During a Mental Health Crisis, a SMART Approach
The teenage girl stood in her driveway in fuzzy slippers and a black coat pulled tight like a security blanket. She wiped at tears.
Her parents had called 9-1-1 because they didn't know where else to turn. They had discovered disturbing videos on social media of their daughter talking about drug use and suicide. Just four days earlier she had celebrated her 16th birthday. Now two police officers said she needed an immediate emergency mental health evaluation.
But being seen climbing into the back of a patrol car or a red, white and blue ambulance brings a lot of unwanted attention and carries a powerful stigma, especially for a fragile adolescent.
Instead of rushing her off or escalating the scene by summoning an ambulance, the officers instead called for the San Mateo County Mental Health Assessment and Referral Team, or SMART.
Within minutes, an SUV quietly -- no lights, no sirens -- pulled up. Will McClurg, a paramedic with special training in mental health and crisis intervention, climbed out carrying only a pen and a clipboard.
He spoke with police, the parents and the girl. After completing his evaluation, he escorted her "like a celebrity," he told her, to the backseat of the SUV with its heavily tinted windows before driving her to see a doctor.
Paramedics in the SMART program, freed from the need to rush patients to a hospital and get back in service as quickly as possible, can interview family members or friends of a patient, contact a patient's therapist and conduct an assessment to determine the best course of action, said McClurg, a veteran paramedic with American Medical Response, which operates SMART under a contract with the County of San Mateo.
Patients -- who sit up in the backseat of a SMART SUV or van rather than lie down on stretchers -- can be taken to a therapist's office, a substance use treatment program, a shelter or even their own home.
The goals are to avoid, if possible, sending patients directly to costly and overcrowded emergency rooms while providing appropriate care and services.
The SMART program is seen as a less expensive, more effective and more humane way to care for patients exhibiting signs of mental illness or undergoing a crisis.
1 in 25 adults experiences a serious mental illness in a given year
"Many people undergoing a mental health crisis do not need to be rushed to the emergency room," McClurg said. "While we are doing what's best for the patient, we are also freeing up a regular ambulance that would otherwise be needed to transport a medical patient."
The SMART program began in 2005 with one unit covering the entire county. Due to the program's success and at the request of law enforcement, AMR began staffing SMART with two units in 2015 with additional funding from a variety of sources including Measure K, a half-cent countywide sales tax approved by voters.
AMR now staffs SMART with two, 12-hour shifts seven days a week, one unit from 8 a.m. to 8 p.m. and the second from 10 a.m. to 10 p.m. SMART paramedics are sent by San Mateo County's Public Safety 9-1-1 dispatchers solely at the request of police. Only nonviolent, cooperative patients can be transported in a SMART vehicle.
9.9% of calls for emergency medical services are for behavioral/psychiatric needs
Expanding SMART is part of a wider strategy to improve the mental health system of care for adults in San Mateo County. That effort also includes providing alternatives for mentally ill adults booked into jail for non-violent and minor offenses and building a respite center, to be called Serenity House, where people with a mental illness can stay for a short period of time to stabilize and enter long-term treatment.
"There is a deep reluctance and stigma in our society about seeking mental health treatment, even though we know it is effective for treating suicidality and other mental health problems," said Louise Rogers, Chief of the San Mateo County Health System. "The SMART program staff and vehicle help neutralize that barrier to treatment through quiet and respectful engagement when people are their most vulnerable, rather than raising anxiety with lights and sirens."
Within San Mateo County, law enforcement and mental health professionals are increasingly working together to enhance training and coordinate the response to complex calls involving mental illness or drug and alcohol use.
Suicide is the 10th leading cause of death in the U.S. For ages 15 to 24, it is the 2nd leading cause of death
As of February 2017, nearly 500 law enforcement officers from agencies across San Mateo County have undergone Crisis Intervention Training, or CIT. The 40-hour course introduces police officers, probation officers, public safety dispatchers and support staff to recognize the signs and types of mental illness, learn and use suicide intervention techniques and ways to calm people in the throes of a crisis.
One of the most valuable aspects of the training is showing officers the resources available to them. Officers meet face-to-face with health care providers, mental health counselors, substance use treatment providers and paramedics with the SMART program. They also learn when and how to summon a SMART paramedic, said Jim Coffman, a San Mateo County Sheriff's Deputy who until recently oversaw the crisis training program.
"CIT is not magic, but it does give officers in the field a greater understanding of how to calmly handle stressful situations," Coffman said. "It's another tool at their disposal."
Studies have shown that people with a mental illness are overly represented in the criminal justice system: the National Alliance on Mental Illness estimates that nearly 15 percent of men and 30 percent of women booked into jails have a serious mental health condition.
McClurg, the SMART paramedic (it's an ongoing joke over who's "SMART" on any given shift), sees his role as the first step in helping patients find longer-term solutions on what is often, he notes, the worst day of their life. "There are so many reasons people feel the way they do and act the way they do," he said. "It's never-ending and it's challenging."
On a recent 12-hour shift, the call came over the radio: "Nine-year-old male. Danger to self."
After a short drive McClurg pulled up in front of an elementary school. A boy in a white polo shirt and tan pants sat quietly at a table in an office eating a snack.
Over the weekend his mother had taken away his video game console after repeatedly warning him to put it down and to do his homework. School officials called authorities after the boy told classmates and school staff that he planned to jump into traffic to kill himself if she didn't return it.
McClurg interviewed school staff, a police officer called to the scene and the boy's mother before asking him a series of questions. McClurg ultlimately drove the boy to see a mental health professional. He was released to his family later that day with referrals to ongoing mental health resources.
Half of all lifetime cases of mental illness begin by the age of 14
Next, McClurg responsed to South San Francisco where a 74-year-old man had learned he was going to be evicted from the only home he has known for more than 40 years, or about the same span of time since he had last seen a doctor. The man threatened to kill himself if he was forced to leave.
He had received numerous eviction notices but didn't believe, or couldn't believe, he would actually be evicted. Police had just removed a firearm from the man's home when McClurg pulled up in cold rain. After an assessment, McClurg drove him to a hospital where he was admitted for observation and evaluated for further services.
On any given day, McClurg sees the spectrum of human emotions, from children acting on impulse to senior citizens no longer able to cope with life's complexities to teenagers struggling with emotions and family turmoil.
While half of all lifetime cases of mental illness begin by age 14, the average delay between the onset of symptoms and intervention is eight to 10 years. Health experts say this is why it is so important to invest in early intervention and prevention programs.
The 16-year-old girl who posted worrisome videos on social media said little on the way to see a doctor at a psychiatric emergency room. McClurg escorted her inside and then exchanged paperwork with medical staff before climbing back in the SUV to await another call.
Later, he followed up: after an evaluation she was admitted for treatment, an important step in the recovery process.