Angels in Crisis: How Mobile Crisis Intervention Changes Lives

Angels in Crisis: How Mobile Crisis Intervention Changes Lives

by Bill Martin
A psychologist's poignant account of a challenging case referred by Child Protective Services while working on a mobile mental health crisis team.

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"I don't know why he's so angry all the time," Ruby Clarke said of her 11-year old son, Lucas. Ruby had grape juice all over her hair and clothes, and her face was scratched. Having met Liz and me, clinicians for the Mobile Crisis Team, just the week before, Ruby made this first crisis call to help her get Lucas under control.

Upon discharge from a nine-day psychiatric hospitalization, Lucas's Child Protective Services (CPS) social worker referred him to Mobile Crisis and gave Ruby our hotline number. We soon followed up with an introductory visit. The Mobile Crisis Team goes to a family’s home to de-escalate a crisis in order to prevent unnecessary psychiatric hospitalizations, and in some cases to facilitate necessary hospitalizations by liaising with the police. We always visit the family first in a non-crisis situation, so they can get comfortable with us. People would much rather call someone they know at the mobile crisis team than an anonymous hotline number.

 

Family History

We had learned a lot about both Lucas and Ruby at the introductory meeting. Lucas was indeed a troubled boy. He once put the family cat inside the microwave. He used to beat their dog with a sock full of ice. In the middle of the night, Ruby would find him on the floor in the hallway, rocking in a dazed state.

When Lucas was four years old, CPS removed him from his home because Ruby and her then-boyfriend, Matt, were operating a methamphetamine lab in the basement. When the police crashed the lab, they found Legos and Tonka trucks on the floor within six feet of deadly bottles of anhydrous ammonia. Ruby had been up for eight days straight. Matt had been beating both Ruby and Lucas.

Ruby began a trying half-decade of recovery work, while Lucas spent the next seven years in foster care, getting kicked out of several foster homes due to his hyperactive and violent behavior. Ruby worked hard to get her son back, following all the therapy and substance abuse treatments that were asked of her by the courts. Even though she had done a lot of work on herself, she still had an edge to her, and could easily become exasperated. After seven years without Lucas, and on the heels of a difficult recovery, she found herself alone, raising this emotionally disturbed child. She sometimes withdrew into her own space in order to calm down, often chain-smoking cigarettes on the porch.

Introductions

During our introductory visit, Lucas showed us around his room like a miniature tour guide. He pointed out his TV, video games, basketball, and dart game. He didn’t mention the duct-taped holes in the wall from previous angry outbursts, and neither did we. It was no time to rub his nose in it.

Then Lucas showed us his “angel doll,” which seemed out of place amidst the other toys. The angel doll was dressed in a worn white robe with a crinkled gold foil halo. Lucas referred to it as “my angel.” Ruby had bought it for him at a garage sale one Christmas when Lucas was three years old. Back then she was so high most of the time that she almost forgot to buy him anything at all. She had spent most of her money on drugs. She found the angel doll three days before Christmas, and bought it for two dollars. To Ruby, the doll was now a reminder of a shameful time in her life. She wished Lucas would get rid of it, but she marveled at how much “he loves that old thing.”

As Lucas talked about “his angel,” Liz and I caught each other’s glance, knowing this doll was significant. It was a link to an idealized time, and was the most tangible thing he had of his mother for all those years apart. ”Your doll must be really happy that she’s had you all these years,” Liz said. “It can be scary sometimes, especially with all the new places you guys have been to.” Liz had a beautiful way with kids—she was caring, authentic, fun, and always optimistic about a child’s ability to recover.

“I guess so,” Lucas said.

“She probably wasn’t too worried, though. I bet she always knew you would never leave her behind.”

Lucas smiled sheepishly, leaned in close and whispered to Liz as if he didn’t want to embarrass her, “You know, she’s just a doll. She doesn’t really have feelings. I like her because she can fly and she reminds me of Christmas.”

Liz acted as if this was the first she’d heard about dolls not having feelings. “Oh, I see!"

Lucas had a right to be angry, but he didn’t know that. Any irritation in the present triggered an outpouring of pain from his past. He feared his angry self. Lucas was also more resilient than he could ever know. He still managed to smile, laugh, help others, and even make friends no matter how often he moved. Maintaining those friendships was tremendously difficult, but he could always win people over initially.

The First Crisis Intervention


Now, six days after our introductory visit, Ruby called our hotline. Lucas had arrived home from school in a foul mood, throwing his backpack down hard on the floor. A few days before, Ruby had instituted a 30-minute quiet time for Lucas in which he would relax after school. Lucas had taken to playing his videogames during this time, which actually only served to further stimulate him. The day Ruby called the hotline he was hyper and irritable, yelling for his mother to cook tater tots while he never took his eyes from the TV screen, thumping and tapping buttons and triggers rapidly. When Ruby suggested something else for dinner, Lucas knocked over his grape juice and began throwing a fit. He toppled a kitchen chair and stomped one of the legs off. He threw things around the house and yelled obscenities at Ruby.

The Mobile Crisis Team arrived at the home and we began our intervention. We address each crisis without taking sides. We present ourselves as compassionate to the child’s plight. We know he’s having a difficult time and probably has a logical reason to be upset. So we often ask, “How can we figure something out together?” From beginning to end, we deal with each crisis with an understanding that the situation is relational; there is no one “bad guy.” From the introductory visit onward, we make it clear to the parents that we are not “the heavy,” not to be used as a punishment, as in “You’d better calm down or I’m gonna call Mobile Crisis on you.” Our effectiveness depends entirely on being able to build rapport quickly and problem-solve collaboratively. If exasperated parents are allowed to remove themselves from the situation, they tend to insist that we “fix” the child. This results in a child feeling scapegoated and colluded against, and renders crisis intervention ineffective. Therefore, we also tell parents that this is a family intervention, and that they will be encouraged to be actively involved in crisis resolution and prevention.

The first step in a heated situation is to “separate the combatants” and “do crowd control.” That means we make sure that family members are not milling around, adding to the chaos. Generally, we initially meet privately, first with the parent, and then the child.

When we met with Lucas in his room, we allowed him to vent and say horrible things about his mother. We told him he had good reason to be frustrated, but that we had to figure out a better way to get his needs met. Lucas began calming down, so we started guiding him toward a more complete understanding of what had happened. We emphasized how his pre-existing mood set him up to explode, and how quiet time can help prevent problems. We discussed how he felt in his body when he was getting upset (“My ears get hot”). All of these interventions were aimed at helping Lucas to recognize and regulate his own mood. We explored alternative explanations for his mother’s intentions, so Lucas could build empathy. Empathy decreases a child's motivation to act out aggressively toward others. It also prevents the abusive cycle of demonizing the other person and believing that they deserve punishment.

We then brought Lucas out to the living room and had a family meeting in which we developed a brief safety plan to prevent future crises. The plan outlined questions Ruby would ask that would prompt Lucas to notice when he was feeling irritable, at which point Lucas would choose from a list of fun and relaxing activities to engage in. Whenever he did this, he would earn stickers on a sticker chart, leading to privileges and special toys. At this point, Lucas got very excited. He chose to earn Dragonball Z cards, which was no surprise to us—so many boys we worked with said they wanted them as rewards that we put our Pokemon cards in storage and started supplying Dragonball Z packets to parents. The safety plan and sticker chart were posted on the refrigerator.

Aftercare

We continued our crisis interventions for Ruby and Lucas one or two times per week for the next few months. We were usually able to calm things down. Lucas only had to be hospitalized once more during that time, for only two days. During this time, we had also referred the family to Wraparound Services, which consists of a team designed around the individual needs and wants of the family. The team is made of mental health professionals, a family partner (i.e., a peer-counselor who is the parent of a child in the mental health system), and others, such as the family's pastor or school psychologist.

Ruby and Lucas had a long road ahead of them. Lucas still had conflicted feelings toward his mother—he rejoiced at being home again, yet feared it could all be taken away at any second; he was angry at Ruby for not protecting him earlier in his life, yet he feared that his anger would force her to go away. He felt she’d left him because he was bad, and that his anger and dread might again prove his badness. The tension caused him to test limits repeatedly, almost as if he wanted to see if his mother would cut and run before he committed to loving her. One time, when we asked him if he loved his mom, he replied “not all the way.” Sometimes he could be overheard in his room venting to the angel doll as if it were a counselor.

We knew that Ruby needed to set firm, unemotional, consistent, and fair limits. In her case, it was essential that she not express exasperation or otherwise be too emotional when setting limits. Lucas would see that as a sign that things were still negotiable. He knew that if he pushed hard enough, she would give in. These interventions are filed under "parenting education." But Ruby and Lucas were also in a developmental crisis (i.e. a transitional state that anyone would struggle with). They were suddenly engaged in a parent-child dynamic. They were a reunited family with emotional baggage left to unpack. So as part of our interventions, we devised ways to help Ruby and Lucas rebuild their relationship.

Because they needed to intensify their positive interactions, the refrigerator soon had a second sticker chart of a blue sky with some puffy clouds in it. We gave Lucas and his mom each a roll of smiley sun stickers and instructed them to put a sticker on the chart anytime they acknowledged the other person doing something positive. When the whole sky was full of sunshine stickers, they earned a very special outing together. Lucas got a tremendous kick out of being able to give stickers for a change. They earned many outings together and their relationship blossomed. They saw the Harlem Globetrotters; they went on a safari; they went to an NBA autograph signing.

In good mobile crisis work with children and families, the heart of the work is this kind of ongoing aftercare. The acute crisis may end quickly with directive interventions based on ensuring safety and restoring emotional equilibrium. But the family is almost always in a vulnerable state in which other stressful events will trigger more crises. Therefore, we focus on crisis prevention. It's not about putting out fires, it's about fire-proofing. In addition to parenting education and relationship-building, aftercare involves enlisting (or developing) the family's natural social support. Most families don't want to have to rely on professional support all the time. To do so quickly becomes demoralizing. There are usually a few neighbors, extended family, and friends at work or church who are more than willing to help. Ruby had such helpers as part of her Wraparound team.

Five months later, things were going well. Wraparound was helping a lot, and Lucas was responding well to a new therapist. Lucas was his “usual hyper, moody self,” but he hadn’t had any major outbursts. He was passing all his classes at school. All the pieces were coming together—Mobile Crisis, Wraparound, psychiatry, therapy. The crisis calls tapered off.

A Celebration

Roughly six months after our last visit, the Wraparound coordinator called to invite us to a celebration for Lucas, who had just made Eagle Scout. Liz, now seven months pregnant, nearly fell off her chair when I told her about the invitation.

The atmosphere in the home was jovial and relaxed. Ruby took our coats and Lucas offered us something to drink. As often happens when emotionally disturbed kids turn the corner, they seem somehow more mature than their chronological age, perhaps as a result of all the storms they’ve had to weather. Many familiar faces were there from the Wraparound team, and several new friends that Ruby had met through church. She had built up quite a group of support for herself. Everyone was gentle and kind toward Lucas. Several people made toasts to Lucas and his mom. I spoke about how thankful we were to have worked with them.

Lucas trotted to his room when it came time for us to leave. He emerged a minute later carrying the angel doll. As Liz was wrapping her coat around her giant belly, Lucas held the angel doll up to her. “Here’s a present for your baby.”

“But this is your angel doll,” Liz said. “You’ve had it forever. I couldn’t possibly take it.”

“Go ahead,” he said, nudging it toward her. Liz looked over at me.

“Well,” I said, “I think the doll likes you. How can you turn down an angel?” Ruby stood behind Lucas, smiling the widest smile I had ever seen.

Liz’s eyes were swelling with tears as she took the doll. “Thank you.”

Lucas seemed concerned. “It’s okay. I don’t need it anymore.”

“No, I suppose you don’t.” Liz said. When we got to the car, she collapsed in tears. “Can you believe that? What that must mean to him!”

That was the last we heard from the Clarke family. Liz had a baby boy seven weeks later. She keeps the angel doll on a shelf in her baby’s room. She plans to give the doll to her son, and one day when he’s old enough, she’s going to tell him a story about how angels really do exist, even against all the odds.

Copyright © 2006 Psychotherapy.net. All rights reserved.
Bios
Bill Martin Bill Martin holds a PhD in Clinical Psychology from the Union Institute and University. Currently a therapist on an inpatient psychiatry unit in the San Francisco Bay Area, Bill has worked both as a clinician and a supervisor for two separate mobile crisis teams. He can be contacted at bmartin@hsd.cccounty.us.