Crisis Care Centers vs ERs

The first time Mike became psychotic, I drove him to a hospital emergency room. We didn’t know any psychiatrists and Mike needed immediate help. Taking him there turned out to be a mistake.

Emergency rooms are where everyone goes nowadays whenever they have any kind of health-related crisis, but many are poorly equipped to deal with psychiatric patients in the midst of  a mental break.  

Some patients are turned away, as Mike and I were, without getting help. Or a patient might be held down and given a shot of Haldol or another strong anti-psychotic  that will help stabilize him but also can turn him into a walking zombie for days.

How a person is treated when they have their first major breakdown is important. If the first time you went to see a dentist, he pulled one of your teeth without giving you novocaine, how eager would you be to ask him for help the next time you had a toothache? The same is true about a mental breakdown.

This is why many progressive communities are shifting the focus from emergency rooms to crisis clinics specifically designed to help people who are experiencing some sort of behavioral or emotional breakdown.

Jewel Denne directs a clinic for  re:solve Crisis Network in Pittsburgh, which is part of the University of Pittsburgh Medical Center,  and last weekend she explained to an enthusiastic audience attending  a conference hosted by the  Southwestern Pennsylvania chapter of the National Alliance on Mental  Illness how her clinic operates.

The first step the clinic’s planners took was talking to persons with mental illnesses and their families. They asked them what sort of services might be needed in the clinic and what was the most effective way to offer those services to persons in need. The clinic’s directors asked them to describe good and bad experiences that they’d had. They even asked for ideas about how the building should be designed, down to what color the walls should be painted.

Asking families and consumers (persons with mental illnesses) for their opinions may sound like an insignificant thing,  but it isn’t. One of the biggest myths about mental illnesses is that persons,  who are sick, are psychotic all of the time and therefore can’t be trusted to know what’s good for them.  This attitude dates back to days when a patient had no voice in how he/she was treated. 

Who better to ask than someone who has been through treatment and their family members about what works and doesn’t?  All to often, family members are cut out of the process or seen as enemies.

Because of the input of family members and consumers, the center ended-up looking like a neighborhood Starbucks rather than a hospital.

Denne said her clinic receives an average of 8,000 calls a month and 770 walk-ins seeking help.  The clinic has medical personnel on duty but its primary job is plugging people into the right services that they need to recover.  The clinic also operates  a mobile crisis team that goes anywhere in Pittsburgh to evaluate someone who is having a crisis. It doesn’t matter if they are in their home, a park, or on a street corner.

The mobile crisis team performs about  800 evaluations per month and in  85% of those cases, it is able to help the person without admitting them into a hospital.

Open 24 hours per day with a staff of 130, the crisis center’s credo is “engagement is the key.”   Denne explained that her counselors try to develop a trusting relationship with clients. When that happens, the chances of getting someone to agree to treatment and comply with medication and other services greatly improves.

Peer-to-peer specialists are a crucial part of the center’s staff. Pennsyslvania  has become a leader in training and hiring peer-to-peer specialists and now boasts more of them on the payroll than in any other state.

 A peer-to-peer specialist is someone who has a mental illness and is now stable.  The idea of having a person with a mental illness help another person with a mental illness was met with much skepticism at first. But the impact it has had in Pennsylvania is phenomenal, according to Joan Erney, the state’s outgoing deputy secretary for Mental Health and Substance Abuse.

Peer support is not much different from having someone who is a recoverying drug user or alcoholic help another addict. Someone who has been down the same road is a better guide than someone who hasn’t.

More than a year ago, I visited a similar crisis clinic in San Antonio, Texas, and was impressed not only with the emergency services that it provided but with its cost effectiveness. An audit showed the city was saving significant sums by using its drop off center rather than emergency rooms.

Of course, if a person is psychotic and doesn’t believe he is  sick, the job of helping him becomes much, much more difficult. This is why a few of the persons who come to the clinic end up in a hospital involuntarily.

In a twist, Denne said that the 911 operators in Pittsburgh often referred calls to the clinic.  She also said that calls to the center came in many different forms.  One caller said he was in crisis because he couldn’t get dog food for his pet. When Denne’s workers investigated,  they discovered that the caller had schizophrenia and not only was out of food for his pet, but also had no food for himself.

Crisis centers are gaining in popularity, especially with family members. Too many of us have needed help only to have the police arrive and watch as someone we love is handcuffed and driven away to an emergency room.


I was attending the 10th Annual Education Conference in Pittsburgh to participate in a Minds on the Edge panel discussion. The audience was shown a brief clip from the show and then the panel discussed that segment. It was fascinating to me because most of the other panel members lived in Pennsylvania so I got to hear what is happening in their communities.

When I mentioned Psychiatric Advance Directives (see last Friday’s blog), Dr. Suzanne Vogel-Scibilia began whispering in my ear. A well-known and highly respected NAMI leader, she is a medical doctor and a person with a mental illness. 

I told her that three people had commented on my blog and had claimed that PADs were not effective. The problem, they said, was that a person who was psychotic could change their mind about their PAD when they got to a hospital simply by declaring that they no longer wanted the PAD to be enforced.

Dr. Vogel-Scibilia said that wasn’t true if the PAD had a “Ulysses clause.”

Here is how Ron Honberg, the national director of policy and  legal affairs at NAMI, describes this important clause:

It has been suggested that the insertion of a so-called “Ulysses clause” in an advance directive could effectively avoid this dilemma. This name originated from the mythical Greek hero, Ulysses, who knew that the lure of the beautiful Sirens was so powerful that he would be compelled to sail his ship towards the rocks they were sitting on, thereby destroying it. To prevent this, he ordered his subordinates to bind him to the mast of the ship and to keep the ship sailing straight, no matter how strongly he argued to the contrary.

 A Ulysses clause in an advance directive instructs treatment providers about specific treatment preferences, and explains that any statements made refusing treatment during periods of incapacity should be ignored.

If you are going to get a PAD, I would strongly suggest that it includes a Ulysses clause, otherwise you may find yourself with a useless piece of paper during an emergency.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.


  1. As always, very useful information. Thank you. How are the peer supports at Resolve Crisis Network funded? We are very interested in best practices across the country and what Resolve is doing sounds outstanding. Funding tends to be the key, though, to making these services available.

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  4. Excellent advice in closing yet another dangerous loophole.  Also, I thought under the law, people who were mentally incapacitated could not sign a legal document, and if so, why would they have the right to change a legal document orally, during a period of questionable functioning?