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Mental health crisis "living room model" expands in First State, focuses on peer support

Delaware is attempting to revolutionize the way it treats individuals experiencing mental health crises.



It’s turning to a “living room model,” with two centers - one in Sussex, County and a new one in New Castle County.


The model focuses on peer-support to help lessen stigma, and is designed to de-escalate situations and treat guests in less than 23 hours.

Delaware Public Media’s Megan Pauly takes us behind the scenes at the new center in Newark and introduces us to an individual who’s seen its benefits.

“There wasn’t a day went by that I didn’t wish I was dead. I went into treatment, out of treatment into treatment…I just couldn’t stay sober.”


That’s David Tribble. He struggled with alcoholism and drug addiction for years, and at his worst ended up living on the street.


Tribble’s story has a happy ending: he’s now working as a psychiatric nurse for RI International.


But when he was really sick he cycled in and out of the Maryland mental health system. He was often sent to the emergency departments – known as EDs. But they were ill equipped to provide crisis mental health services.


“I know firsthand what it’s like to be spit on," Tribble said. "What it’s like to be told to leave, have doors slammed in your face and you’re not welcome here. I know exactly what that’s like. And it’s.. you know, you’re already discouraged. You already think that you’re worthless because people have been telling you for years that you’re worthless, that you’ll never amount to anything. And then you come in looking for help and they tell you that you’re worthless. There he is again, back again. He’ll never get sober.”


Tribble says the experience left him reeling. He often waited 3-4 hours - and sometimes longer - to even be noticed.


With the help of devoted friends, he finally found a treatment plan that worked for him.  

He says the doctor he saw eventually helped him introduced an element he hadn’t experienced before in treatment: compassion.


“She said, you can do this Dave, you’re a very strong person. You can do this, you just have to work at it every single day.”


And that’s the same thing that RI International – a global non-profit – is hoping to do with its alternative crisis centers: incorporate recovery into the traditional crisis model.


The concept of “recovery” was coined by Dr. Bill Anthony, a researcher at Boston University in the 1990s.


"There was a term called 'broken brain.' You know, your brain was broken. It was the way your life was going to be." Anthony said. "Where I saw a lot of people personally who were getting better and tried to figure out a way to define what I was seeing."


Anthony has worked with RI to incorporate elements of recovery into its model of care. RI isn’t an inpatient facility, providing a maximum of 23 hours of de-escalation and stabilization.


Leon Boyko, Chief Recovery and Crisis Service Officer for RI gave me a tour of their new facility in Newark that opened just a couple of weeks ago.


“What we’ll do now is taking you downstairs into the unit itself where we actually provide psychiatric crisis services."


The location of the building is tucked into a serene cove of trees just off the freeway that Boyko says was chosen for its close proximity to Christiana Care’s emergency department and easy access for first responders.


“So here we are. We are currently on the unit, and they come in for a variety of reasons, primarily suicidal ideations," Boyko said.


When individuals first come to RI he says the first focus is on their immediate needs: things that will go a long way in increasing their level of comfort.


“Before we really get into anything else we ask them: what do you need? What can we help you with? And a lot of times people will say you know what, gosh I’ve been home crying for hours, I was talking to the police …I need some water, I need some juice or something. And we provide that right away,” Boyko said.


They’re also called “guests,” not patients.


“We call them guests, we want them to feel as if this is almost like a hotel,” Boyko said.


Boyko showed me one of the 16 units onsite. Since the model only allows for 23 hours of care, each room has two recliners instead of a bed.


“Here’s what you can see is a typical room," Boyko said. "These are recliners: they recline all the way back if an individual wanted to sleep, they can sleep. If they just want to sit in here and be quiet they can, or if they want to spend their time out in the common area they can do that as well.”


The common area is modeled after the look of a living room.

After the guest is made comfortable, they’re introduced to a peer recovery coach like Denae Spence– someone who can relate first hand to some of their experiences.


“They probably see me within the first 10 minutes, and sometimes I’m the first person they do see,” Spence said.


50 percent of RI staff members – including Spence - have “lived experience” of struggling with a mental illness themselves.


And another unique feature: what’s called a “recovery island,” an open counter with no glass barriers where guests can have easy access to mental health professionals, peer coaches and more.


Within 60-90 minutes, they’ll see a psychiatric medical provider either in person or via telemedicine depending on the time of day.


RI has opened facilities similar to the one in Newark in four other states - Arizona, North Carolina, California and Washington – as well as New Zealand.


It started with the Arizona facility in 1997, and reached the First State in 2012, when a six-unit facility was opened in Ellendale.


The effort was part of the state’s settlement with the U.S. Department of Justice over Delaware’s over reliance on institutionalized care. That settlement encouraged the state to provide alternatives to incarceration and hospital diversion.


"It was a model intended to be an alternative to traditional psychiatric treatment of folks who continued to re-cycle back through systems without really making any progress because they weren't getting empowered and reminded of their strengths," said Dr. Gerald Fishman, RI’s Eastern Regional Director, overseeing programs in Delaware and North Carolina.


He says RI’s recovery-based model is a large departure from the old method of treatment.


“These folks were being essentially handcuffed at times, shackled to gurneys, and in many ways re-traumatized," Fishman said.


Anthony says the new model called for what he says is a “no force first” policy: that is, that force by way of medication or other restraints should be avoided at all costs.


“Because we were asking the field to do something dramatic: in other words, believe they could run a crisis service or state hospital without forcing people either through seclusion, restraint, medication – force them to do what we want them to do," Anthony said. "So it was a big step.”


And that’s exactly what RI aims to do, by involving guests in their own recovery process.


“They from the moment they enter in our welcoming partnership process they get to actively engage, talk about what brought them in, the challenges they’re facing, tell their story and then they generate solutions that we can try to assist them with,” Fishman said.


David Tribble – who we met earlier – moved to Delaware after working for five years as a psychiatric nurse in Maryland.


“I was, I guess, just getting a little disillusioned with the type of care I saw being given. It went against my values…the things that I was witnessing,” Tribble said.


But he says RI aligns with his morals, and feels he can empower guests in his new role.


“I want them to look inside themselves and find what strengths they have," Tribble said. "Because I can give them all the information in the world, they can be sent out on medications and told to see your therapist, see this psychiatrist once a month and attend AA meetings or whatever. But unless they feel inside themselves that they can do this, they’re not going to do it.”


He told me about a recent experience when he was able to ask a guest what he wanted.


“I had a guest who came in last night and in the course of my assessment I asked him: where do you see yourself 5-10 years from now? What would you like to see if you had a life you could pick out? He said, I’d like to have gainful employment, have a steady job. I’d like to meet a woman, get married, settle down, buy a house and have a family. And then he said, you know what Dave? Nobody’s ever asked me that before. Of all the hospitals I’ve been in, nobody’s ever asked me what I wanted,” Tribble said.


Which Tribble says leads to what he sees as a key ingredient to success: hope.


“I think a journey begins with a first step. And the first step is to get some hope into somebody that things can be different this time. That you can change, you have that power," Tribble said.


Both Boyko and Fishman agreed that the model is working well so far, with over 70% of guests stabilizing within the 23-hour window, and not needing to escalate to higher levels of care.


“The recovery-based model that we employ says what more could we offer to help you meet the challenges in your life more effectively? And we own that," Fishman said. "So it really is a shift in accountability that we see in outcomes for these folks.”


When I spoke with them, Boyko said he received a call the day before from someone in Oklahoma who’d heard about the success of the program in California.


“We’re constantly getting asked: when can you open these facilities?"


The hurdle to expanding elsewhere is money. Right now, the state of Delaware is footing the bill for the centers here through its Division of Substance Abuse and Mental Health.


The operating budget for the centers in Newark and Ellendale is 7 million dollars, but Boyko says the costs are a third of inpatient care – and exponentially smaller when compared to emergency department costs.


Since 2012, the Ellendale facility has been very full: seeing 130-150 people each month. And just a week after opening, the Newark location was also filling up.


Boyko is hopeful that similar crisis services will become more common nationwide, especially after he and Fishman helped publish a white paper detailing the model’s success earlier this year.


And the staff – including Tribble – remain hopeful as well.


“This is the wave of the future, there’s no doubt in my mind," Tribble said. "This is the way healthcare is going. People say the mental health system is broken and I don’t believe that. It’s not broken, it’s just changing.”



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