Psych Crisis: End-of-the-year update
Focusing the plan: preparing to rebuild the psychiatric crisis system from the ground up
For those who are new: I founded Psych Crisis at the beginning of this year, fueled by a grant from Emergent Ventures, to work on transforming the psychiatric crisis system. My brother died after going through the existing system and I was fucking mad about it. At the start, I had this giant goal but no single hypothesis about how to get there–my plan was to learn enough about the problem, and start down enough possible paths to find one.
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This post will describe the current vision and plan for Psych Crisis, after (roughly) its first year of operation, and ask for your help to make the next part happen.
The current situation: what happens when people try to improve psychiatric crisis care
I knew that in order for a single person’s experience of crisis care to change, a lot had to go right in all the systems that coordinate to make that care happen.
This year I learned a lot about the different systems that go into making care happen–medical centres, social services agencies, insurers, funding providers, individual clinicians’ businesses, training programs for clinicians, licensing programs for clinicians, legislatures that make laws that govern how crisis care works, legislatures that make laws that fund crisis care, research programs that try to assess what is working right now, research programs that try to study the components that go into successful recovery, government departments that try to nudge these institutions from afar with financial incentives and training.
I discovered stress, entropy, and bits that don’t work very well in each of these systems, but I expected to find that, and most systems should be able to tolerate a bit of dysfunction and still be able to meet their goals. I also met and learned about the people working to change these different systems: social entrepreneurs founding new mobile crisis teams, activists lobbying to repeal specific legislation, nonprofit leaders advocating for funding for specific new services. Everyone agrees there needs to be more funding, but believe it should prioritise their part of the system.
Here’s the thing, though. It seems that no one’s individual preferred improvement is going to make crisis care work properly, because it can’t improve a person’s experience within the system without the coordinated change of other key parts of the system. It doesn’t make a big difference to find a medication with fewer side effects if doctors don’t have time to learn about it, or to improve the wages of mobile crisis teams to reduce their stress so they have more time and patience if triage nurses are still hurried and stressed, and people generally get handed from one to the other.
Understanding this dynamic helped make it obvious why the psychiatric crisis system hasn’t been able to improve itself, despite there being lots of people (executives, consultants, process improvement managers, measurement and evaluation analysts) whose job it is to improve it, and multiple millions of dollars thrown at trying–anyone with the power to change one system only has the power to change that one, and not the other systems it needs to coordinate with to work.
In order for a single person’s experience of crisis care to be better, all the systems they interact with need to function together, but this change is impossible to make, regardless of how powerful you are or how much money you have, because no one person, group or coalition can change enough parts in the system. If Psych Crisis had the power, influence, money and supporters of NAMI, a large mental health nonprofit in the US with annual donations of $30 million, thousands of volunteers and regular national news coverage, we could not have a hope of improving psychiatric crisis care enough to change whether lots of people live or die. The system is stuck.
(I don’t believe this is the right conclusion to draw for the process of fixing problems in all social systems; but specifically for social systems that have to work together to do something that is right for a single individual).
The alternative solution
Given this, the alternative is to regrow it: to build an alternative system that is designed so that it can easily be changed in response to feedback about how it is doing at its goal, and it can adapt to solve similar problems for people in different situations.
What is ‘an alternative system’? The smallest possible thing that could meet this definition has:
Enough people with enough training, emotional stamina, motivation and their own safety to support a single person from crisis, through repair to recovery
Enough money to pay fairly for the time, attention, energy and opportunity costs of those people, in a way that doesn’t hinder the recovery process
The legal permission to do the work
The administrative capacity to make this arrangement reliable enough to continue helping the person through recovery
Optionally: somewhere for those people to meet the person they are helping, and prepare for that work
Optionally: easily accessible sources of skills training, survival resources and therapeutic healing to use in the recovery process
So, the answer to ‘how big does the smallest possible crisis system have to be? “Big enough for one person.”
The key questions to ask, to tell how good such a system is:
Does it work (at all)?
Does it work reliably (over time)?
Does it work reliably (for different people in different situations)?
Is it available, reliably, for the total number of people who need it?
These questions are in increasing order of difficulty. While most people in government and advocacy focus on improving the answer to 4), I believe it is more important to focus on the answer to 1) first, because there are only a handful of crisis services currently operating that can give a positive answer to it at all.
This plan is fundamentally about designing the new system so it has the correct structure to learn to handle increasingly difficult crisis situations, protect the people and resources in it from burnout, and adapt in response to feedback. It involves starting extremely small and only growing to take on new difficulties (more people, more difficult cases) when it can reliably handle the previous level of difficulty.
This plan does not rely on:
The development of a specific drug, research technique or technology
Massive increases in investment in treatment of mental health overall
Massive increases in the ability of clinicians to resist burnout, learn new things, comply with rules, or tolerate low wages
Legislation to be successfully passed through legislatures
It does rely on:
Resolving unanswered questions about how it will be funded sustainably
Resolving unanswered questions about how it will attract, retain, and protect from burnout enough clinicians (or counsellors) to do the work, sustainably
Being able to jump through the (still unknown) required legal hoops to operate
Protecting whatever aspects of the work culture are necessary components of successful recovery as it grows (such as a respect for interpersonal boundaries, a capacity for conflict resolution and compassion)
Being able to grow at all
My new aim, with this organisation, is to create the smallest possible crisis service that can respond in a real, risky crisis situation and answer a) successfully.
Once we can be confident that the service can work, we can increase the challenge by attempting to serve more people, attempting to serve people in more difficult situations, and attempting to serve people in more places, all while keeping the service successful as it gets older and the initial excitement of starting wears off.
(If you are operating a service with similar goals, or the necessary resources I listed above, particularly if you are located in the Bay Area, please, please, please reach out and let’s talk about how we can do this together!)
Theoretical aside: what problems should the new system be solving, and how?
A fully-functioning psychiatric crisis system has to handle an almost infinitely varied collection of problems, because the human mind is extremely varied and so are the sorts of situations we find ourselves in when we’re in crisis. I don’t intend to find one kind of treatment, or even a set number of treatments, that will reliably resolve crises for everyone. Clinicians are too varied in their beliefs and personalities to agree on one treatment process anyways.
The plan, instead, is to focus on improving each group of clinicians’ ability to figure out what’s going on in a particular situation, try things that might help, check to see whether they helped, and make different plans if those things didn’t work. The current system ties clinicians’ hands behind their back and restricts them to an extremely limited set of ‘treatments’ depending on their medical or social work specialty.
Essentially, the aim is to help clinicians become more strategic.
In order to use this strategic ability, they need to know what’s going on. There are a few things required for them to know what is going on:
They need to get enough time to develop a picture of the situation, instead of playing musical chairs and seeing lots of random clients for short periods of time
Their clients need to develop enough trust in them to show them what’s really going on, even things that are difficult or painful
They need to feel safe enough to see what’s going on, including when they don’t like it
They need to be able to withstand jumping to conclusions when they don’t know what’s going on, and also make hypotheses about what might be going on that they can’t see
There may be psychiatric, psychoanalytical, sociological, philosophical, or biological theories thrown about. That is to be expected, and is fine, as long as it doesn’t risk destroying the trust of the client (i.e. by treating them without dignity). I expect multiple theories to be used, sometimes even at the same time.
I have a current experimental framework for developing situational awareness of a crisis, but it’s tentative, and I expect to work with people who disagree with it!
What have we done to get this far?
The main useful output Psych Crisis has created in its first year of operation (if we consider it to have started in Nov 2021) has been my improved model of the problems and constraints of the mental health system that keep it from successfully carrying out its purpose. I regularly meet practitioners now who assume I have been working in the field for years because of the depth of my understanding, which gives me some confidence that an approach based on this initial perspective has some chance of success.
In order to develop this perspective I have:
Trained in a method for extracting expertise using interviews called ACTA and interviewed 10 people who have successfully navigated their own mental health crises, producing a presentation called Learnings from the Lived Expertise Project.
Gotten some basic training in counselling, and practice helping those in crisis: I trained in Intentional Peer Support, and as a suicide hotline counsellor, and regularly take calls as a hotline volunteer.
Interviewed the leaders of other projects aimed at improving crisis response, producing podcast interviews (to be published!) and case studies about what can be learned from them.
Met practitioners working to change crisis care–at conferences (LEAD-CAMHPRO, ISPS-US, Peerpocalypse, APA, Alternatives) and through outreach and introductions. Interviewed them to learn their motivations, constraints, and worldviews.
Researched the funding structures of existing crisis systems, including getting an overview of the insurance industry, grant funding system and Medicaid funding processes, producing writing on how funding influences treatment and developing concepts for alternative funding mechanisms.
Learned about philosophical and paradigmatic issues that limit psychiatric treatment, ran a book club on Enactive Psychiatry, and developed a novel model of psychiatric crises and a taxonomy of psychiatric treatments.
In order to do this I have needed to find the money and resources to direct towards the project:
I recruited board members Jasmine Wang and David Ernst and established an approved 501(c)3 organisation.
I won a $60K grant from Emergent Ventures and a $80K grant from the FTX Future Fund regranting program (now in limbo).
I set up to receive cryptocurrency and received two other significant donations in crypto.
I established a monthly update newsletter that now has 116 subscribers.
I published a marketing website at psychcrisis.org.
My initial theory of change implied that if I could successfully capture the demand for crisis services before clients and their families found help I could use this power to persuade crisis service providers to improve their services. This led me to create a guide for responding to a loved one’s manic episode which is available online.
The guide has been read and used by three people in live crisis situations.
The guide was also read and evaluated by several people with lived experience and clinical practitioners.
This is all to give you a sense of what I and others working on the project have done so far, and where it is currently at.
So, what do we need to do next?
Many of the structural elements of this pilot service will mirror the structure of the Suicide Crisis Centre UK, run by attempt survivor Joy Hibbins, which has a zero suicide rate amongst its clients in nine years of operation and which our community donated $16K USD to in memory of my brother last year. They’re able to train a new crisis service team in order to transmit important cultural elements that support their success. In order to establish the first end-to-end crisis service, we need:
A minimum number of Bay Area-local counsellors with the necessary skills (likely three)
A lead counsellor to establish the norms and run the team
A channel for recruiting clients experiencing that type of crisis
Communication methods–phone, email
A centre for people to visit and stay at
Legal approval to operate the service
A chosen first crisis type
A prototyped design of a funding process
Agreements with institutional funders who will contribute via the funding mechanism
Funding to pay for the project’s expenses prior to breaking even
All the items in the first list could be met by partnering with a suitable local organisation that has a lot of the relevant resources and values already. My focus now is preparing Psych Crisis to launch such a project, ideally with a partner but otherwise as the main organisation running the project. The pilot project itself will require funding at least in the order of ~$300,000 for a year of operation. However, being in the preparation stage costs less than that–approximately $100,000 for a year of operation (mostly for a single fulltime staff, legal advice, office space, admin, recruiting), and the better the preparation is, the better the chance of success once it’s running.
Psych Crisis recently received an $80K grant from the FTX-funded Future Fund regranting program specifically for our crisis guide (FTX, which has since gone bankrupt). There is a lot of legal uncertainty about whether that grant will be clawed back as part of bankruptcy proceedings, so in the meantime we are setting it aside awaiting legal clarity on whether we can use it.
If we can source some of the funding needed to work towards opening a first crisis service from individual donors, we a) are less dependent on bigger institutional donors and b) can spend more of my time and the board and volunteers’ time preparing to open the first service, rather than fundraising.
How to help
If you have read this far, thank you! If you are excited about supporting this project with money or volunteer time, amazing, that is incredible to know.
There’s now a donation page where you can contribute to support the project (with a donation that is tax-deductible in the US). You can donate here.
The more this project is supported by individual donors, the more flexibility we have to address the problem without fitting into existing grantmaking paradigms (which are often aligned with the sorts of problems that already plague the mental health system). Please share this post with anyone you think might be interested in the project.
If you’d like to volunteer, particularly if you have interest or skills in fundraising, legal research, or nonprofit administration, email me at email@example.com. And, if this piece resonates with you and you are a mental health practitioner (or practitioner-in-training) in the Bay Area, please definitely email me–I’d love to talk to you.
And if you have questions or comments on this plan, please add them in the comments below! I have left out many details for brevity that I’m happy to go into in the comments.
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