On testing out a new kind of crisis response training with crisis responders

Retrospective on our event for mobile crisis teams in the Bay Area

Jul 12, 2023

One of the core principles of this project is the recognition that ‘how good a crisis response someone experiences’ is determined by enough different systemic factors that any appropriate strategy for improving it must come at the problem from many angles.

One particular angle that has been bearing fruit lately has been asking ‘how are crisis responders currently trained? What needs to be improved about it, and why hasn’t it been improved already?’ Another angle is more like ‘if you find a $20 dollar bill on the ground, pick it up.’ (take advantage of surprising opportunities that come your way, regardless of their origin).

Last month we ran an event that was sort of a combination of the knowledge and questions from both those angles.

I have had a hypothesis for a while now that large chunks of the training approach for crisis responders had a problem that was similar to what expertise researchers had discovered in other fields–that the problems in the field demand the ability to respond improvisationally to a lot of different situations that do not have a predetermined format, yet the training teaches programmatic responses as if different crisis situations all have the same characteristics and thus most appropriate responses.

The upshot of this is that a crisis responder may try to respond to every different crisis in the same way, which means most people getting crisis help are getting a response that doesn’t match or suit their specific situation at all.

Hypothesis 1 - a new training paradigm might be useful

I wanted to test whether a new approach for developing training programs (from the field of naturalistic decision-making research, originally developed for military training and for the training of responders in high-stakes situations like NICU nurses and firefighters) would be interesting or useful in crisis response training. This is the approach I trained in myself and then used to do the interviews in the Lived Expertise project last year, which was the first application of one specific technique (Applied Cognitive Task Analysis) to uncover expertise about subjective phenomena, like a person’s own mental health crisis.

I’ve spoken to one of the top research teams in NDM and created a proposal to work with them to create a preliminary version of such a training program (and if anyone would like to fund it, let’s talk!) but in the meantime I wanted to see if we could learn something meaningful with myself and some Psych Crisis volunteers.

Hypothesis 2 - bringing local mobile crisis teams together might be useful

One night, while trawling around the in-house resource website for the crisis hotline I used to volunteer at, I came across a spreadsheet that listed the locations and contact information of almost fifty mobile crisis teams in the Bay Area alone. My immediate impression was: a) that’s way more teams than I expected and b) I wonder if they all know each other, or if they’re all working in parallel. I also met a crisis responder called Jill from UC Santa Cruz who was enthusiastic about the idea of bringing together mobile crisis teams in the Bay Area, and so the idea of doing a meet-up and training event specifically for people in these fifty crisis teams was born.

In the back of my mind was the idea that a) if the mobile crisis teams wanted to network that being the host for that networking could have unexpected benefits, and b) if we’re looking for teams to partner with to try new stuff, perhaps this is a good way to find them.

Profoundly unsexy work - the invitations

Have you ever done cold calling? We had a few existing connections, but the bulk of the teams on this giant spreadsheet Jill and I split up and called up to invite one-by-one. Some of them we called back several times, when someone said they’d have their supervisor call us back and it never happened. Getting to meet the supervisors of a large number of these teams, even if they didn’t attend, meant getting a window into their working life and the culture they operated in, and I had a lot of interesting brief phone chats with teams and supervisors. Sometimes, I just got intimately familiar with their automatic phone tree system.

This several-week-long inviting process resulted in responses -at all- from about half, RSVPs from 10 teams (about 20 people) and actual attendance from 5 teams, or about 12 attendees (plus our team of 6).

This included Ben Adam Climer, a crisis team trainer who used to work at a renowned crisis team in Oregon, and who flew up from LA to come. Meeting Ben Adam, understanding what he thought of this training approach, and jamming about ideas for the future was definitely a highlight of this whole project.

The training materials

The idea was to develop some case studies based on situations that happened to real-life experts, based on interviews I did with those experts. As a test run, I prepared one of them several weeks before the event with a participant from the Lived Expertise project last year and then tried teaching it at an online conference on the Peer Workforce.

THis, uh, did not go so well. Of about 20 people who showed up online, about 8 started the exercise and about 5 finished it. In my exit survey about half of the people who actually completed the exercise made it clear that they found it confusing! I had not made it clear in the title of the presentation that it was going to be about a manic episode and many people who arrived were overwhelmed by the level of technical detail about mania in the case study (especially if it was their first time learning about mania). We only had an hour to do it, and so the key part of the exercise (where you compare your decisions with those of the expert in the story) was rushed and confusing. Also, most other presentations at the conference were talks and most people did not arrive prepared to dive into doing a participatory exercise (some people were listening in while driving, for example).

Still, actually testing out the exercise with a bunch of people with no other connection to Psych Crisis was helpful because once that conference was done I had a laundry list of things that needed to be improved before the event with the crisis teams. This list went into the second round of work, which was doing the interviews and developing the training scenarios for the remaining case studies.

I wanted to develop a handful of scenarios that had a wide range of situations and different vantage points. So, I planned out four scenarios that I thought I could get prepped in time:

Person experiencing a manic episode (from the person in crisis’s perspective)
Person making a suicide attempt (from the responder’s perspective)
Person experiencing psychosis (from the responder’s perspective)
Person experiencing psychosis (from the person in crisis’s perspective)

I reached out and lined all these up, and did the interviews (if you want to nerd out about it, I used the Critical Decision Method which is geared towards digging into single scenarios, in comparison to ACTA which identifies capabilities). A Psych Crisis volunteer, Alanna, worked with me to turn them into written scenarios ready for the training event. In the end, I didn’t get the fourth one ready before the event, so there were three.

I wasn’t sure exactly what process to use to take the scenarios and use them to make useful exercises. Even though I wasn’t dictating what the ‘right answers’ were (as I was aiming to faithfully record the expertise of the experts, even if I had differing opinions from them), the choice of how to structure the training would still make a big difference in how the participants experienced the scenarios.

I decided to follow the process used by ShadowBox (a consulting organisation run by Gary Klein, one of the founders of the field of naturalistic decision-making research) and break the scenarios into sections where at each section participants would consider their own responses and then later, at the end, compare them to the expert’s. Of particular use was a tiny sample exercise ShadowBox published about training soccer. This helped determine the basic structure.

I then had to teach the method of facilitation to a group of Psych Crisis volunteers.

The team

This event had the biggest team Psych Crisis has ever had at one time, and it was great to have different people meet each other and also get to know the crisis professionals. Aside from event planning and prep, the lead-up involved training the volunteers who would be facilitating the training exercises in small groups on how to do it. They were very committed to getting the details right (and only acting as a support/facilitator, rather than a teacher) and teaching the format led to the volunteers tweaking and improving the format quite a bit to get practical details down more smoothly.

(On a side note: oh god is it so much nicer to be working with other people on things, particularly other people who care so much about the project! Still doesn’t happen all the time.)

The event

Our initial intention was to spend half the event (it was about 4 hours long) doing the training and about half the event having dinner, where everyone could mingle with other teams and talk about whatever they liked. What we didn’t anticipate was how much appetite there was for debriefing the training and particularly learning about what had happened in the other groups.

If you’ve ever facilitated an event you’ll know that carrying on an engaging conversation between more than about six people gets impossible pretty fast. So, that’s why I was amazed to see the group (around 15 total) pull all their chairs into one big circle and proceed to have one big, in-depth, voracious conversation about the training for almost two hours that we’d allocated for having dinner. There was a tonne of curiosity from team members who did one scenario about the scenarios from other groups, from the volunteers who had their own mental health experiences to the professionals about the constraints that shape their work, about the various approaches that each expert took, and how that differed depending on the physical environment they found themselves in…

The level of energy for talking and making sense of it all together astounded me. Sometimes, about frustrations about how their scenario wasn’t applicable to their work (for someone starting a team mostly focused on people who are homeless, whose clients do not have the social support of the lived-expertise expert in their story), and sometimes, about disagreements in approach from more experienced responders. There was a lot more sharing and agreement though–making sense of what to do when forced with dropping someone off to an indifferent hospital clinician, or dealing with time pressure, or vast cultural differences.

Eventually after an hour and a half of conversation (during which almost no one had moved a muscle) I wrapped it up and we all said goodbye.

What does it mean?

In the intervening time I’ve gotten to know some of the responders and their teams a bit better, and also gotten to know some of the people who couldn’t make it, and their teams (we had a few covid drop-outs). I was interested to discover that there are at least two teams that already use a model of crisis response that involves more intensive follow-up over time (albeit with a different person than the original responder). In mainstream mental health terms, this is called crisis response plus case management.

Another interesting, and pretty cool aspect of the event was that there was very little cross-cultural communication difficulty. My background is as an artist and meditation weird person, as was true for some of the Psych Crisis team, and we were in a venue (hi Alembic!) decorated with paintings of naked ladies, Tibetan thangkas and statues of the Buddha. We expected to encounter people speaking a very different, and perhaps irreconcilable language.

However, this went more smoothly than I expected. I think we could attribute it partially to the Psych Crisis volunteers’ willingness to learn about the way the crisis professionals’ world and culture worked, a shared desire to make crisis situations go better, Ben Adam and the SAFE Petaluma team’s ability to speak both in mental health jargon and in frank ordinary language, and the fact that the people who showed up seemed very curious about their clients and willing to try new things that might work for them. There was a lot of empathy amongst the professionals for why someone might not want to take medication or go to hospital, and grief at the lack of options available. The sense of ‘being on the same team’ felt strong, and that was something I was glad to discover.

What now?

Will we run these again? There was certainly demand to. Almost everyone wanted to be added to an update list so they could come to the next thing we did, and many wanted a copy of the scenarios to review later. It did seem like for the people attending at least, there was a desire to connect with people on other crisis teams like I’d suspected. There was also interest in developing context-specific cases with the experts from some of the teams that were present, and we’ll see how that pans out in the coming months.

There are discussions about developing more and different kinds of training that I won’t talk about publicly just yet.

It seems like if we did run them again, many more of the teams who couldn’t make it would be interested in coming.

For me, I’m particularly interested in developing a more specific, more unique set of case studies–ideally more from the perspective of the person in crisis, or even with multiple perspectives, and more specifically targeted to ‘the sort of cases a responder might see most often’ or find easiest to start with. We had two cases where the expert was the responder, and the scope of how they could respond was extremely limited by their role and the available resources. So, I couldn’t find cases where the client fully recovered, because this was not information any of the responders would ever get.

At this event I stood up with other Psych Crisis people and shared an approach we’d been working on with this new organisation with people who’ve been professionals in the field for a long time, and not only did they not laugh us out of the room, they couldn’t stop talking about it and asked us to do it again.

Thank you so much to Jill Heron of UC Santa Cruz, Ben Adam Climer, Anna-Teresa, Alanna, Taylor Elnicki, Deepa, Peter, our anonymous crisis experts and the crew of the Alembic for helping make this event work!