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Training pivotal as cuts to mental-health services take hold

The Daily Inter Lake - 6/10/2018

June 10--Print Article

It's 8 a.m. on a Friday, and all is not quiet at the Gateway Community Center in Kalispell.

The only thing louder than the music blasting from an upstairs room is the screaming. A woman shrieks as her "daughter" is escorted out of the room, while officers, equipped with pink model guns, attend to another daughter huffing a bag full of glue in the corner.

The commotion is rattling, but the chaos is not actually real. This is scenario day for Crisis Intervention Training, a week-long program to teach law enforcement officers skills and strategies to de-escalate mental-health crises. In between the scenarios, the actors -- including many employees of the Western Montana Mental Health Center in Kalispell, which organized the training, and this journalist -- recover their voices and pick up scattered M&M "pills." Officers reflect on what went well -- the removal of a triggering agent, or a question that revealed important information -- and what did not.

There are no do-overs in the field, and the practice of defusing a loud, unstable situation is critical for officers on the front lines of mental-health crises. And as the ripple effects of state budget cuts to mental health care threaten to tip more people into destabilized situations, cooperation between law enforcement and community mental-health resources, such as the Crisis Intervention Training, can make the difference between a crisis ending in treatment, or in jail, hospitalization or harm.

Crisis Intervention Training is a 40-hour, evidence-based training program to give officers, detention staff and dispatchers the skills to engage, assess and ultimately assist those in the throes of a mental-health or addiction crisis, as opposed to a criminal situation. Gallatin County ran the first training in 2009; since then, CIT Montana, the umbrella group that facilitates trainings across the state, has brought the targeted situational training to several other counties, including, as of three years ago, the Flathead Valley.

The training focuses on strategies for responding specifically to mental-health or addiction crises -- inherently yet uniquely unstable situations that require a different approach than standard first-response procedures. Over the course of the week, participants learn how to identify different mental illnesses, what happens when a person is involuntarily committed for a mental-health crisis and how to approach each situation with the question, "What if this was my family member?"

There are three days of presentations and discussion, a day-long trip to the state hospital in Warm Springs and, on the final day, a chance to apply new skills in the live scenarios.

A key part of the training is to bring in representatives from several agencies and programs in the valley with a hand in mental health care.

"It's a great opportunity for different agencies in the community to represent the services they offer while providing some education -- the county training office, adult protective services, Western [Montana Mental Health], law-enforcement departments, chemical-dependency clinics, Flathead Industries, people in the field at KRMC," said Jason Mallonee, the clinical director at the Western Montana Mental Health Center in Kalispell, and one of the organizers of the training.

The community fabric of mental-health professionals, local resources and law enforcement is essential, said many participants and organizers, as recent state budget cuts to mental health care leave many clients without long-term case management, destabilizing holes in care that could lead more people to fall into crisis situations, with law enforcement the ones expected to catch them.

As has been reported previously, a state budget shortfall forced an emergency legislative session, and then $49 million in cuts to the Department of Public Health and Human Services last November. The cuts have fallen across all aspects of health care in the state, such as a 2.99 percent decrease in the Medicaid reimbursement rate for all services -- but have taxed mental health care especially hard. On top of the general rate cut, the budget for case-management services, which help clients maintain stability and navigate resources, was nearly halved.

As a result, numerous case workers across the state have been laid off, leaving some people with severe or disabling mental illnesses without their point person for what can be an overwhelming maze of daily challenges.

"You're asking people who are very ill to be able to negotiate some very difficult systems," said Sheila Smith, director of Western Montana Mental Health in the Flathead. Case managers absorb a bevy of often overlooked tasks required for people to maintain their illnesses, said Smith; without them, many of the most vulnerable mental-health clients are left unmoored.

"Who's going to take on that huge task of monitoring their social security, monitoring if they've still got Medicaid, intervening with their landlord ... making sure they get to their appointments, making sure they get their medical care taken care of?" Smith asked. "The role of case manager is to coordinate all those services and make sure they're occurring and making sure the client is getting them."

Professionals such as Smith warn that without the buffer of case managers, those with critical mental-health concerns will be left untreated or unseen until a crisis hits.

"As we go along, and people can't get the support they need, I think we'll see more people having to be intervened with by the police, having to be seen in the emergency room," Smith said.

This is where the strategies developed in the Crisis Intervention Training can make the difference between tragedy and restabilization. By understanding how to analyze situational triggers, how to talk to someone in psychosis, or how to meet someone where they are to calm them down, first responders can bring worst-case scenarios back from the brink.

It all comes down to listening, said organizers Mallonee and Paula Sullivan, deputy sheriff for the Flathead County Sheriff's Office.

"It teaches officers not to just go into a situation and confront an issue that someone's having," Mallonee said. "They listen actively to validate the experiences that they're having and then work with them to try to find a solution."

"From Day One, they're learning how to talk to people in a certain way, and to help that person when they're in crisis, all the way to scenarios where they're putting it into action," Sullivan added.

The scenario's loud, chaotic and open-ended practice solidifies the lessons learned from community mental-health providers, said Ron Clacker, a patrol officer for the Kalispell Police Department who participated in the training.

"The more realistic the scenarios are, the more it helps us in training. We fight like we train, so you need to train like you fight," he said, noting a refrain from his days in the military. "And so having the realism to the scenarios really helps to be able to develop the connection that you need in these incidents."

Understanding the process behind de-escalation goes beyond first responders. When the detention center has someone suddenly on suicide watch, "our first call is to mental health," said Tammi McDaniel, president of court security within the Flathead County Detention Center and another training participant. "The relationship with mental health is priceless, even in detention."

In another place, the increased responsibility on law enforcement could spell disaster for mental-health clients and their families in their most vulnerable moments. But the cooperation and communication between law enforcement, providers and professionals in the Flathead and Kalispell -- as evidenced by the Crisis Intervention Training -- make for a prepared community, Smith stressed.

"I can tell you story after story after story where law enforcement has intervened with people and did not shoot them, even in some cases where the person had a weapon. Our people are amazing," she said.

The health-care landscape in Montana remains uncertain, as long-term impacts of the cuts are revealed and the Legislature looks to either extend or end Medicaid expansion in 2019. But the open dialogue, preparation and relationships between community services -- mental health, law enforcement and others -- provide a sturdy foundation amid the volatility.

"I will always say this," said Smith, "because it's maybe the best part about living in Kalispell: We have a phenomenally, phenomenally good system of care in our community."

Reporter Adrian Horton can be reached at ahorton@dailyinterlake.com or at 758-4439.

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