Presented by Alaska Mental Health Trust Authority

Part 2 of 6

If you were born anytime in the last 60 years, you were probably taught from a young age that in an emergency, the very first thing you do is call 911.

Dial that three-digit number from nearly anywhere in North America and you’ll be connected to a local public safety answering point, or PSAP, from which dispatchers can send police, fire and EMS units to help you with whatever your emergency may be.

But what if your emergency isn’t a crime or physical ailment? Is the emergency response system really equipped to provide meaningful aid to someone who is experiencing a behavioral health crisis?

In Alaska, the answer, according to first responders, is often no -- but, they add, that is beginning to change.

What happens when you call 911

No matter why you call 911 in Anchorage, your call will always be answered initially by the Anchorage Police Department, which is the primary PSAP for the Municipality of Anchorage.

“The first thing we’re going to ask is ‘Where are you?’,” said APD Dispatch Manager Amy Foraker. “The next question will be ‘What is the emergency?’.”

Depending on the answers to those questions, dispatchers may send police to respond or route the call to the Anchorage Fire Department for fire, rescue or emergency medical services. Last year, APD received 161,338 emergency calls, 31,039 of which were routed to AFD, according to data shared by Foraker. Often calls may be “joint response” -- for example, if police can get to the scene more quickly and render aid until the fire department arrives, or if there’s a medical emergency with a criminal element.

At peak times, APD dispatch is staffed by nine to 11 employees, four or five of whom are actively answering calls while others handle radio channels or supervisory roles. The job requires six weeks of classroom time, followed by eight to 10 months of on-the-job training. It’s a lengthy process for good reason -- it’s a high-stress, high-impact job that requires dispatchers to remain level-headed and think critically while simultaneously engaging with a caller who may be experiencing the most frightening moments of their life.

“We need to be the calm voice in the storm,” Foraker said.

In some cases, dispatchers need to remain on the phone with a caller until first responders arrive to take command of the scene. Often that’s just a few minutes, but in the case of a behavioral health emergency -- such as a person experiencing thoughts of suicide -- that call can stretch into 15, 20, 30 minutes as the dispatcher works to keep the caller calm and safe.

Even with their extensive training, Foraker emphasized, dispatchers aren’t clinicians. But often they are the only resource available. In fact, it’s not uncommon for dispatch to receive calls from suicide hotlines seeking help for one of their own callers.

“If we were able to take that caller and transfer them to a call center where they’re talking to a clinician or a mental health professional, that’s going to be huge,” Foraker said. “Ideally, we need to get that person the help that they need and not just take them to jail or a hospital emergency room.”

‘We don’t have the training’

Unfortunately, jail and the emergency department are often the only options available to police who respond to a behavioral health call.

Credit for Title & Above Photo: Anchorage Police Department

APD officers receive an introduction to crisis intervention in the police academy, and there is an additional 40-hour training made available to APD personnel through a longstanding partnership with the Alaska Mental Health Trust Authority and NAMI Anchorage, but the department doesn’t pretend to have expertise in mental health, said Deputy Chief Kenneth McCoy. Officers’ primary objective is public safety, and while that includes the safety of the person having a behavioral health emergency, when that emergency involves laws being broken -- often trespassing, shoplifting or causing a public disturbance -- they do what they are trained to do and make an arrest. Other times, the mere presence of police escalates a volatile situation.

“A family member or friend may call us to assist, and sometimes just a person seeing a uniform and everything that comes along with that, all the equipment and lights, triggers them, and they can have a violent response to that,” McCoy said. “We can end up in a physical encounter that leads to arrest, and sometimes, tragically, it can lead to a fatal (incident).”

While these encounters gone wrong make national headlines -- like the case of a young girl who was pepper sprayed by police in Rochester, N.Y. -- most of the hundreds of behavioral health calls to which APD responds each month are far less dramatic.

“Our officers are very resourceful, so they’ll work with them … sometimes hours at a time trying to find a family member or someone who will take them in for the evening,” McCoy said. “(They try) every resource they have to see if there’s something they can do for the person.”

That may mean taking them to the emergency department, where an officer must wait sometimes for hours to hand off custody to ER staff. Beds in treatment programs are incredibly limited, especially for the many people who experience co-occurring mental health and substance abuse disorders, and McCoy said it’s not unusual for an officer to spend hours driving around with a person in the backseat of their car, trying to find someplace to take them for help. Sometimes, if the person has committed a crime in the course of their crisis, the only place to take them is jail -- and that’s not good for anyone, McCoy added.

“Police officers are problem-solvers,” he said. “We’re trained to show up and to identify the problem and resolve it. This is one call type that we’re not equipped to resolve, so it definitely leads to a lot of frustration.”

Anchorage Fire Department personnel have even fewer options -- by municipal ordinance, they can only transport patients to a hospital, and currently there aren’t any alternative facilities where they can transport behavioral health patients. Often people come willingly, especially if they have a co-occurring medical emergency, but sometimes AFD will arrive on the scene to find a combative person experiencing a behavioral health crisis.

“We don’t have the training for that,” said AFD Paramedic Michael Riley. “Our training is for acute medical responses. We’re trained for cardiac arrest, we’re trained for traumas and for breathing problems. We’re not trained in trauma-informed care. We’re not trained in de-escalation.”

With no way to help behavioral health patients -- sometimes the same individuals over and over again -- first responders can start to lose patience, Riley said, and that only compounds the problem.

“It has to do with resiliency and empathy for this individual,” he said. “Your glass of empathy just kind of gets spilled over.”

A new way to respond

Over the years, Riley became convinced there was a better way to approach behavioral health crisis care.

“I was often frustrated because I lacked the skills to help,” he said. “I didn’t get into this job to not help people.”

Riley began to get interested in community paramedicine, a relatively new model that involves emergency medical professionals in preventive public health, particularly among underserved populations. He served on an inter-agency team that made recommendations resulting in a 30 to 40 percent reduction in calls to the Brother Francis Shelter/Bean’s Cafe campus. When a community needs assessment found that 1 percent of patients accounted for 10 percent of AFD encounters, Riley led the establishment of the Community Outreach, Referral and Education (CORE) Team, which includes a firefighter/paramedic and now, in partnership with the University of Alaska Anchorage and Providence Alaska Medical Center, a Ph.D. candidate in psychology. The CORE Team works with “high utilizers” of the EMS system to proactively address their health needs so they don’t rely on calling 911. Since 2018, calls from those individuals have decreased by 40 percent.

Now AFD is employing the same “person-centered” approach to behavioral health. In February, the department began receiving funding generated by the new municipal alcohol tax, which it is using to establish a Mobile Crisis Team (MCT) headed by Riley. Expected to launch as soon as this summer, it’s the first step toward establishing Crisis Now, an initiative currently in development to expand behavioral health crisis care in Anchorage, Fairbanks and the Matanuska-Susitna region.

The Crisis Now framework envisions multiple avenues for crisis resolution, increasing opportunity for intervention at less intensive levels of care, and decreasing reliance on law enforcement response and inpatient psychiatric beds. Credit: Alaska Mental Health Trust Authority

“We saw an opportunity to provide a service that we’re not doing yet that already aligns with the individuals we’re seeing today,” Riley said.

The MCT will consist of a paramedic and a master’s-level mental health clinician who will respond to calls in a light duty vehicle that is both less intimidating and less expensive to operate than an ambulance or fire apparatus. The objective will be to de-escalate and resolve cases on the scene whenever possible, with follow-up afterward by a social worker. Riley has studied similar programs that are active or in development in cities like Portland, Colorado Springs and Toronto to learn what’s working in other places.

“What this does is it has a downstream effect,” Riley said. “They are not going to an emergency room, they are not going to a psych ED, they are not going to jail.”

In the long term, plans call for MCT to become a Medicaid-eligible billable service, and further down the road, to be integrated into a larger spectrum of Crisis Now services, including a full-time call center, 23-hour stabilization clinic, and specialized peer support. The Alaska Mental Health Trust, which is leading the effort to implement a Crisis Now Model in Alaska, envisions a future in which additional community-based crisis mobile teams, composed of clinicians and peer support specialists, will further enhance the service provided by the MCT.

In addition to providing more effective care, mobile crisis response teams could potentially replace thousands of hours of police, fire and EMS time. Because of the way the fire department records data, it’s hard to quantify exactly how many cases each year are purely behavioral health calls, but Assistant Chief Erich Scheunemann, who has been tracking the numbers since 2015, estimates that AFD responds to about 1,000 such calls every year, while the police department handles probably two to three times as many.

“It’s freeing the police, the firefighters, the medics up to do the primary focus of their jobs, rather than the parts of their jobs that they may not necessarily be trained so much to do,” Scheunemann said. “What we’re going to be establishing, it’s another spoke in the wheel of the continuum of care. This is just becoming a natural evolution of public safety.”

“This is the future of first response,” Riley added.

Fully implemented, Crisis Now also promises to have a significant impact on APD dispatch. Foraker said the framework’s planned call center probably won’t change the volume of 911 calls they receive, but it will give them a reliable place to transfer callers who are experiencing behavioral health emergencies, which in turn frees up dispatchers to answer more calls more quickly.

“They’re able to resolve a high percentage of the calls on the phone,” Foraker said. “I think it’ll help us exponentially in saving time and also getting them the help they need. A police officer is not always the best answer for someone in crisis.”

Read the rest of the series: Part 1 - Part 3 - Part 4 - Part 5 - Part 6

The Alaska Mental Health Trust Authority is a state corporation that administers the Alaska Mental Health Trust to improve the lives of beneficiaries. Beneficiaries of the Trust include Alaskans who experience mental illness, developmental disabilities, chronic alcohol or drug addiction, Alzheimer’s disease and related dementia, or traumatic brain injuries. Learn more at AlaskaMentalHealthTrust.org.

This story was produced by the sponsored content department of the Anchorage Daily News in collaboration with the Alaska Mental Health Trust Authority. The ADN newsroom was not involved in its production.