Mental health crisis teams are entering rural areas

Jeff White has been assisted several times in recent years by crisis response teams that serve some rural counties in Iowa. White, who has depression and schizophrenia, can now call a state hotline and request a visit from mental health professionals instead of being admitted to a psychiatric unit or arrested by the police. (KC McGinnis for Kaiser Health News)

NEWTON — Jeff White knows what can happen when 911 dispatchers get a call about someone feeling desperate or agitated.

He experienced it repeatedly: 911 operators dispatched police, who often took him to a hospital or jail. “They don’t know how to deal with people like me,” said White, who struggles with depression and schizophrenia. “They just don’t. They are only guessing.”

In most of these cases, he said, what he really needs is someone to help him calm down and find follow-up care.

That’s now an option for him, thanks to a crisis response team serving his area. Instead of calling 911, he can call a state hotline and request a visit from mental health professionals.

Teams are sent through a program that serves 18 mostly rural counties in central and northern Iowa. White, 55, has received help from the crisis team several times in recent years, even after heart problems forced him to move into a nursing home. The service costs him nothing. The team’s goal is to stabilize people at home, rather than admitting them to an overcrowded psychiatric ward or locking them up for behavior stemming from mental illness.

For years, many cities sent social workers, paramedics, trained field workers or mental health professionals to calls that were previously handled by police officers. Supporters say such programs save money and lives.

But crisis response teams are slower in rural areas, even though mental illness is just as prevalent. That’s partly because those areas are larger and have fewer mental health professionals than cities, said Hannah Wesolowski, chief advocate for the National Alliance on Mental Illness.

“It’s definitely been a tougher hill to climb,” she said.

Melissa Reuland, a researcher at the University of Chicago Health Lab who studies the intersection of law enforcement and mental health, said she doesn’t have hard statistics, but that small police departments and sheriff’s offices seem increasingly open to finding alternatives to the standard response of law enforcement agencies. These could include training employees to better handle crises or seeking help from mental health professionals, she said.

The lack of mental health services will continue to be a barrier in rural areas, she said: “If it was easy, people would fix it.”

Still, the crisis response approach is making its way.

White has lived most of his life in small Iowa towns surrounded by rural areas. He’s glad to see mental health efforts boosted outside of urban areas. “We are being forgotten here – and this is where we need help the most,” he said.

Some crisis teams, like the one helping White, can respond alone, while others work in pairs with police officers or sheriff’s deputies. For example, a program in South Dakota, Virtual Crisis Care, equips law enforcement officers with iPads. Employees can use the tablets to set up video chats between people in crisis and counselors from a telehealth company. It’s not ideal, Wesolowski said, but it’s better than having police or deputies try to handle such situations themselves.

Counselors help people in mental health crises to calm down and then discuss what they need. If it’s safe for them to stay at home, the counselor calls a mental health center, which later contacts the people to see if they’re interested in treatment.

But sometimes counselors determine that people are a danger to themselves or others. If so, counselors recommend officers take them to an emergency room or jail for evaluation.

In the past, deputy sheriffs had to make that decision themselves. They tended to be cautious, moving people out of their homes temporarily to make sure they were safe, said Zach Angerhofer, a deputy in South Dakota’s Roberts County, which has about 10,000 residents.

Detaining people can be traumatic for them and expensive for the authorities. Deputies often have to spend hours filling out paperwork and shuttling people between the emergency room, jail and psychiatric hospitals. This can be especially burdensome during hours when a rural county has few deputies on duty.

The Virtual Crisis Care Program helps avoid this situation. Nearly 80 percent of people who complete the video assessment stay home, according to a recent state survey.

Angerhofer said no one refused to use the telehealth program when he offered it. Unless he sees an immediate safety concern, he offers people privacy by leaving them alone in their home or letting them sit alone in his patrol car while they talk to a counselor. “From what I’ve seen, they’re completely different people after the tablet has been deployed,” he said.

The South Dakota Department of Human Services funded the Virtual Crisis Care Program, which received start-up money and design assistance from the Leona M. and Harry B. Helmsley Charitable Trust. (The Helmsley Charitable Trust also contributes to Kaiser Health News))

In Iowa, the program that helps White always has six pairs of mental health workers on call, said Monica Van Horn, who helps run the state-funded program through the mental health nonprofit Eyerly Ball. They are sent through the state crisis line or the new national 988 mental health crisis line.

In most cases, Eyerly Ball’s crisis teams respond with their own cars, without the police. A low-key approach can benefit customers, especially if they live in small towns where everyone seems to know each other, Van Horn said. “You don’t necessarily want everyone to know about your business – and if a police car shows up outside your house, everyone and their dogs will know about it within an hour,” she said.

Van Horn said the program averages between 90 and 100 calls a month. Callers’ problems often include anxiety or depression, and they are sometimes suicidal. Other people call because children or family members need help.

Alex Leffler is a mobile crisis responder for the Eyerly Ball program. She previously worked as a “behavioral interventionist” in schools, has returned to college and is close to earning a master’s degree in mental health counseling. She said that as a crisis responder, she has met people in homes, workplaces and even at the grocery store. “We respond to almost every location,” she said. “You can just make a better connection in person.”

Thomas Dee, a Stanford University economist and professor of education, said such programs could garner support from across the political spectrum. “Whether one is ‘defunding the police’ or ‘supporting the blue,’ they can find something to like in these types of first-

Dr. Margie Balfour is an associate professor of psychiatry at the University of Arizona and administrator of Connections Health Solutions, an Arizona agency that provides crisis services. She said now is a good time for rural areas to start or improve such services. The federal government is offering more money for the effort, including through pandemic response funding, she said. It also recently launched the 988 crisis line, whose operators can help coordinate such services, she noted.

Balfour said the current national focus on the criminal justice system has drawn more attention to how it responds to people with mental health needs. “There’s still a lot to disagree about with police reform,” she said. “But one thing everyone agrees on is that law enforcement doesn’t need to be the default first response to mental health.”

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