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Designated crisis responders, a 'last resort' in mental health care, face overwhelming demand

Seattle Times - 8/11/2022

Aug. 11—In a mental health crisis, police officers or EMTs may be the first to a scene.

They're not, however, tasked with evaluating whether the person in crisis must be involuntarily detained for treatment. That daunting decision is the responsibility of the designated crisis responder, a straightforward title for a complicated role.

"I think a lot of times people don't know [who we are] and so they'll call and ask for a DCR, not really understanding what they're asking for," said Justina Nieciag, a licensed clinical social worker and a designated crisis responder in Lacey, overseeing crisis calls in Thurston and Mason counties.

"We'll go on and explain a little bit about involuntary commitment. I'll find a lot of times that's not really what they wanted," she said. "They just want help for their loved one. They don't want to scoop them up into a mental hospital."

Designated crisis responders are a unique key in Washington state's crisis mental health system. The Involuntary Treatment Act designed in the 1970s appoints them as the gatekeepers who can detain people in mental health emergencies — if they're a danger to themselves, others or property, or are gravely disabled and can't care for themselves — but it also means that without them, people who could benefit from therapy and medication may forgo it until their condition gets severe enough to qualify for involuntary treatment.

It's a high but necessary bar, say civil rights advocates. A person has the right to refuse treatment, and involuntary detention can be a traumatic experience itself, compounding what's already a vulnerable moment.

DCRs are also facing enormous backlogs that have worsened during the COVID-19 pandemic. They are tasked with responding to jails and hospitals first, and getting one to come out to a home or other location in the community can take a long time: In King County, recent wait times averaged more than 11 days.

"That's not something that any of us want to do ... when we have to tell a family, 'We're almost there, but we're not there yet,' " said Frank Couch, the involuntary commitment act coordinator with the King County Behavioral Health and Recovery Division.

A DCR's role

Designated crisis responders are clinicians, typically social workers or counselors with a master's degrees and field experience.

They undergo additional training before becoming DCRs and work within their county to provide evaluations to people in crisis. There are around 350 to 375 DCRs in the state — though, like in many behavioral health professions, there's a shortage of workers, and not all of them work full time.

DCRs do not provide therapy. Rather, they kick-start the civil process of involuntary treatment or search for an alternative setting.

They will interview friends and family of the person in crisis, attend court proceedings when necessary, and help find a proper placement at an evaluation and treatment center or a secure withdrawal management facility. If the person has other comorbidities like autism or substance use, it may be harder to find an appropriate bed.

"DCRs are really the last resort — should be — a last resort when trying to do crisis management," said Joe Avalos, the chief operating officer of the Thurston-Mason Behavioral Health Administrative Service Organization, overseeing around a dozen DCRs in Thurston and Mason counties.

"[Committing someone is] not an easy decision. It's not a decision that any DCR wants to make lightly."

Involuntary treatment

Law enforcement, hospital workers and jail staff can get in touch with DCRs through a phone line specifically for professionals if they believe a patient meets the threshold for commitment.

Current Washington law requires DCRs to prioritize calls from hospitals, stating they must respond within 6 to 12 hours after an adult has been medically evaluated and cleared, depending on how they arrived (for example, voluntarily as opposed to brought in by law enforcement). Calls from jails are also prioritized so that a DCR can meet a person upon release and potentially get them into treatment, disrupting the revolving door of untreated mental illness and incarceration.

People can initially spend up to five days in forced treatment, and an additional 14 days with a judge's court order, with further extensions if needed.

Family and community members call through a separate, public line. (In King County, Crisis and Commitment Services can be reached at 206-263-9200.) Due to the laws governing response times, though, DCRs can't respond to all the calls from the public as quickly as they want, said Couch, with King County.

"We're triaging all day, every day," he said. "For timelines and we're triaging for severity."

On any given day of the week, Couch says their call list is about 100 people long.

For people in the community with a loved one in crisis, it can mean waiting for several days, even as their condition worsens. As of December, DCRs in King County took an average of 262.8 hours to respond to community calls, or about 11 days, according to local county reports.

This has to do in part with staffing shortages, and a deluge of other challenges including the pandemic; the effects of HB 1310, which curtailed law enforcement's response to crisis calls; and general burnout and career recalibration, causing backlogs even as more people sought out mental health services. Before 2020, wait times averaged closer to five days for community members who reached out to DCRs.

Jessica Shook, president of the Washington Association of Designated Crisis Responders gives the following example of the type of scenarios DCRs often face: "I've got a woman in her living room who's depressed and telling her family she wants to die. Then I've got a guy in his living room who keeps trying to run out in the street, and his family is trying to keep him in the living room and keep him safe. And then I've got three people in the ER. Who am I going to go see first?"

Shook said the best choice would be to tend to the man running in the street, but DCRs "don't always have the bandwidth and the ability to triage the way that we want." The law would typically require them to prioritize the hospital instead, especially if a patient has been waiting overnight.

A delicate balance

The continuum of mental health crisis care is like a stool with four legs, Avalos and Nieciag with Thurston-Mason Behavioral Health Administrative Service Organization said. DCRs provide the initial evaluation, EMTs or law enforcement provide the safe transport of patients, hospitals provide medical clearance, and treatment and detox facilities provide beds and services.

Together, when each part independently works, they provide care for people in crisis. If any of those legs breaks, however, the stool doesn't hold, leaving people without full access to care. Each leg needs to be strong.

In some places, DCRs are trying different partnerships and approaches to improve relationships within the system.

In Thurston County, for example, DCRs ride along with the Olympia Police Department. Similar to other co-responder models, it allows trained mental health professionals — not armed police — to provide the therapeutic component of listening and connecting people to resources when responding to calls. Likewise, social workers armed only with clipboards can then enter residences more safely.

"If you want to have a crisis system that can respond to anything that people call in about then you've got to be flexible," said Shook, referencing peer navigator models and co-responder programs.

She's also heard of collaborations in which DCRs sit in on 911 calls and help dispatchers triage and work through calls that are related to mental or emotional crises.

In recent years, adjustments to the involuntary treatment process have been made. Ricky's Law, for example, allows the civil commitment process to start for people in crisis due to drug and alcohol use, not just mental illness. Joel's Law, passed in 2015, allows for immediate family members to petition the court for involuntary treatment if a DCR's assessment did not find the person in crisis to meet the threshold for detention. Similarly, family-initiated treatment allows parents to get help for their children with mental and behavioral health challenges.

Still, it's a lot of connecting the dots between different systems for people not already familiar with the laws.

"It's so hard," Nieciag admitted. "Nobody understands how this whole process works."


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