- Welcome to "Healthy Minds".

(gentle music) I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on "Healthy Minds"... One of the early efforts that you're involved in is the development of 9-8-8 as an emergency call center, a direct line to the suicide hotline.

- When you've identified that you have a mental health line, 9-8-8, lots of people will call and you wanna make sure that at the local level, in communities, people know what to do in emergencies.

- That's today on "Healthy Minds".

This program is brought to you in part by... the American Psychiatric Association Foundation, the Bank of America Charitable Gift Fund, and the John and Polly Sparks Foundation.

Today, I speak with Dr. Bill Carson about the new 9-8-8 phone number which can be used by people who are experiencing suicidal risk or who are agitated, paranoid, and need help.

(gentle music continues) Bill, thank you for joining me today.

- Thank you.

It's a great pleasure.

- I want you to tell us about the Sozosei Foundation.

- Sozosei is the Japanese word for creativity.

And the foundation was established to continue the work around taking care of people who have psychiatric disorders.

And one of the big issues that we are addressing is decriminalization of mental illness.

We believe mental illness is not a crime.

And as you know, by default, the prison and jail system in this country is the default psychiatric system for many places.

This is really quite unfortunate.

There are lots of reasons why it happened historically starting with the deinstitutionalization of state hospitals in the '70s and moving on from there.

- People left the state hospitals but basically they were abandoned.

They didn't have treatment, a place to live, et cetera, and that was a part of the problem.

- That was a part of the problem.

And most people don't know but the last bill that President Kennedy signed was the Community Mental Health Center Act.

And the Community Mental Health Center Act was put in place, it was going to cover every 250,000 people across the country with a catchment area.

So that as you deinstitutionalized the hospitals, they would've been picked up in the community with all sorts of support that was there.

And that program was never funded fully.

And unfortunately the hospitals were closed, the program was not funded fully.

And even later on we had the war on crime in the Reagan administration.

More people were put in prisons, the growth of the prison industrial complex.

So we have prison beds, no state hospital beds, patients with no care, so that ends up with the default of prisons and jails being the default mental health system in many communities.

- And often being homeless as being the place to live for people who are left without the services, with the closing of the institutions and the lack of services for those people.

- That's exactly right.

And somewhat of a revolving door, because you go in, you get arrested for a nuisance crime, urinating in front of a drug store, and you're in prison.

And then most people have no understanding that you can take a misdemeanor nuisance crime, and if you were to hit a prison guard because you're a paranoid, once you hit the prison guard, you have a felony.

Once you have a felony, your entire life has changed completely because you lose access to housing, you lose access to your services.

So you might, at that point in time, end up having a life in prison when in fact all you did was do a nuisance because you were homeless and out on the street and not taking your medication.

So we're trying to make sure that those people are appropriately treated and taken out of the system because it's an illness.

We would never think of treating a heart attack, dialysis, breast cancer.

It would be unbelievable for someone to say the only place that you can go for your dialysis is jail or prison.

For many people, we say the only place you can go for your paranoid schizophrenia is a prison or jail.

Doesn't make sense.

- Because people aren't aware of this.

And it's an amazing and sad statistic that there are more people with a psychiatric condition in jail and prisons than there are in psychiatric hospitals.

And that is a travesty in our country and in countries around the world.

- That's correct.

And one of the things that most people are not aware of is by default, the prison and jail system in this country is the default psychiatric hospital in many places.

And we think that that's really quite unfortunate.

You know, as psychiatrists, we really believe that patients should be taken care of in a kind, compassionate, medical-based fashion - Right, often some of the behaviors that a person may have as a result of their illness can look as if it's criminal activity, could even be illegal, but what they really need is treatment and help.

- That's right.

And one of the types of situations where there are a lot of patients who have, lots of people who have a diagnosis or previous psychiatric history, is a homeless population.

So upwards to 60 plus percent of the homeless population has some sort of psychiatric diagnosis.

Now, that being said, you still should say are they being appropriately treated?

Are they taking their medications?

What kinds of symptoms are they having?

Is it appropriate for you to be out on the street?

And with regards to what you said earlier, their behaviors, especially nuisance behaviors in situations in the public have them multiple times going into hospital settings.

So if you happen to be nude and urinating in front of a store several times a day, you're not going to do that without someone intervening, when in fact it just may be that if you were appropriately treated, you would know that that's not something you should do.

- Exactly, with treatment, those kinds of symptoms and actions would get better.

- Correct.

- One of the early efforts that you're involved in is the development of 9-8-8 as an emergency call center, a direct line to the suicide hotline, really is a way to avoid calling 9-1-1.

So I'd like you to talk about 9-8-8 and its implementation in July of 2022.

- Yes.

Well, when we started the process, the foundation really was established early 2020.

We did not hire the first executive director until March.

A person came in virtually and for most of the time, no one within the whole organization ever got to meet in-person because of the pandemic.

What we decided to do is move our conversations online.

And we had a "solutionist" meeting, because if you think about it, decriminalizing mental illness is really quite broad.

And instead of trying to boil the ocean, we asked those experts, "What's the best thing that we should start with?"

And what rose to the top is the mandate to change the current suicide prevention line to an easier number, 9-8-8, in 2022.

And everyone says it's important to get that right, because when you've identified that you have a mental health line, 9-8-8, lots of people will call and you wanna make sure that at the local level, in communities, people know what to do in emergencies.

- So instead of dialing 9-1-1 because you're concerned about a loved one killing themselves, taking action on their suicidal thoughts or because a loved one is agitated and you're afraid of safety for yourself, others, and the loved one, instead of 9-1-1, a person would dial 9-8-8.

- I think that is the intention.

The concern is around the country in different localities, the preparation to get to 9-8-8 may not be there in time.

So, we just had our first face-to-face summit for the Sozosei Foundation, all really focused on 9-8-8, and it was absolutely fascinating.

There's a weekly meeting, I think they call it a jam session on 9-8-8 or something like that where people are just saying, are we ready, how are we doing?

And so they're trying to, and it's led by NAMI.

So NAMI, Dan Gillison, he takes the lead in putting that together and coordinating the conversations.

So what they're looking at is a red, yellow, green staging of all the states so that the people at local levels can say am I in a yellow state or a red state where things are not actually prepared, I might actually have to call 9-1-1 because things are not exactly going to be ready yet.

And, but in other states there may be many more services and 9-8-8 would be appropriate to call.

So the question is, how do we communicate that?

It may just be in some places the suicide hotline with the new number.

In some other municipalities, you may have many, many more services that are in place when that comes on.

And the jam session, the preparation is really about making sure that people on the ground know what's available in their communities.

- So NAMI is a national organization but also with local components of the organization.

- That's right.

So people in each locality need to know what's available for them, with the goal being that at some point when you dial 9-8-8, you really can have access to whatever services the person needs.

- That's correct.

I think in the, Vibrant that is managing the current suicidal hotline, they are able to transfer all of that to the new number.

And in some municipalities, they are able to immediately get appointments for people on their first call.

Now, that's a luxury for those folks.

That's really a great benefit.

But to have that expectation everywhere is unrealistic at this point in time.

So it really is about trying to say these are the services, these are the people who are manning the phones, and this is what's available to you here to help your family.

- For people who end up getting directed to 9-1-1 anyway, or let's say they do call 9-1-1- - Right.

- what do you say in order to increase the likelihood that the interaction will be a positive interaction and not one that is negative and sometimes resulting in death or injury?

- It really is a preparation for the families to think about.

So, as you know, it is unlikely that the emergency would be the first thing that the family notices something being off with their family member.

So you've already got some understanding that something is happening.

Maybe they've been to the doctor, maybe they have a diagnosis, maybe they don't.

But as soon as you have this idea that there might be an emergency, I would have a plan that would, that's what I would say to families, that's what I used to say when I took care of patients, and just understand when you make that call 9-8-8 or now for 9-1-1, what's going to happen.

And 9-1-1 by design attaches almost collectively to a policing element.

So there is every likelihood in most municipalities that one of the responders will be from the police.

And for many, most mental health emergencies, a police is not necessary.

And there are lots of communities that are adapting their systems and thinking about who should respond, co-responders with mental health, patients with lived experience only, you've got all sorts of models, and know what's available in your community.

And to your question about what should you say, you should say this is a mental health emergency that we don't think this requires anything that's criminal or any level of force or violence.

Be very clear.

- Very important.

Upfront to say that upfront.

- Yes.

And that doesn't mean that police and sirens aren't gonna show up.

And that's where families and even the patients might be activated because the challenge is that's part of what's built into the 9-1-1 system.

So, you have to be very clear and ask for other solutions.

Does this community have another solution when I make that call?

Because you don't want to escalate, just unavoidably escalate a situation that doesn't need it.

- A person who because of their illness may feel paranoid, may be hearing voices, when all of a sudden sirens appear and the police appear, they're gonna get more agitated and more frightened.

And the goal is to sort of simmer that down in a safe way.

- That's right.

That's right.

And I think having those discussions, being very clear when you're making any kind of crisis call, what is happening, what do you need help for.

Some of the challenges, as you know, and as we've seen in many of the instances with really tragic outcomes, there's a level of erraticness and psychiatric symptoms like paranoia may actually cause a person to be afraid of everyone.

And that fear that is in the paranoia then without the person who's approaching on the crisis side knowing that it's an internal fear, it's not a real fear that they're not attacking you, that they're attacking what's going on in their mind, looks like they're being attacked.

And that's when you get some of those really unfortunate outcomes because it's just a lack of understanding that they're not coming for you.

They're coming from what the paranoia is causing within them.

- Right, if you could put your self in the shoes of the person experiencing this, they're frightened about a lot of things going on and that's the illness, and that's why their behaviors may manifest themselves.

- And even in us having this conversation now, look how long it is for us to say that.

If you're in a crisis, your child is sick and thinking that way, and you're trying to call for help, and you're like, "I need help now, please come help me now," you're not going to necessarily remember to say, "They're on medications, that we've been taking them these places.

We think that this could be psychiatric.

We believe that that's the kind of care that's necessary."

You may just be saying, "We need help."

And they're going to approach it as if this your child or your family member is doing something potentially to harm you.

And the most interesting and unfortunate understanding of the situation is, as you know, most psychiatric patients are not violent, even when they're in their worst crises.

And the challenge for the answer in the current mental health crisis system is that everything is seen as being quite violent or attacking, when in fact it's not.

It's just a symptom of the illness.

And it's trying to get the clarity around this person needs a different kind of care.

They're not being violent towards you.

- I wanna shift gears from the agitation and violent emergencies to suicidal emergencies.

And as you know, the suicide rate has increased.

It's the 10th leading cause of death in the United States.

For younger people, it's the second leading cause as of death.

And part of 9-8-8 is to help to make it easier to reach the suicide hotline.

I'd like you to speak a little bit about that aspect.

- It's a great point.

It really is one of the most interesting and frightening aspects of the COVID pandemic.

So I think the response in our young folks has started to look like depression and as you said, suicidal ideation.

And along with the statistics, we used to think that the suicide rate among Black and Brown youth was lower than, but now in the pandemic, it's one of the groups that has the highest number that's rising.

So, I think we have a new population where people are making complaints and actually acting on those complaints.

So, it really is a problem.

I think that the suicide prevention lines are very good in what they do.

And so I think on that side of the equation, we should be in a pretty good place because we're taking a current suicide prevention line and we're just putting a new number which should make it easier for people to get to it.

But the services behind that number are really focused on suicide prevention.

So most of those lines, many of those lines have volunteers as well as a staff.

They've been trained on how to ask questions.

They know how to deescalate the situations.

And their sense, their statistic is that they can handle 90% of suicidal calls and have a resolution at that call.

- Based on the phone call- - Based on the phone call- - without other intervention at that moment.

- without anything else.

So I think, and if there's a point of hope in all of this transition, is that should continue unchanged.

I think the 10% beyond that is where it becomes more challenging when something beyond those services are necessary.

So I think utilizing the suicide hotlines and the suicide prevention aspects of it should continue and should continue to provide great services.

I think the numbers that we're talking about, the increase in it happening may stretch the systems because the systems themselves need lots of people to man the lines, and so you start to have a capacity issue.

And in the summit, one of the things that we heard is retaining talent in all the emergency crisis response lines is quite difficult in the great resignation that we're all experiencing.

- It's a stressful job for the volunteers or paid employees doing this.

One of the concerns that people have, and it's based on really a misconception, which is if you ask somebody about whether or not they may be suicidal, that could increase the risk when in reality, that could save a life.

And I'd like you to speak about that.

- That's, it's so true and you hear it all the time, like, "I don't wanna talk about it 'cause it may make them do it."

And it's like, well no, actually not talking about it is more likely to make people do that.

And I think it's what we were saying earlier.

As families and their children and family members start having these types of issues, it's really important to know what you can do.

How can you intercede?

What does a crisis look like or what does suicidal?

And to your last point, being comfortable with saying, how are you feeling?

Why are you feeling suicidal?

You're not trying to do therapy, but you're just having a conversation.

"Is there anything I can do?

Should we try to get help?"

So it's trying to have a conversation and understanding how to have that conversation versus saying, I'm not doing anything.

This frightens me.

I don't wanna make it worse."

Get yourself ready.

Prepare yourself for an understanding of what's going on.

It's the best way to help your family member.

- If you saw a loved one limping, you would say, "Did you hurt your foot?

How are you, what could we do to help?"

- What can we do to help?

- This is the same except more dangerous if it's left unsaid and untreated.

- And when you have people who say, "Well, they've been in their room for two days."

It's like, well, that's probably not a good idea.

And maybe you should try to work with them, talk to them, encourage them, love them.

Just give them care and say, "How can I help?"

And have an understanding, try to just talk so you can know what they're feeling and you can try to help them express what they're feeling.

And one of the aspects that's really true as you know, it can be quite frightening when you're talking to them and you've never had that kind of conversation.

And the darkness and depth that people go into is unimaginable to most people 'cause we're not depressed.

But for that person, they go into some really deep holes.

And to be able to try to lift them up or just understand and help them, and, "What can I do?"

I think that's incredibly important and helpful.

- Bill, I wanna to thank you for joining me today, for the work that you're doing with the foundation to make this happen, and look forward to continuing the conversation down the road.

- Thank you very much.

It's been a pleasure.

(gentle music) - If you or a loved one is experiencing a mental health emergency, reach out for help.

Don't suffer in silence.

Remember, with help, there is hope.

(gentle music continues) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by... the American Psychiatric Association Foundation, the Bank of America Charitable Gift Fund, and the John and Polly Sparks Foundation.

Remember, with help, there is hope.