VA and CIT: A Community Partnership

NAMI National ConventionJuly 7, 2009

San Francisco, California

Thomas M. Kirchberg, Ph.D., ABPPChief Psychologist

VA Medical Center at Memphis

The views and/or opinions expressed in this presentation are solely the responsibility of the author and do not necessarily represent those of the U. S. Department of Veterans Affairs, the VA Medical Center at Memphis, the Memphis Police Department, or the University of Memphis CIT Center.

VA and CIT: A Community Partnership

• Lincoln and the Mission of the VA

• 2003 President’s New Freedom Commission

• 2004 VA Strategic Mental Health Plan

• 2008 Uniform Mental Health Services in VA

• People with mental illness in jail

• Memphis Police Department and VA

VA and CIT: A Community Partnership

1. You will be able to verbalize an understanding of Abraham Lincoln as a transformational figure for individual, family, community and national attitudes and behaviors toward persons with mental illness.

VA and CIT: A Community Partnership

2. You will be able to verbalize an understanding of VA Mental Health Services.

3. You will be able to verbalize how the mission of VA Mental Health Services, NAMI and CIT are mutually supportive in the process of transforming mental health services.

VA and CIT: A Community Partnership

4. You will be able to initiate a conversation between local law enforcement/CIT and local VA with the goal of improving care for persons in mental health crisis in your community including Veterans.

President Abraham LincolnSecond Inaugural Address, March 4, 1865

“With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

Factors in Depression

1. Biological Predisposition

- Mother—Nancy : “intellectual, sensitive, sad”

- Father—Thomas : “blues and

often alone”

- Uncle—Mordecai : “broad mood swings”

- Cousins : “moody spells and humor”

Factors in Depression

2. Environmental Influences- Mother: died October 5, 1818- Father: went to Kentucky to find a

new bride- Sister, Sarah died January 28,

1828- Troubled relations with his father

Lincoln’s Melancholy, J.W. Shenk, 2005, pp. 11-15; 107

Springfield Illinois, 1860 ©Granger Collection

Black Hawk War 1832

• Lincoln was elected captain of the New Salem, Illinois militia company called up to take part in the Black Hawk War.

• Illinois and federal troops routed a small band of Sauk and Fox Indians who sought to return to their ancestral lands

• Lincoln saw no action.

Abraham Lincoln, McPherson, J.M., pp. 5-6; Lincoln’s Melancholy, Shenk, J. W., 2005, p. 16

July 27, 1848

“By the way, Mr. Speaker, did you know I am a military hero? Yes, sir…I fought, bled, and came away” after “charges upon wild onions” and “a good many struggles with the musquetoes.”

Tried by War, McPherson, J.M., 2008, p. 1

Lincoln’s 1860 Recollection of Militia Service

“…a success which gave me more pleasure than any I have had since.”

The Collected Works of Abraham LincolnThe Collected Works of Abraham Lincoln, vol. 3, p. 512 in Shenk, p. 16

Granger Collection

Summer 1835…• Anna Mayes Rutledge• Dismal weather• Lincoln “told me that he felt like committing suicide

often…”• “… Mr. Lincoln’s friends were compelled to keep watch

and ward over Mr. Lincoln…he being from the sudden shock somewhat deranged. We watched during storms—fogs—damp gloomy weather…for fear of an accident”

Mentor Graham to William H. Herndon on April 2, 1866 in Lincoln’s Melancholy, Shenk, J.W., 2005, p. 19; Abraham Lincoln, McPherson, J.M., 2009, pp. 6-7.

…Summer 1835

• “After several weeks of worrisome behavior—talking about suicide, wandering alone in the woods with his gun—an older couple in the area took him into their home…”

• “Bowling Green and his wife Nancy took care of Lincoln for one or two weeks. When he improved somewhat, they let him go, but he was quite melancholy for months.” G. Miles to William H. Herndon on March 27, 1866 in Lincoln’s Melancholy, Shenk, J.W., 2005, p. 21

January 1841

• Mary Todd• Matilda Edwards• Joshua Speed ended partnership in store• Deadline for State of Illinois on debt

interest of $175, 000• Sarah Rickard• Medical concerns

Team of Rivals, Goodwin, D.K., 2005, pp. 92-98

January 1841

• Missing votes; sessions; whole week• “Lincoln went Crazy—had to remove

razors from his room—take away all knives and other dangerous things—&c—it was terrible.”

• January 17, 1841, Edwin Webb wrote: “He has grown much worse and is now confined to his bed sick in body & mind.”

Lincoln’s Melancholy, Shenk, J.W., 2005, pp. 57; 261; Abraham Lincoln, McPherson, J.M., 2009, p. 10; Team of Rivals, GoodwinD.K. 2005, p. 99

January 22, 1841Letter to John Stuart

“I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I can not tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or better, it appears to me.”

Team of Rivals, GoodwinD.K. 2005, p. 99

1841• January 29: Springfield Register: “Mr.

Lincoln has now recovered from his indisposition…..”

• March: “hanging about—moody—silent etc.”

• June: Mary Todd wrote, “[I] wish [he would] once more resume his station in society.”

• July: Farmington on Bardstown Road near Louisville

• Steamboat Lebanon: “slave trader and 12 negroes”

Lincoln’s Melancholy, Shenk, J.W., 2005, pp. 63-64

The Civil War

The Civil War

• President Lincoln made more than a dozen trips to the front lines

• “He gave himself, night and day to the study of the military situation.”

• Lincoln made frequent visits with his wife to sick and wounded soldiers in Washington hospitals

• John Hay: Dead soldiers on the battlefields “tore at his heart”

Team of Rivals, GoodwinD.K., 2005, pp. 536; 539; Tried by War, McPherson, J.M., 2008, pp. 3; 249

Civil War Deserters

• “I have not made up my own mind how I should behave when minie-balls were whistling and those great oblong shells shrieking in my ear.”

• “It would frighten the poor devils terribly to shoot them.”

Team of Rivals, GoodwinD.K. 2005, pp. 536; 539

Civil War Deserters

• “Although ‘officers only see the force of military discipline…’—a picket so exhausted that ‘sleep steals upon him unawares…’—a young boy ‘overcome by a physical fear greater than his will.”

• John Hay was struck “at the eagerness with which the President caught at any fact which would justify him in saving the life of a condemned soldier.”

Team of Rivals, Goodwin, D.K., 2005, pp. 536; 539

http://www.abrahamlincolnartgallery.com/archivepage4.htm

Resisting the Draft

“The mother said, ‘Mr. President I will meet you in heaven.’ Lincoln answered, ‘I am afraid with all my troubles, I shall never get there, but if I do, I will find you. That you wish me to get there is the best wish you could make for me.’ ”

J. Speed to W.H. Herndon, June 10, 1865 in Lincoln’s Melancholy, Shenk, J.W., 2005, p. 203

Resisting the Draft

“ ‘… I am very unwell but that is the only thing I have done today which has given me any pleasure…that old lady was no counterfeit… die when I may, I want it said of me by those who know me best that I always plucked a thistle and planted a flower where I thought a flower would grow.’ ”

J. Speed to W.H. Herndon, June 10, 1865 in Lincoln’s Melancholy, Shenk, J.W. 2005 p. 203

1864 Election

• President Lincoln more popular among soldiers than General George B. McClellan

• “I cannot fight for one thing and vote for another.”

• “I would rather stay out here a lifetime, much as I dislike it than consent to a division of our country.”

Tried by War, McPherson, J.M., 2008, p. 249-250

1864 Election

• Lincoln won 78 % of soldiers’ vote

• Lincoln won 53 % of civilian vote

Tried by War, McPherson, J.M. , 2008, p. 250

Empathy

“The inclination to exchange thoughts with one another is probably an original impulse of our nature. If I be in pain I wish to let you know it. And ask your sympathy and assistance; and my pleasurable emotions also, I wish to communicate to, and share with you.”

Abraham Lincoln, February 11, 1859

1864

• Empathy for citizen soldiers

• “Father Abraham”

• Sought to mitigate military punitiveness

• Commuted many court-martial death sentences

Tried by War, McPherson, J.M., 2008, p. 249

April 14, 1865Good Friday

• Patrick Murphy deserted one regiment and joined another under assumed name

• Court-martialed• Found guilty and sentenced to be shot• Court-martial recommended the sentence

be commuted because the soldier had mental illness

April 14, 1865Good Friday

“This man is pardoned, and hereby ordered to be discharged from the service.”

Records of the Judge Advocate General, National Archives, MM761in Lincoln’s Melancholy, Shenk, J.W. 2005 p. 210

“Of Abraham Lincoln, who can say enough? Lincoln was not much of a churchgoer. But he risked his life and finally lost his life to save the Union and to bring freedom to slaves. ‘As I would not be a slave,’ he wrote, ‘so I would not be a master.’ There have been few people in the history of the world, or in the history of our country, who better deserved the name ‘father of faith’ than did Lincoln. He delivered this country from its foundational sin: he led us out of the twin horrors of being slaves or owning slaves.”

Patrick J. Ryan, S.J., America, March 24, 2008

Lincoln’s legacy remains

“The hope is not that suffering will go away, for with Lincoln it did not ever go away. The hope is that suffering, plainly acknowledged and endured, can fit us for the surprising challenges that await.”

Lincoln’s Melancholy, J.W. Shenk, 2005, p. 216

2003 New Freedom Commission

“Americans with mental illness deserve our understanding, and they deserve excellent care. They deserve a health system that treats their illness with the same urgency as physical illness… mental disability is not a scandal—it is an illness. And like physical illness, it is treatable, especially when the treatment comes early.”

New Freedom Commission …continued

“After a year of study, and after reviewing research and testimony, the Commission finds that recovery from mental illness is now a real possibility. The promise of the New Freedom Initiative— a life in the community for everyone—can be realized”

New Freedom Commission…continued

“…the commission recommends a fundamental transformation of the Nation’s approach to mental health care. This transformation must ensure that mental health services support and actively facilitate recovery, and build resilience to face life’s challenges. Too often, today’s system simply manages symptoms and accepts long-term disability.”

New Freedom Commission…continued

Three obstacles prevent Americans with mental illnesses from getting the excellent care they deserve:

• Stigma surrounding mental illnesses• The fragmented mental health service

delivery system• Unfair treatment limitations and financial

requirements placed on mental health benefits in private health insurance

2004 VA Mental Health Strategic Plan

• Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.

New Freedom Commission Recommendation 1.1

• Address mental health with the same urgency as physical health.

New Freedom Commission Recommendation 1.2

September 11, 2008 Uniform Mental Health Services in VA

Medical Centers and Clinics

• High priority on returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans

• Implement goals of President’s new Freedom Commission on Mental Health 2003

• Continuation of VHA Comprehensive Mental Health Strategic Plan 2004

September 11, 2008 Uniform Mental Health Services in

VA Medical Centers and Clinics• Establishes minimum

clinical requirements for VHA Mental Health Services

• Delineates essential components of mental health program

• Ensures access to needed mental health services

• Specifies services that must be provided in VAMCs and Community Based Clinics

• Mental health care is essential component of overall health care

• Coordinate care of substance use disorders and other conditions

Uniform Mental Health Services in VA Medical Centers and Clinics

• VA mental health services must be recovery-oriented

• Mental health services must be provided with cultural competence

• Evidence based psychotherapy

• Evidence based pharmacotherapy

• Suicide Prevention• Homeless Programs• Supportive

Employment• Rural mental health

care• Veterans Justice

Outreach

May 27, 2009Requirements for VA Medical Center and VISN Activity Focused on Justice-Involved

Veterans

Each VA Medical Center must designate a VJO Specialist…responsible for:

1. Direct outreach2. Case management3. Liaison with local justice system partners4. Provide or coordinate training for law enforcement personnel…on

Veteran-specific issues

“…jails and prisons have increasingly become surrogate mental hospitals for many people with severe mental illnesses.”

Out of the Shadows, Torrey, E.F. 1997.

People with Mental Illness in Jails

• Annually in the US, approximately 11.4 million people are arrested and booked into jails

• Approximately 1,100,000 people—8 percent of annual jail bookings—have current symptoms of serious mental illness

• Of these approximately 75% have co-occurring substance use disorders.

Bureau of Justice Statistics, 2006; The National GAINS Center, 2004; Steadman & Naples, 2005; New Freedom Commission, 2004

People with Mental Illness in Prisons

• 1,528,041 prisoners in state or federal prisons

Bureau of Justice Statistics, 2007

• Estimates of persons with mental illness in prison run as high as 15 percent

Department of Justice, 2006

• Persons with mental illness “often rotate back and forth between being homeless and in jails or prisons

Out of the Shadows, Torrey, E.F. 1997

Veterans with mental illness in jails and prisons

• Veterans constitute 10.4% of US Adults

• Veterans are 11.7% of Jail inmates• Veterans are 9.4% of State and

Federal Prison inmates

Bureau of Justice Statistics, 2004; US Census Bureau, 2006

VA Medical Center Memphis and the Memphis Police Department Crisis

Intervention Team:

A Community Partnership

1987 A Mental Health Crisis Becomes a

Community Crisis in Memphis• Officers called to Lemoyne Gardens

• Young male threatening family and neighbors with knife

• Young man ignores orders to drop knife and advances toward officers

• Young man is shot multiple times and dies

Community Outcry

• Young man was African American with long history of mental illness

• Lemoyne Gardens was African American Community near Lemoyne Owen College an Historic Black College

• Officers were of European descent

Memphis: A painful history

• Racism

• Poverty

• Mistrust of Police

• Assassination of Dr. Martin Luther King

Dr. Martin Luther King

• “Our loyalties must transcend our race, our tribe, our class, and our nation…”

• “We are tied together in the single garment of destiny, caught in an inescapable network of mutuality.”

• “The end is reconciliation, the end is redemption, the end is the creation of the Beloved Community.”

Community Opportunity

• Mayor Richard Hackett organized a meeting of community leaders:– Law Enforcement – Mental Health Agencies– NAMI– Academic Institutions

• Initial discussions led to recognition of need for change in how police interact with persons with mental illness

• Police training program envisioned

Integrated Crisis Services for Behavioral Emergencies

A Community Partnership Since 1988Memphis Police Mental Health NAMIServices Community

Patrol Division U of Memphis National Alliance on

Mental Illness (NAMI)

Crisis Intervention Regional Medical Team (CIT) Center (MED) NAMI Memphis

VA Medical Center

Community MHC

U of Tennessee (1988-2003)

Community Collaboration

• Systemic change within local mental health delivery system

• Systemic change within law enforcement/criminal justice system

• Persons with mental illness are able to access care more readily in times of crisis

2 Questions

1. “How much is Crisis Intervention Team (CIT) training going to cost?

2. “Who’s going to pay for it?”

Dr. Burl Gilliland

• World War II and Korean War Veteran of the US Navy

• Co-Author of Best Selling Text: Crisis Intervention Strategies

• Director Counseling Psychology Doctoral Program at University of Memphis

“This is our community. We aren’t going to be paid. We will provide the training and resources necessary to make CIT a success because this is our community.”

Dr. Burl Gilliland, University of Memphis

VAMC Memphis & CITVAMC Memphis & CIT

1. VA provides staff to teach select CIT curricula at Memphis Police Academy

2. VA psychologists provide consultation to CIT

3. VA provides staff, volunteer Veteran patients, and space for dialogue with police officers in CIT training

4. VAMC Memphis Police Officers receive CIT Training

VAMC Memphis CIT Training

1. PTSD didactic

2. Introduction to Verbal Skills didactic

3. Verbal skills building exercises

4. Combat Veterans and CIT officers dialogue at VAMC Memphis

5. Traumatic Brain Injury didactic

6. Crisis de-escalation training

7. Ride-along with CIT Officers

VAMC Memphis CIT Training

7. In-service training– TBI

– Mental health updates

8. Consultation– Supervisory staff

– Honor Guard

VAMC MemphisCombat Veterans and MPD/CIT

Dialogue

1. To provide Veterans from the VAMC Memphis with an opportunity to assist in the education of police officers and mental health professionals about how persons with post traumatic stress (PTSD) might present in crisis situations; and the qualities of a successful crisis intervention with individuals who have PTSD.

VAMC MemphisCombat Veterans and MPD/CIT

Dialogue

2. To provide Veterans with an opportunity to share their personal experiences and knowledge of PTSD with police officers and mental health professionals with goal to assist them in protecting themselves against PTSD.

VAMC MemphisCombat Veterans and MPD/CIT

Dialogue

3. To provide police officers and mental health professionals participating in the MPD CIT training course with an opportunity to interact with Veterans diagnosed with PTSD in a non-crisis situation thereby decreasing stigma associated with PTSD.

Veterans and CIT Veterans and CIT

• Veterans report that CIT officers have saved their lives

• Many police officers are Veterans of the US Armed Services

• Combat Veterans volunteer to assist with CIT training

• Combat Veterans want to help other Veterans

• Veterans are proud to assist in program with potential to positively affect Veterans across US

• Veterans inform police officers about PTSD

• Veterans talk with other Veterans about their experiences in training CIT officers

Empathy — the Core Element of CIT

“To my mind, empathy is in itself a healing agent…because it brings even the most frightened person into the human race. If a person is understood, he or she belongs.”

Carl Rogers

VA Memphis Psychology Internship Emergency Services Rotation

• Didactics• Skills building• Ride-along

experiences

• Annual CIT Awards Dinner

• MPD Trauma Recovery Program

• MFD Trauma Recovery Program

• Ride-along experiences with MPD & MFD fire suppression vehicles and ambulances

CIT benefits the VAMC Memphis

• VAMC Memphis and Veterans are well- known to CIT Officers

• VAMC recognized as community partner by other mental healthcare facilities

• CIT Officers drop by to visit Veterans with mental illness in non-crisis times

• CIT responds quickly to calls for assistance by VAMC personnel (Suicide calls, welfare visits, MHICM, and VAMC EAP Program,)

• VA Police officers receive CIT Training

• CIT Commander calls on VA for consultation

• Police Supervisory Staff

President Abraham LincolnSecond Inaugural Address, March 4, 1865

“With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

Thomas M. Kirchberg, Ph.D., ABPP

Chief Psychologist VA Medical Center Memphis

Thomas.Kirchberg@va.gov

(901) 523 8990 ext. 5320