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African Americans seeking mental health care are specifically affected by the general lack of fiscal commitment to community-based care. They also are more likely to delay seeking mental health treatment until their problems become more severe (Neighbors, 1984). Furthermore, African Americans are less likely than white people to obtain ambulatory or inpatient mental health services (Freiman, Cunningham, & Cornelius, 1994). They are also less likely to seek health care be cause they are uninsured, are less likely to have a regular provider, and are more likely to believe that they are victims of discrimination When they do seek mental health care, African Americans suffering from depression were more likely to seek informal mental health services from places such as churches (Neighbors, Musick, & Williams, 1998). In addition, African Americans in general are less likely to seek formal sources of mental health care, and studies indicate those who do seek community mental health services may not be able to obtain the type of care needed (Brown, 1984; Brown, Ahmed, Gary, & Milburn, 1995; Neighbors & Jackson, 1984).
Krupinski (1995) proposed a model of community mental health services that would provide regular psychiatric nursing supervision for people with chronic illnesses, 24-hour crisis intervention, outreach teams, and a range of rehabilitation programs, including social and living skills, budgeting, occupational training skills, workshops and recreation (Krupinski, p. 578). This column examines a service-delivery model, based on Krupinski's approach, that attempts to address the gap in the delivery of community-based mental health services to urban African Americans. This model combines a 24-hour crisis management hotline with a mobile support team and a residential care unit.
Depiction Of The BCRI Program Model
Slightly more than two-thirds of the BCRI program staff are African American. The top tier of the program is represented by six clinical administrators, half of whom are African American, who are responsible for the management of this program. The second tier of the organization includes eight master's levels mental health counselors, including social workers and psychologists, a quarter of whom are African American; 10 nurses, 70 percent of whom are African American; and six physicians, half of whom are African American. The last tier of the organization comprises 16 program aides, people with a high school diploma, associate of arts degree, or bachelor's degree, all of whom are African American.
Regardless of status or previous training, on entering the organization all staff members participate in a required 40-hour in-service orientation to the BCRI model. This includes lectures and participatory discussions, which integrate role playing and experiential exercises in the methods of crisis intervention as well as attendance in a three-hour class that focuses on interpersonal relationships between African Americans in the workplace. This class examines the historical and contemporary legacy of racism in local and national mental health service delivery and its impact on the treatment of African Americans. It also focuses on the interface between socioeconomic status and race/ethnicity, with an eye toward helping professionals understand how indigent people perceive them and helping professionals learn how to be nonjudgmental in working with poor people of color. This introductory training is followed by periodic in-service trainings, and peer-to-peer sessions based on topics provided by the staff.
The first point of contact with BCRI and the heart of the service-delivery model is the 24-hour hotline. The hotline serves as a screening mechanism and a source of referral for clients and service providers. The hotline must be the initial source of referral. At the time the call is made, the client either receives immediate assistance or is referred to the mobile treatment team. Immediate assistance can include telephone support by the hotline worker; a call to the police department, the emergency medical services, or the fire department for immediate assistance. In fiscal year 1998, BCRI responded to over 7,351 hotline calls. Approximately 30 percent of the hotline calls were for the resolution of an immediate crisis. Another 19 percent were for people at risk of attempting suicide. Approximately 14 percent were for people needing information regarding community-based social services. Approximately 26 percent of all the hotline calls were for supportive counseling. The remaining 10 percent of the calls were for referrals to other social services or a follow up from a previous call.
The information provided to the hotline counselor determines the next step. For example, hotline calls related to medical conditions such as high blood pressure may require the assistance of the nursing staff or the staff physicians. A hotline call in which the person has reported that someone has carried out a suicide plan require that the hotline worker immediately contact an EMT or police officer. On the other hand, a hotline call in which the person indicates that she or he has a suicide plan, but the contract for safety is in place, would result in the treatment team making either a phone contact or an in-person visit to intervene. In each case, the mobile crisis team would attend to the client needs depending on the nature of the call.
After the completion of the hotline call, clients who are believed to need additional services are referred to the mobile-crisis treatment team, which is made up of a master's-level social worker or a psychologist, a nurse, and a physician. In 1998 approximately 17 percent (n = 1,242) of all the hotline calls resulted in referrals to the mobile-crisis treatment team. All clients are given a clinical assessment by the mobile-crisis treatment team before a decision is made whether or not to admit them to a crisis residential unit. Seven hundred and forty two of these 1,242 calls to the mobile-crisis treatment team resulted in a person being admitted to the crisis residential unit. In addition to screening the clients, the mobile-crisis treatment team serves as the clinical arm of the residential program. In this capacity, the team sees each client every day while they are in the residential program. Each team is supported by the program aides who provide 24-hour-on-site support. The program aides focus on providing daily activity support to the residents, ensuring the safety of the clients, and supplying the clinical data that is used each day to plan the interventions for the residents.
For crisis, residential unit admissions, BCRI provides crisis intervention, supportive counseling, suicide prevention, mental health and substance abuse counseling based on a psychosocial assessment and the development of a treatment plan. The average length of stay for a person admitted to the crisis residential unit is 4.5 days. Approximately 73 percent of the patients admitted to the residential unit are African American. All residents have daily group meetings with the members of the mobile-crisis treatment team. The first daily meeting focuses on setting the goals for that day. The last daily meeting focuses on reviewing the group's accomplishments and planning the activities for the following day. Although there are a multitude of group activities based on the clinical needs of the clients, the most common group encounters focus on trauma, grief and loss, and psychoeducational issues. The trauma groups focus on coping with community and interpersonal violence, the psychoeducational group focuses on identifying and dealing with substance abuse trigger events; whereas the grief and loss group focuses on the loss of loved ones to HIV, violence, or intergenerational substance abuse. Because the average length of stay is three to five days, the groups are open-ended. As indicated earlier, as part of the treatment process, all people seen by the mobile crisis treatment team or in the crisis residential unit receive a psychiatric evaluation, as well as general counseling, mental-health counseling, and case management services. Nurses educate clients as well. Other services may include initiating medication, procuring housing, or starting substance abuse detoxification.
The majority of the BCRI treatment interventions are short-term, comprehensive, individualized, and dynamic. Mental health counselors at BCRI perform multiple roles, ranging from group leader or individual counselor to case manager. Mental health counselors are responsible for the coordination and implementation of several groups related to substance abuse, educational awareness and mental-health support. Furthermore, group leaders are responsible for assisting clients with locating such groups in their community. Residential groups are open-ended. Clients typically do not receive the full cycle of a 12-step meeting, but rather are educated mainly in substance-abuse relapse prevention. This is consistent with research findings that indicate that open-ended support groups are useful for inpatients with chronic and psychiatric illness because of the flexibility and the close, time-limited functions of the group (Cannon, 1923, cited in Fobair, 1998). Moreover, BCRI staff believe that clients introduced to this type of intervention while in the residential setting may be more likely to attend support groups in the community.
Our experiences suggest that to better serve the poor urban African Americans, a comprehensive, community-based, mobile-crisis intervention approach is needed. The BCRI model is an example of how to bridge the gap between service needs and service delivery to urban poor people. Implementation of models such as the BCRI model can increase social worker's responsiveness to the needs of neglected and vulnerable populations.
- Cornelius LJ, Simpson GM, Ting L, Wiggins E, Lipford S; Reach out and I'll be there: mental health crisis intervention and mobile outreach services to Urban African Americans. Health & Social Work, 2003 Feb, Vol. 28, Issue 1
Personal Reflection Exercise #9
The preceding section contained information about the BCRI Model for providing crisis intervention services to urban African Americans. Write three case study examples regarding how you might use the content of this section in your practice.