Mobile unit aids D.C.'s mentally ill during crises
In its first year, program has helped more than 1,500 people

By Henri E. Cauvin
Monday, November 9, 2009

The woman wasn't budging.

It was late on a Friday afternoon last month, and there she was, 64 years old, mentally ill and refusing to return to her Southeast Washington nursing home.

"I am fed up," she shouted as she sat bundled in a motorized wheelchair that was stuck on F Street NW. "I have had it."

The MetroAccess van that was to have taken her back had left hours before. Police had come and gone, unable, they thought, to do anything.

So the woman's attorney, who had been with her that morning in D.C. Superior Court and was with her outside the Judiciary Square Metro station, made one last call -- to the city's mental health mobile crisis unit.

A year earlier, the lawyer might have been stuck. The mobile unit was just an idea taking shape, an effort by the D.C. Department of Mental Health to rebuild its capacity to help people in crisis and those veering toward one.

Now, counselors crisscross the city every day and night, the frontline of the District's reinvigorated emergency psychiatric care program. In its first year, the mobile unit, with 17 counselors, psychiatrists and social workers, has helped more than 1,500 people.

With the city's mental health system in the midst of a major overhaul, the need for a mobile crisis team has perhaps never been greater.

The District has been shifting thousands of its outpatient consumers to private providers, raising the risk that some patients will become disconnected from their care and medication. For years, the city's public psychiatric hospital, St. Elizabeths, has been reducing its patient population, now down to about 340 from more than twice that in the 1990s.

In an agency with hundreds of employees and a budget of more than $200 million, the mobile crisis team and the rest of the Comprehensive Psychiatric Emergency Program play an outsize role in the effort to provide treatment and curb unnecessary admissions to psychiatric wards.

"A mobile crisis team is the backbone of a public mental health system," Stephen T. Baron, the District's mental health director, said in a recent interview.

'We're here to help you'

For decades, the District's mental health agency has operated under federal court supervision, and for years, the court-appointed monitor has been calling on the department to do better by people such as the woman in the wheelchair to create a way to serve people in crisis when and where they need help.

The woman had been in Superior Court that morning for a probate hearing. During the hearing, she told her attorney and her health aide that she wasn't going back to the nursing home. After trying to remain at the courthouse, the woman motored away, with the lawyer and the aide racing after her. She made it a few blocks before her pursuers were able to activate the brake on the wheelchair.

So began the standoff, which was more than three hours old when Isha Edwards, Nicholle Hill and their boss, Luis Vasquez, showed up from the mobile crisis unit. (As a condition of accompanying the unit, The Washington Post is not identifying the woman.)

"I'll just sit here and die," the woman told the new arrivals.

It wasn't the first time Hill had encountered the woman. Hill knew that she had a history of schizophrenia and could be belligerent and violent.

"This is kind of typical of her," Hill said out of the woman's earshot. "She can't be moved when she doesn't want to be moved."

And she was only getting started. "Just get out of my face and don't talk to me."

"You know we can't leave you here like this," Hill told the woman.

"I have a right to stay where I want." And then the woman suggested she would be in danger at the nursing home. "I'd rather be here and die than be raped," she said.

"What if we can take you somewhere safe?" Hill asked.

"We're here to help you out," Edwards said.

"You can't help me out," the woman roared back. "You can't help me out. It's too late. . . . I don't want your help! I don't want your help! Leave me alone. Leave me alone. I beg you to leave me alone. If somebody kills me here, there's nothing I can do about that. But I'm not going to no institution."

Building a reputation

The prevailing view is that many mentally ill people can and should be treated in their communities. Not only is it what laws require; it is what states are demanding as budgets shrink and health-care costs skyrocket.

Baron was tapped as the District's mental health director in 2006. As head of Baltimore's mental health authority, he had created a widely admired mobile crisis unit. By 2007, he had the District's mental health agency rethinking its approach to emergency services. And by last year, a plan was in place for a mobile unit.

Not since the late 1990s has the District had something approaching what it has today. That's an accomplishment for an agency that, although improving, is falling short of benchmarks set by a federal court and the U.S. Department of Justice.

Now, in Building 14 on the former campus of D.C. General Hospital in Southeast Washington, the members of the mobile crisis unit work down the hall from the psychiatric emergency room where they end up bringing some of the people they encounter.

The unit is staffed seven days a week, from 9 a.m. to 1 a.m. But the dry-erase board in the office is never bare, and so no one sits around for long. The employees don't wear uniforms, and they ride in innocuous minivans, usually in teams of two.

Most of their work plays out in private, in homes and hospitals where families cope with mental illness. Occasionally, though, things unfold on a public stage.

There was the request from the Secret Service one day to help assess someone who had jumped the White House fence. In June, there was a call to respond to the deadly Metro crash near Fort Totten.

In short order, the unit has made believers of some important partners.

"All I know is that for the last year, when I call, they come," said Assistant Police Chief Diane Groomes. She frequently requests assistance from the unit. Last month, she asked for a team to be sent to a deadly Clay Terrace shooting to help the parents of the victim, whose body was on the ground. "They are very responsive."

A willingness to serve

Most of the mobile unit employees were caseworkers at nonprofit agencies serving the mentally ill, and that has been an asset, said Vasquez, who hired them.

"It's nothing against government, but we're not caught up in the mind-set of bureaucracy," said Vasquez, a social worker who came from Catholic Charities. And what Vasquez wanted, more than good credentials, was a willingness to serve people who can't always say thank you.

Dealing with someone like the woman on F Street isn't just about having a thick skin, mental health experts said. It's about understanding the frustration of a woman who senses how powerless she has become. It's about respecting her rights. And it's about thinking through whether to take her against her will.

The police officers wanted no part of it. Neither did the emergency medical workers. "She's going to put up a fight," one of them said. "She doesn't want to be touched."

That was clear. But it had been five hours since the standoff began and almost two hours since the mobile crisis team had arrived. The sun was setting, and the temperature was dropping. And the woman, the team members had concluded, was a danger to herself.

So at their direction, the officers and medics started to lift the woman out of her chair. As they struggled to put her on a stretcher, she screamed and flailed. The officers and medics got her on the stretcher and into the ambulance that would take her to United Medical Center in Southeast.

It was not the way the crisis team had wanted it to end. And it was not how the woman had wanted it to end.

"Je-sus!" she screamed as the stretcher was hoisted into the ambulance. "Je-sus! Je-sus!"

Hill, who's 33 and studying for her doctorate in psychology, reflected on the incident later. She said she didn't see an angry, unappreciative woman. She saw a woman in need. "There is a certain privilege that goes along with being able to be there for somebody in their darkest moment."

© 2009 The Washington Post Company