Crisis Response Services in the Community

What:

Crisis is often defined as "the experiencing of ... a situation as an intolerable difficulty ... that exceeds the person’s current resources and coping mechanisms (1).” It “ ... usually refers to a person’s feelings of fear, shock, and distress about the disruption, not the disruption itself (2)”.

Individuals with developmental disabilities often communicate feelings that overwhelm them through “challenging behaviors” which often lead to inappropriate and costly stays in more restrictive settings (psychiatric hospitals, jail, or mental health institutions). However, “crisis” in the context of developmental disabilities services, also refers to the caregiver’s perception that an individual’s needs and challenges exceed the caregiver’s capacity to keep the individual safe.

In a medical (and more traditional mental health) model, psychiatric hospitalizations are one of the more common responses to crisis; the goal of a short term hospitalization is the stabilization of acute symptoms (through medication adjustments) in a safe and therapeutic environment. Safety refers to both the actual quality of the environment (supervision, locked doors, etc.) but also to the patient's perception/sense of feeling safe in that environment (respite effect).

Why:

Although hospitalization can be very helpful to many individuals, it can be problematic for people with developmental disabilities:

• hospital staff might have difficulties relating to individuals with DD and their unique communication strategies
• therapeutic resources cannot easily be adapted and individualized to accommodate the learning styles of individuals with DD
• individuals with DD might not be able to transfer acquired coping skills to their home environment
• the hospital routine can be disruptive for individuals who are accustomed to a rigid, very personalized routine
• individuals with DD are more at risk to be taken advantage of by other patients and are more likely to copy unsafe coping techniques from other patients
• hospitalizations can be expensive
• hospitalizations often require the individuals to give up some control (requires Dr’s permission to leave).

How:

A community-based Crisis Response system for individuals with DD strives to provide an alternative to hospitalizations. It should be:

• proactive in nature (no division between pro-active and reactive supports) and part of an ongoing outreach effort to train and prepare direct care providers for crisis intervention
• individualized and person-specific (the crisis team needs to have a thorough knowledge of the person they are serving; relationships are the key!)
• positive (anchored in the principles of Positive Behavior Support)
• consumer directed: the individual and/or his/her guardian participates in the team process and directs the development of his/her crisis plan
• easy to access at all times
• free of charge to the consumers and guardians
• work well with existing service providers.

It should offer the following service components:

• consultation on positive behavior supports and clients rights issues (restrictive measures)
• consultation on environmental adaptations & more intensive supports/interventions
• assistance in navigating emergency mental health services (emergency detentions) and coordinating interventions with the criminal justice system
• assistance with health care coordination
• access to community-based therapeutic resources and emergency psychiatry
• access to well trained additional support staff who can assist in the assessment process, provide situational counseling, provide respite and guidance to direct care staff and support the person where he/she lives/works, or plays
• short term respite in a safe, neutral environment that is modified to accommodate behavior challenges
• follow-up consultation to prevent future crises.

A functioning crisis response system will creatively and flexibly (it’s more of an art than a science) piece together additional supports on a temporary basis. It should not be considered as a permanent placement option – especially in times of dwindling public funding, but can be a cost-effective alternative to an inappropriate and lengthy institutionalization. At best, it can help individuals and their support teams to buy time, get some breathing room and hopefully contribute some ideas and instill confidence how to tweak existing supports for the better.

Crisis interventions are highly individualized: One size does not fit all. Just as individuals are different, communities are different and a model that works in one urban setting might not work at all in a rural setting, or even another urban setting. Although the key elements of crisis response might be very similar, they might be organized in very different ways. Successful Crisis Response programs draw from the strength of existing providers and try to expand capacity starting with the resources available.

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(1) James, R. & Gilliland, B. (2005). Crisis Intervention Strategies. Belmont, CA: Thomson Brooks/Cole, p. 3.
(2) Brammer, L. M. (1985). The helping relationship: Process and skills (3rd ed.). Upper Saddle River, NJ: Prentice Hall, p.95. Cited in James, R. & Gilliland, B. (2005). Crisis Intervention Strategies. Belmont, CA: Thomson Brooks/Cole, p. 3.