August 24, 2020

A Co-Response Model That Works: An Interview with Michelle Muething, Executive Director of the Hope Center, on Clinicians and Law Enforcement Responding to Mental Health Crises

By Fred Bernard, MA

One of the many issues raised in the outcry following the killing of George Floyd has been that the social response to mental health crises, including suicidal ideation and behavior, is often to default to calling the police. In a popular segment on the Floyd protests from Last Week Tonight with John Oliver, Oliver plays a clip of a former Dallas police chief lamenting, “We’re asking cops to do too much in this country. Every societal failure, we put it off on the cops to solve. Not enough mental health funding. Let the cop handle it.” Such a state of affairs, Oliver argued, is the result of the police being “essentially the only public resource in some communities.” Commentators have previously pointed to the 2014 police shooting of Christian Sierra, a suicidal teenager, and other incidents of ‘suicide-by-cop’ as indicating a need to apply psychologically-informed de-escalation responses as an alternative to police force. An increased role for mental health practitioners in responding to personal crises has been proposed as part of an overall national conversation about altering the scope of police activity.

In the interview that follows, Michelle Muething, LPC, provides one concrete example of what such an increased role for mental health practitioners might look like. Muething is the Executive Director and a founding member of the Hope Center, a nonprofit organization that provides mental health services in the Aspen/Roaring Fork Valley and Eagle River Valleys of Colorado. Focusing primarily on individuals in crisis, the Hope Center dispatches mobile-crisis units of clinicians to the locations of people in distress, links them with community resources once the crisis is stabilized, and bases clinicians in area schools and first-response programs to allow for immediate intervention. The Center’s co-response program, in which clinicians meet police at crisis scenes and provide assistance when mental health issues are thought to play a role, exemplifies this willingness to work within and alongside the community and to go where help is needed.

Crisis clinicians in the co-response program are a specialized group of mental health workers whose particular duties include crisis assessment and stabilization, grief counseling, and helping mentally distressed individuals and their families access resources once the crisis ends. Muething, who worked as a clinician alongside police in Indianapolis prior to her time at the Hope Center, emphasizes that the role of the co-response clinician complements the role of police officers, rather than eliminating the need for the police outright. Law enforcement, she insists, creates the security that is the foundation for any clinical work, a position she holds based on her own considerable first-hand experience. However, once co-response clinicians have ensured the safety of a situation, they have been able to dismiss police officers from the scene and allow them to return to patrol, an arrangement welcomed by law enforcement. The outcomes of this program, according to Muething, are more humane and less expensive for mentally distressed people than those of the default 911 response, which often include escalating situations with overwhelmed first responders or exorbitant medical bills for time spent in hospital emergency rooms. 

Below, Muething and the James Kirk Bernard Foundation discuss how the co-response program works, the relationship between the police and co-response clinicians, and how this might serve as a model for other communities. This interview has been edited for length and clarity, and is presented as a two-part series. 

Co-Response, Part I

JAMES KIRK BERNARD FOUNDATION: Could you describe the Hope Center’s co-response program? How does it work? 

MICHELLE MUETHING: When we opened the Hope Center, our goal was to respond to the community. We didn’t start with a law enforcement response goal, but it happened very, very quickly.

When we got one of our first calls, I showed up on scene with law enforcement, and I learned very quickly how little they knew about mental health. Coming from a program where I worked very closely with the first responders, it kind of became a personal passion of mine to work with law enforcement out here. I started doing a lot of education with law enforcement. Then we started getting more and more phone calls from them. Even if they weren’t sure how we could help, our answer was, “You know what? Let us just show up and figure out what’s happening.” We would just show up and help out.

Over the years (in the United States), law enforcement has become our default mental health clinicians. People get into a crisis, they dial 911, and a badge and a vest show up with lights on a car. Very often it’s not needed. An officer knows enough to know that they don’t know how to deal with mental health issues. So what has happened over the years is they would show up on scene, and they would just put someone in a car and take them to an emergency room for an assessment. Across the country, law enforcement officers were becoming taxicabs. They were just driving psych patients to an emergency room.

That holds a lot of liability for law enforcement. Technically, law enforcement is not allowed to put people in their car if they are not charged with a crime and under arrest. Many of them stopped doing it and would call an ambulance and have an ambulance transport patients. But then you get a medical bill from an ambulance service. Someone who is depressed and staring at a bottle of pills ends up with a $5,000 bill, all because they needed to see a counselor.

Our whole theory was: keep people out of the emergency rooms and return police officers back to patrol by having mental health show up so that law enforcement doesn’t have to be the mental health provider.

We started doing that over here, and it grew to the point where people started talking about what we were doing on a regional level. We were brought to Eagle County by the first responders and immediately started our co-response program. We get called by dispatch, we get called by officers, we get called by medics. Whenever someone shows up on scene and realizes ‘This is an emotional or a behavioral health issue,’ they call us. We either travel with them or we go to the scene where they are.

Do you think that the training that the crisis clinicians have, which helps them to talk to people with mental health problems or who are in distress, prevents an escalation of incidents that can often come with police/civilian interactions?

Very much so. 

The crisis clinicians at the Hope Center go through a 90-day kind of boot camp, what we call a “crisis training academy.” You’re not a therapist in an office simply moving your practice to someone’s home. Crisis work is not about doing therapy in any way, shape, or form. Crisis clinicians are investigators; they’re advocates. They are protectors. They’re grief counselors. We kind of consider ourselves the ER of mental health.

We show up and assess: what is the crisis? We talk to families, friends, officers, neighbors, coworkers, whoever we can talk to, asking them “What did you see when you showed up?” Once we know kind of the core of what’s happening, we get an idea of how to stabilize that person in the moment so that they don’t need to be hospitalized. Our goal is to keep people out of inpatient facilities. I call it “the duck in the mud puddle.” Sometimes your life gets so stressful that it’s like sitting in a mud puddle. You can take the duck out of the mud puddle and put him in a psych facility, and all you do is wash the mud off the duck and send it right back to the mud puddle.

Case in point: we had a woman many years ago who overdosed on a bottle of Prozac. She ended up in the emergency room, and the physician said she needed to be in the hospital. We said, “Why?” He said, “Well, she overdosed on Prozac. Clearly, she’s suicidal.” We said, “No. She was desperate and angry.” She had realized, “I’m about to be a single parent. I’ve got a kid in trouble. I’ve got a kid being bullied. My husband is leaving me. I’m never going to be able to keep my job the way I want it.” And in a moment of desperation she downed a bottle of Prozac. Did it kill her? Absolutely not. What does three days in a psych facility do for someone in that state of mind? Nothing. It just helps them incur a $16,000 bill that they now add to their already muddy life. Instead, we sent her home and we got therapy for her six year old. We got therapy for her 13 year old. We helped find her an attorney to be able to get through her divorce.

One of the things that we do is try to get a hold of as many people in your natural support system as possible to help surround you. Kind of like what you would do in an intervention. When people are in a really dark place or a state of crisis, they think they’re all alone, despite the fact that there are people everywhere. We pull all those people in. Aside from just depression and suicide, we’ve had people who come to us who are experiencing their first psychotic break, and their family is not sure what’s happening. If we can wrap those people with loved ones to be around them, we can get them medication and get them stable.

We have individuals who have a long time history of psychosis. We had a gentleman who came in and had a long history of being in and out of the hospital, long history of medication, his family knew what to do. But the go-to was always, “Oh, he’s psychotic. Throw him in the hospital.” We said to him, “If we were able to get you medication today, would someone be able to be with you for 48 hours to see that the medication starts to work?” We had someone prescribe medication, and the individual went home with his family. When he woke up he was less psychotic, took more medication, came back in, saw us, went back home with family, and we were able to help them avoid a $15,000 psychiatric bill by being able to keep him at home.

 

Another story: we showed up on scene with law enforcement with a guy who had a shotgun to his head. Law enforcement said, “We’ll place him on an M1* and hospitalize him.” We said, “Let’s not jump to that conclusion. Let’s sit and talk to him.” We took the shotgun away from him, cleared his house of weapons, and the clinician sat there for several hours trying to figure out why he wanted to end his life. At the end of it all, we walked out and told law enforcement, “He has a friend that’s showing up. We’re going to stay and he’s going to stay here.” Everybody was shocked that we weren’t going to put him in a facility. There is no, “If this, then that” formula for a Hope Center clinician, because every person’s life is different and all the variables in your life are different. That was eight years ago. This guy today is doing wonderfully.  

*
Under Colorado law, to “place on an M1” means to determine that an individual should be involuntarily committed to a hospital due to imminent risk to himself or others.

This is hypothetical, but what do you think might have happened in the cases you mentioned if the co-response program wasn’t available and the default response by the police or ambulance services occurred?

In recent years, we know that we have shown up on scene and have been able to say to law enforcement, “Stop. I realize they’re being argumentative, but something’s not right. Give me just a second.”

The clinicians at the Hope Center are not afraid to stand in someone’s way who’s being difficult. There are individuals who are psychotic or manic, and they’ll get in your face. They are not thinking clearly. They are not in the same reality that we are. Very often, they will lash out or act in a manner that puts them in the way of potentially being tasered or arrested, handcuffed. One of the things we really talk about a lot in our program is having a medic there on scene. If someone does get out of control, it is necessary to subdue them for everyone’s safety, including the person’s safety. But if there is a way to do chemical restraints and give them an injection to keep them from having to be tasered or thrown to the ground and handcuffed, that’s the route we want to go. It’s more humane to give them an injection than it is to put them in handcuffs.

We had a guy who was psychotic many moons ago. I was told when I got the phone call (about him) that he was talking about demons, and he was covered in dried paint. When I showed up in the emergency room to talk to him, he was talking about God and Satan battling for his soul and that Satan killed his dogs. The more I listened to him, the more I looked at him, I thought, “I don’t think this is dried paint on him. I think it’s dried blood.” I called the sheriff’s department and I said, “I need you to go to the residence and make sure everything is okay.”  Sure enough, law enforcement showed up at his house, and this guy had stabbed both of his dogs to death. He ended up having criminal charges put on him. One of the things we did was try to advocate for the fact that this truly was not his fault. He wasn’t a criminal. He was a psychiatric patient. He needed court-ordered medication and treatment.

Law enforcement is starting to really learn the difference. We do so much education with them.

How do the police departments feel about the co-response program?

They love it. If you talk to some of the police departments we work with, the first thing they’ll say is, “Oh my God. When you show up, I can take a backseat. I don’t need to solve a problem anymore.” I think that’s the thing we have to all understand is law enforcement officers are trained to protect; they’re trained to enforce laws. When it comes to mental health, law enforcement defaults to dropping people in an emergency room or walking away because they don’t know what to do. With a co-responder program, they don’t have to do that. They can go back to “Scan my environment, keep everybody safe, do my job, because someone else is here to do the mental health job.”

In Co-Response, Part II we will talk with Michelle about the opportunities of this approach for other communities, and why she believes pairing, not replacing, is important to serving the needs of the public.

Fred Bernard is a board member of the James Kirk Bernard Foundation and clinical psychology doctoral student at The Chicago School of Professional Psychology. He has a Master’s Degree in Psychology from The New School for Social Research.