The tragic street spectacle of a fellow District resident talking to himself—a visual shorthand for unaddressed serious mental illness—would not look strange to Tyreese R. McAllister, a licensed professional counselor and a 27-year veteran of emergency mental health work in the D.C. area. “I see it on a regular basis,” she says.
No one is immune to issues of mental illness, which cut across race, gender, income, and social status, she says. Stigma makes it hard for people who need help to get treatment, and easy for society to react with a shrug to human suffering.
Since 2017, McAllister has directed mobile crisis services and the homeless outreach program within the Department of Behavioral Health’s Comprehensive Psychiatric Emergency Program, overseeing approximately 23 DBH employees.
When people who could be diagnosed with mental illness are out on the streets, other people “drive by, walk by, see them, and think that they’re a lost cause. And they’re not,” says Michael L. Young, a peer specialist at CPEP and a Marine Corps veteran who went undiagnosed for 20 years. “They’re just going through something at that point. And if they could get the help that they need, you would see that there is a marked difference in what could go on.”
Enter CPEP as one crucial option in the District’s mental-health system of care. The CPEP operation is housed in Building 14 on the DC General campus in the Hill East neighborhood. While patients can walk into the building 24/7 to receive emergency services and/or observation beds for people 18 and older, the mobile crisis services unit opens at 9 a.m. and takes its last call at 1 a.m.
A phone call to the CPEP crisis line activates mobile crisis services—teams of two workers who drive a vehicle to an adult who is experiencing a psychiatric crisis and is unable or unwilling to travel for treatment. A crisis can mean being in trouble with the law, injuring yourself, developing a plan to take your own life, or considering hurting others.
Most people with mental-health needs lead their everyday lives and go about their daily business in D.C. But CPEP is crisis-based. It’s for people who, through no fault of their own, are in the grip of a medical nightmare, trying to survive a terrible time in their life.
McAllister says her team visits some people whose homes are in disarray. Or they may not have bathed in a year because they’re street-bound. They may have gangrene that smells awful, lice, or bedbugs hopping all around.
“This is not a job that everyone can do. This is not a job everyone should do,” she says. “You may have a heart. You may feel bad that people live like this. But to be able to work with them is a whole different skill set. It’s not even a skill. It’s a level of compassion that not everyone can reach in themselves.”
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Rachelle Ellison, who lives in D.C., says that someone called the CPEP crisis line on her behalf back in 2002.
“I had substance abuse and mental-health issues that were unaddressed at that point. I was in a psychotic state. I was pretty much having a mental breakdown. And someone called because I would just—I wouldn’t respond,” she says. “When the police came, I wouldn’t respond to their commands. And the police called CPEP.”
A team arrived, and took her to the CPEP building for emergency psychiatric services. After that, the only thing Ellison can remember “is them holding me down,” she says, “to put the Haldol shot in me.”
When she “came to,” she was calm. “Everyone was very professional, very friendly,” she recalls. Once she was stabilized, they let her go.
She says now, “That service is in place for clients who have situations just like mine, who can’t mentally function in the city or on the streets, or who become so overwhelmed that they may need to go to CPEP not to be a danger to themselves or others in society.”
Ellison is now in recovery, soon to celebrate her fifth year clean and sober. She is a DBH-certified peer specialist trained to assist others in recovery and wellness, and a speaker and advocate for the National Coalition for the Homeless.
Is this hard to talk about?
“Actually, no, it’s not,” Ellison says. “Department of Behavioral Health is a big part of the reason I’ve grown so much, and I’ve been able to elevate, and I’m very grateful.”
***
DBH is not without its troubles. This year, DBH has unwittingly found itself in the spotlight.
In February, a sweeping report by the D.C. Auditor and the Council for Court Excellence, a nonpartisan organization that works toward an equitable criminal justice system in D.C., lambasted DBH for its handling of people with possible mental illness in the criminal justice system; among the vast array of issues were timely evaluations of defendants and insufficient treatment and resources such as housing. In August, attorneys filed a class action suit against the D.C. government, alleging that its failure to provide adequate outpatient treatment to children led to damaging, repeated institutionalizations. On Nov. 30, former DBH Director Tanya Royster was ousted as Mayor Muriel Bowser announced that LaQuandra S. Nesbitt, Director of the Department of Health, would also serve as Interim Director of DBH.
Lawsuits and oversight by the federal court and the U.S. Department of Justice have shaped D.C.’s behavioral health system, the CCE wrote in the report’s introduction. “The District’s public mental health agency has spent more years under federal oversight than not, with the most recent case concluding in 2014.”
Drill down to the moment of someone in crisis, though, and you have a person in need and workers devoting their days to helping. The auditor’s report acknowledged: “While we found that much of its staff are passionate about their work and are dedicated to improving the agency’s operations, we also found that DBH has much room for improvement.” CPEP is one section within one of the five administrations that compose DBH, and was not the focus of the report.
***
In Building 14, CPEP’s mobile crisis unit works out of a bright room painted robin’s egg blue that’s off a dimly lit hallway, along which people in flimsy hospital gowns are relaxing on seats and chatting on a recent fall afternoon.
The room is stocked with a half-dozen or so landline phones and workstations. Opposite the phones is a large whiteboard that contains critical information: Date of the phone call. Name of the mental-health consumer. Name of who or what program referred the consumer. Red dots mean staffers are out on a call to visit that consumer.
The board, sort of a dry-erase spreadsheet used to track people in crisis from referral to handoff, is a quiet reminder of the lives at stake. Any given person who relies on D.C.’s public mental-health system may have a long history of mental illness, or be experiencing their first psychotic break, or they may not have a mental illness, such as someone in crisis after surviving a traumatic event.
Often, the CPEP crisis line gets calls about people who have stopped taking their medicine; family members are concerned. Or neighbors call in about hoarders.
“Anybody can call us in the District. We not only deal with District residents. We deal with visitors,” McAllister says. The White House is here. The Pentagon is close by. The CIA. The FBI. “You have people who have delusions all over the United States,” she adds. “Or I could really say the world because we’ve had some foreign visitors, too.”
A phone rings. Bill, a mental-health professional in mobile crisis services, answers. It’s a young consumer who calls frequently just to talk. Bill greets the person by first name. When the crisis line gets calls like these, CPEP staff usually assess, see if anything is needed, give a few moments of time, and then disconnect.
Some on the mobile crisis staff are called mental-health counselors. Those with higher degrees are mental-health specialists. Certified addiction counselors and peer specialists round out the team, along with interns in social work from Howard University and George Mason University. McAllister herself is also certified as a sex-offender treatment provider and a clinical trauma professional.
The phone rings again. Bill takes the call. He checks the electronic record system to see if this person is in it. Then he confirms the address and phone number. He documents the issues and checks the history. “We have to know where he is,” Bill says into the phone.
From November 2017 to November 2018, CPEP’s mobile crisis services team received 2,702 referrals and responded in person to 1,707 of those phone calls for face-to-face visits, according to DBH. Crisis intervention is just one service provided by the team. The range of services also includes traumatic event response, grief and loss response, follow-up with domestic violence survivors referred from DC SAFE (an organization that also provides crisis support), links to providers, referrals, and well checks. The average response time is 49 minutes, 17 seconds.
Mobile crisis services cover two shifts, from 9 a.m. to 4:30 p.m. and from 4:30 p.m. to 1 a.m. At least four mental-health professionals must staff each shift so they can field two teams of two to cover the entire District. Three teams are preferable. They go out on about 10 to 12 calls per shift.
Whoever picks up the phone is often the same person who goes out on a call. They do their best to get there within an hour.
Sometimes even before the day shift begins, the phones are ringing because things have happened overnight.
At the start of the day, McAllister or a supervisor goes over the board and assigns cases. The team takes their marching orders of who’ll work together in a pair. They get their DBH-issued things together to take out into the field, including a resource book in a white binder with laminated pages, an iPad, and a cell phone. They sign themselves out on the board. Then the two-person teams go out in unmarked government vehicles.
Bill, in tandem with Jennifer, a supervisor, leaves Building 14 to take care of the call.
While CPEP’s mobile crisis services are referral-based, its Homeless Outreach Program is primarily about finding cases. That means they go out to look for people living outside who don’t want services, and they patiently develop relationships with them over many months. They do take referrals if people call in to say a homeless person needs help.
In a different wing of Building 14 are the offices for McAllister and her HOP professionals. They’re out in the community most days, in snow or in rain, doing outreach to consumers who are both chronically mentally ill and chronically homeless.
“They go places where a lot of people won’t go to find them,” says McAllister of her staff.
The HOP team has a list of vulnerable people to see, broken down into each area of the city’s eight wards. The staffers each have their own sections. “That way, they become very familiar with who’s homeless in that area so they’re easier to find and locate, and also to develop a rapport,” she adds. “Many of the consumers don’t want to speak to government workers.”
***
Across the country, funding for mental health services varies from year to year. Many Medicaid programs pay for crisis stabilization services, and a number of states and the District expanded Medicaid through the Affordable Care Act. “Finding adequate funding—not only for crisis services, but for the mental-health system in general—is always a challenge,” says Ron Honberg, a senior policy advisor at the National Alliance on Mental Illness.
Currently, when crises occur, most communities depend on their police to handle them. But that should be the job of the mental-health system, he says. An effective crisis response system includes a 24-hour crisis line, walk-in crisis services, and mobile crisis services that intervene where the crisis is occurring, according to NAMI.
Crisis services ideally can lessen burdens on police and, in the long run, save money by intervening before a person shows up at the emergency room or ends up hospitalized or in jail, Honberg says.
NAMI hears frequently from upset families who called their county’s mobile crisis team only to hear that their loved one didn’t seem imminently dangerous to themself or others, but “if he threatens to hurt you or hurt himself, then call us,” Honberg says. “Of course, that’s very frustrating to families. Because to wait till that happens—it’s sometimes too late.”
McAllister has noticed that as the city changes, more people want to call the crisis line or HOP to help people. “I think many people become disenchanted with DBH when we don’t take people off the street immediately,” she says.
“People have a right to self-determination. People have a right to accept treatment and to refuse it, except if they’re likely to injure themselves or others,” she states. “If they don’t meet the criteria for involuntary hospitalization, we are not able to hospitalize them.”
On the board in Building 14, a red flag next to a name means possibly suicidal, homicidal, or violent.
“A majority of our customers are not violent, and a lot of them don’t even have a history of violence,” says McAllister. “People are protective of themselves in their space. We have a team of people who are strangers going into someone’s home.” They check to see if there’s a history of violence. If so, they take the police with them, often D.C.’s Metropolitan Police Department, but mobile crisis services interface with different kinds of police or law enforcement. “On federal property, we’re dealing with Park Police. If we’re over by the White House, we’re dealing with Secret Service,” she says. “It just depends.”
While out in the field, a mobile crisis team relies on the iPad to, say, look up resources or use a language-translation line. The cell phone is for the GPS, to tell the consumer or the referral source they’re there, to check in with staff, or to call the police if needed.
“You can’t really tell a person while you’re sitting in their living room, ‘I’m going to FD-12 you. The police are going to come and take you to the hospital.’ That’s not safe. Nor is it smart,” McAllister says. “We alert each other that the police have to be called, and we can’t necessarily do it in front of the consumer.”
An FD-12 is a petition for involuntary hospitalization so that somebody who is likely to injure themself or others can get the treatment they need. In addition to CPEP, McAllister says, three hospitals in D.C. take people with FD-12s, as well as the VA for America’s veterans.
Later, after returning to Building 14, Bill conveys that a case manager at a program said someone reportedly went into a police station and was talking about people breaking into his place, then went to the property management and said that the police had given him the green light to kill anybody who goes into his unit. “At which point,” Bill says, “we automatically had an FD-12 started to be written.” They waited for the case manager at the address and waited for the police, having requested at least one CIO—a crisis intervention officer with MPD who’s specially trained by DBH.
The CIO program in the District began in 2009 as a collaborative effort between the MPD and DBH, according to an annual trend report on the CIO program for FY 2011 through FY 2016 by MPD and Pathways to Housing DC. As of 2016, 994 CIOs from MPD and other D.C. law enforcement agencies were trained.
Most incidents to which CIOs respond are resolved peacefully. People brandish weapons 7 to 11 percent of the time. As shown by the data, weapons are only involved in a small number of mental-health incidents, according to the report.
The program increases safety for the public and law enforcement and the diversion of nonviolent people with mental illnesses away from the criminal justice system. It also has led to decreases in preventable arrests, decreased response times, and increases in referrals to mental-health services by law enforcement.
Bill reports that their intervention went smoothly; the consumer was brought to CPEP. “We had him. He’s here,” says Bill.
***
“You’re at your lowest point when you’re in psychiatric care. You’re waiting. You’re scared. You might be angry,” says Christy Respress, a social worker who is executive director of Pathways to Housing DC, the nonprofit organization that brought the Housing First model to the District and that is certified by DBH to provide the highest level of mental-health services in the community.
Involuntary hospitalization, or the FD-12 process, is always used as a last resort, according to Respress, who also serves as president of the Board of Directors of the DC Behavioral Health Association.
“There are no good answers here. There’s no black-and-white, easy answer about taking away a human being’s rights and where that line is,” she says. “People are in this work because they care so deeply about people and their mental health. To have to make that kind of decision when you know it’s required to save a life—it doesn’t make it easy.”
People might be angry at, and distrustful of, providers after an involuntary hospitalization. Respress understands that. But more often than not, “when we stand by people and then continue to just keep offering this unconditional support and care, when they are better, and when they are in a different place in their recovery,” she says, “they will thank us for being with them and understand why we initiated the hospitalization.”
MPD policy is that all people are handcuffed when being transported for mental health services in an MPD vehicle, and further that all adults being transported to CPEP for mental observation in an MPD vehicle are field searched and handcuffed before being put in the vehicle, according to a 2015 MPD directive on interacting with mental-health consumers.
If an adult who shows no signs of being a danger to themself or others voluntarily agrees to go to CPEP, however, transportation is to be arranged by a family member, by ambulance if the person is injured, or using the vehicle of the referring agency. According to DBH, mobile crisis and homeless outreach can and do transport voluntary consumers to either CPEP or a hospital in an unmarked government vehicle.
Many people who are in psychosis do not think there’s an issue, or they would have gone voluntarily in the first place.
Respress says that people ask, “Why did I have to be taken away in handcuffs?” That, to her way of thinking, “should be a different kind of process. We need to have a different conversation as a community about discretion and assessment of care and dangerousness.” Imagine if you believe that the government is out to hurt you, and police officers come, put you in handcuffs, and take you away in a car, she says. “I remember this one person in the program telling me, ‘Christy, I literally thought they were taking me away to kill me.’ And can you imagine that terror?”
D.C. needs to involve more people who have lived experience of mental illness—who have experienced CPEP’s services, including mobile crisis, and the FD-12—in helping to reform the system of care and to better inform it, she says. “The conversation must be led by people who have lived through it. Period.”
Why?
Her voice high and full of emotion, Respress says, “Because I will never fully understand what it is like as a person who has not been involuntarily hospitalized. I will never fully comprehend, no matter how much the people I serve tell me, what that was like and what the system felt like.”
Good enough, she adds, is never good enough.
***
At this moment in Building 14, a man’s voice yelling curse words somewhere nearby is audible and prolonged. His anger, or anguish, is palpable.
Confronted with suffering like this, the average person in our culture doesn’t understand. It’s a reflex to turn away in discomfort from the plight of others. It’s common human nature to ignore the unsettling aspects of our messy human existence, or carelessly make fun of someone in pain. It’s easier, sometimes, to live like meaning resides on the shiny surfaces of society.
McAllister is not a stranger to the horror of personal tragedy. Last year, her daughter was killed by gunfire in D.C. She was 18 years old.
“I find my personal experience helps me to do this job even better,” McAllister says now. “I still go onto gun scenes where somebody has gotten killed.” When McAllister worked in Prince George’s County, she worked alongside the police and gave death notifications for years. “And then, one day in my life, I’m given a death notification, right? But it made me understand.”
It made her stronger, she says. “You have to be able to have enough ego strength that somebody else is in crisis, and they absolutely need you to be present. And you have to stay present because there’s also an element of safety. I still have to keep my head on a swivel. I’m in a neighborhood I don’t know. I’m in a community that does not know me.”
McAllister emphasizes that CPEP works on mitigating crisis, and the dry-erase board used by her mobile crisis unit reflects that. “We don’t see these people long-term,” she says. They erase the names one at a time as they close cases. But the board is never clean, she says. The work is never done.