Brandan Gilliam’s repeatedly failed attempts to get help for his bipolar disorder expose the gaping holes in Maine’s mental health system. Chief among them are a shortage of hospital beds for psychiatric patients and a time-consuming process for securing one for an individual in crisis.
Anyone who has experienced a mental health crisis, and those who love them, know this process all too well. But for those who don’t, Alyssa Russell, crisis program manager at Crisis & Counseling Centers, walks through the steps. Her organization serves Somerset and Kennebec counties, and while not all crisis services groups follow the same protocols, this is generally what the process looks like:
1. The goal is always to meet the person “in the community,” as opposed to a hospital emergency department. That can mean at their house, a park, a police station, a doctor’s office, or even a coffee shop with a confidential place to talk, she said. From there, mental health workers can connect the person with outpatient programs, referrals and other help — but only if they’re stable enough.
2. If the individual poses a danger to themselves or others, there’s no avoiding the ER, she said. That’s because all adult patients who need to be admitted to a hospital for psychiatric treatment must be medically cleared first. The requirement is designed to prevent patients with additional medical problems — untreated diabetes, for example — from winding up in psychiatric units ill equipped to treat those issues. It’s particularly important for psychiatric facilities that aren’t attached to hospitals, such as Spring Harbor Hospital in Westbrook or Acadia Hospital in Bangor. But it means that people in crisis without any physical health problems get funneled through emergency rooms.
3. In other cases, patients arrive at the ER with a medical problem, but staff then discover they’re facing a mental health crisis. During triage, patients are asked if they’re depressed or suicidal. If they say yes, a crisis worker is called. That person could work for an organization such as Russell’s or be employed by the hospital.
4. A crisis assessment is performed. It can take a couple of hours, as a mental health worker informs the clients of their rights and reviews their risk factors, such as suicidal thoughts, psychosis, or self-harming behaviors. If it’s during the business day, the crisis worker reaches out to people who know the person’s history and circumstances, including psychiatrists, primary care doctors, case managers, police, friends and family.
5. If the person needs to be admitted based on the findings of the assessment, the crisis worker starts calling around to hospitals. The goal is to find a placement as quickly as possible close to the person’s home, so the worker usually begins with the closest hospital. But they might try a particular facility if the individual has a specialized need. Spring Harbor, for example, is well equipped to treat children with developmental disabilities.
6. Hospital psychiatric beds might be full. Maine has only about 270 psychiatric beds statewide, and that’s often not enough to meet the need. In that case, the crisis worker starts branching out, sometimes resorting to sending a patient hundreds of miles away to, say, Fort Kent, if it’s the only facility with an open bed.
7. When no beds are available, the individual waits in the ER. If it’s a child, the crisis worker might get special permission to try hospitals as far away as Vermont. Otherwise they try to check on the client every 24 hours and keep calling around to hospitals in hopes of finding an opening. The patient can stay in the ER “until their needs are met,” Russell said. That can mean several days or even a week. Sometimes patients get fed up and leave. Unless they meet the criteria to be held at the hospital involuntarily — they’re a danger to themselves or others or can’t care for themselves — they’re free to go. Other times, the patient stabilizes, such as with a medication change, and the crisis worker can connect them with help outside the hospital.
8. If a psychiatric bed is found, the crisis worker presents the person’s case to the hospital. They inform the hospital of everything they learned from the crisis assessment. The psychiatrist on call then reviews the information to determine if the person meets their criteria to be admitted.
9. The hospital either accepts the patient, denies them, or defers them. The hospital might defer if their psychiatric beds are full but they anticipate an opening soon, or they’re short staffed that night, or they have an open bed but can’t fill it because another patient in the same room has a contagious condition, such as an infection. The crisis worker will follow up to be sure the client is assigned to the bed as soon as it becomes available.
Russell knows this process can be frustrating for patients in crisis and their families. It’s often not as timely as anyone would like, but crisis services groups do the best they can with the resources available, she said. “It may not happen as quickly as they expect. We tell them to brace for that, but know that we’ll do our best to help,” she said.
