency room is the fine line between outpatient and inpatient. Right, because they’re not they’re not they’re getting treated, but they’re not inpatient, or the waiting for a bed. And I think eventually administration didn’t really want to go through with the idea.
Katie Vernoy 35:31
It’s so interesting that er is are considered outpatient when right, especially recently, I’m assuming a lot of people were staying in beds for days. Absolutely, absolutely.
Curt Widhalm 35:43
It’s almost like psychiatric illness shouldn’t be treated entirely like a medical problem. Yeah, I want to go back to this question. You know, since we’re talking about, you know, some of us idealize care, and we asked at the beginning, but even when it comes to the way that administration and reimbursement happens, or is there more that you think needs to go into this idealized care sort of answer?
Kesy Yoon 36:12
I think so. I mean, I don’t, I don’t even know what that would look like, sometimes I have these, you said, these daydreams, or maybe are, what it would look like if we just had psychiatric staff and there wasn’t this revolving door. But it’s such a, it’s a part of a system that needs help, you know, the actual episode with the senator, and then the medical director of gmh was, I was so enlightened. And I was also given so much hope by that episode, because I was thinking, yes, this is like, it needs to be a system thing, the ers part of that system. I don’t know, obviously, it could start with policy, but it’s sometimes I feel like it’s just a smaller part of a much larger problem.
Curt Widhalm 36:50
And so part of the system being that places like the ER, places like the prison, the jails that end up serving as de facto parts of the community care that has lost its funding over the last several decades that proper reimbursement, as I’m hearing, you say it is actually funding some of these community places to take care of people before and after some of these crisis. So that way, they’re not sitting around waiting three days for a placement when there’s no placements that can be found.
Kesy Yoon 37:25
Exactly. I think that’s very true. You know, I don’t have that much experience with either, but even a psychiatric urgent care, there’s not that many. I think the main one I know about is the line of Exodus, or who cares for mental health. And then there’s a new one that was recently built Long Beach, but even having that and they also have their time constraints. Suppose the patients can only stay for 23 hours, I don’t know who came up with that number. And then they get Yeah, or they get transferred. And long before I started in the ER, they told me stories of there was an exodus connected to our emergency room. So they would discharge a patient from the Exodus, urgent care, transfer them on a gurney, basically down the street to our er, and they will kind of just ping pong them around, because they didn’t know what to do with these patients. And so yes, I think proactive care before and then actually having sustainable and viable trend plans after would be immensely helpful.
Katie Vernoy 38:25
Well, I’m also hearing having some way to be comprehensive and how people can do services where the billing isn’t, by the minute, yeah, based on type of service, and I even think the whole issue of inpatient versus outpatient. And can you bill for both services on the same day? Right. Seems like there’s also insurance bureaucracy that needs to be addressed, because people are not doing the best care they can, because they won’t get reimbursed for it. And they’re being incentivized to treat and St. Hmm.
Kesy Yoon 39:03
I agree with that. And I was actually talking to a psychiatrist the other day, what did I ask? I was thinking was asking about, you know, what was his experience like working in the emergency room? And it’s difficult, because I think a lot of them are inpatient. psychiatrists are usually, I don’t know, one group that’s seeing inpatient psych and a detox unit, if they have that, which was the case of my hospital. And so getting someone to come down, just to see a patient out of 50 or 50. It was never fast enough for the ER doctors First of all, and it was difficult for them because, you know, they’re, they’re either going to discharge a patient or they’re going to treat are they going to come every day, the patient’s there, and I think that was difficult, as well.
Katie Vernoy 39:48
It is very patchwork.
Kesy Yoon 39:50
That’s a great way to put it very patchwork. I felt like I was always scrambling to put pieces together and it within a very finite amount of time and everyone was always asking administration was always asking why? Why is the station here for so long? And what are you not doing to either get them upstairs? And it’s, you know, it can be very frustrating.
Katie Vernoy 40:10
I guess the question ties to the reverse, which is, how hopeful did you feel when someone came in with a mental health crisis that they would stabilize, get back to their life? And things would be good going forward? Like how Sure, were you that they were going to get the care that they needed? Honestly,
Kesy Yoon 40:30
I think it would depend on some factors. I think if they came in with a family member, or a friend or roommate who was concerned, and I could tell that they could get connected after I would have, my hope would increase, if they came alone, there are no resources, no family, no social support, then I would almost think, well, there’s a good chance they’re going to be bad. But there’s, there’s some hope in that too, right. Like, I think when I first started working in the emergency room, I was so shocked by how much the ER becomes a part of some patient’s treatment plan. They just know where they know, I don’t know, in the middle of the month, I’m probably gonna have some kind of psychotic breakdown, and I’m going to come to the ER, I think that would affect how much
Katie Vernoy 41:16
What do you see as an ideal for how er services would be working with in relationships, how they fit in the larger mental health system, because it sounds like as a, as a catch all, or sometimes even the first first door, it may be really the wrong match. So how do you think it should fit in to the mental health system?
Kesy Yoon 41:36
You know, ideally, I would, I think the ER should operate, similar to how it should operate for just medical patients, which is for mental health crises and emergencies. Ideally, there would also be things like more psychiatric urgent care centers, where there’s kind of this other level before they get triage as an emergency or a crises. And I think to be great in the ER staff, maybe nurses or whatnot, were cross trained on how to deal with mental health crises and mental health patients, every single er is dealing with mental health, right. And so I understand you don’t need an extensive amount of training, but it’s always divided between the ER staff, and then the site staff that comes in to help and support. So it’s almost like this, oh, the psych nurse will take care of it. And so the ER staff, whatever training, they got nursing school, let’s say, that’s kind of it. So that would be another ideal if there was just more cross training involved, to deal with mental health crises, if that’s what the ER was, in, of course, in my ideal if that’s what was being used for.
James McMahill 42:42
I think, in an in an ideal space, and I always dream about this, whenever I’m at the ER, and I’m really struggling with that tension of freeing up the ER bed, is that I would love to see a mirrored space, a space that is identical in, in every way to the ER, but is staffed with nurses who are trained specifically in mental health that is staffed with psychiatrists, as much as it is PhDs, or medical Doc’s and a place that’s really conducive to that moment of stabilization until you can get someone to a program that will better serve their needs than the ER, because, you know, the ER, fundamentally is about stabilization and about creation of, of safety. And so in particular, when you’re dealing with a psychiatric crisis, a lot of times the moments of sad occurs, the environment in which we’re going and seeing that the rooms for clients that we’re going and doing Christ assessment, it’s a, it is a safe room, you know, quote, unquote, and so it’s a, it’s a bed, and it is four walls, and it’s a locked door. And so, there’s so many incongruencies, to what it is that I’m trying to offer in that moment, which is real human connection, which is true visibility, which is, you know, making sure that that moment, or that person in that moment knows that they’re being heard, and they’re being seen, they’re being treated by someone who has their best interests at heart. And meanwhile, I’m doing it in this hermetically sealed cube. And so, I’d like to see a psychiatric er, that’s where that’s where I would like to be treating the clients when I’m doing the assessment, but
Katie Vernoy 44:22
How would the job for a clinician change in the ER, if this system were, quote unquote, fixed? If people actually were able to that it really was crisis or first door? Not rotten, not revolving door? Not, you know, casual? How would that change? how it feels to be a clinician in the ER?
Kesy Yoon 44:49
That’s I really liked that question. I always have never thought about that. I mean, I in moments, because you’re just there’s so everything is timed. And so you’re just like, Oh my I just have to go out and assess this patient and get them out of here. or have a plan for the doctor because he doesn’t want to deal with it? How would it change? I think there would be more care. I mean, I’ll speak from my own experience. I think when I saw patients who were truly in a mental health crisis, maybe even some of those are revolving door when they would come in, and they were really having a hard time. I think it would just allow for more care, even in that kind of chaotic setting. If we’re the first door, the first, the first learning for these kinds of patients, maybe wouldn’t have to be so chaotic and so hurried, maybe they could feel like this was the right decision they made and it’s safe. For me, that would be one way you could change. But I had to think about that a little bit more in terms of, I guess, I’ve just never thought about what it would be like if we weren’t responsible for just getting them out as soon as possible.
Katie Vernoy 45:55
So now it’s our turn to reflect a little bit on what we heard, close it out. But I was very struck by how similar the perspective was, even though we’ve got folks that are working in two different areas in the country. I think that the desire for a psychiatric emergency room with the training the resources, that person to person connection, that could be possible. I really liked that vision. But I think as as you and I’ve talked about a number of times, it’s huge systemic changes that are going to need to happen for that to really be the case.
Curt Widhalm 46:31
And it’s often with a part of society that gets overlooked as far as being a worthwhile investment. And that’s part of why Katie and I are putting this whole series together is it’s something where looking at one particular space in the system, as it’s being isolated away from everything else doesn’t do it justice, as far as how we look at fitting everything together. In our interviews and some of the stuff that got left on the cutting room floor, especially James was talking about some of the stark differences that he had seen between his work in Southern California and his work in Minnesota. But despite all that, there just seem to be more similarities than not, especially when it comes to where the shortcomings of the system is. And through the remainder of this series and our continued advocacy work of improving mental health in America. I’m hoping that by putting all of this in the context, we’ve got a really good opportunity for some calls to action for some good systemic change.
Katie Vernoy 47:42
So keep listening. We’ve got more episodes that’ll be coming out soon. And by soon it could be in a month or it could be in three months. We’re trying our best to put together really solid interviews so that we’re putting together a nice hole. But if you have ideas to share for our fixing mental health care in the United States series, please let us know.
Curt Widhalm 48:02
Check out our show notes at mcsg podcast calm and for could links to the previous episodes as well as some information on James and Casey and also a welcome to our growing team of Alyssa Davis who helps make some editorial contributions on this episode as well. Till next time, I’m Kurt Woodham Katie Vernoy
Katie Vernoy 48:27
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Curt Widhalm 48:30
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Katie Vernoy 49:20
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