Cheryl Martin (Host):
What happens after someone reaches their breaking point? And what's the path from crisis to stability? We get some answers in this episode. Our guest, Dr. Purcell Dye, the Chief Executive Officer at Spring Mountain Treatment Center, providing acute crisis stabilization and outpatient services to the Las Vegas community. This is Health Talk with the Valley Health System, presented by the Valley Health System. I'm Cheryl Martin. Dr. Dye, delighted you're here to discuss this topic.

Purcell Dye, PhD:
Thank you. Thank you for having me, Cheryl. I really appreciate it.

Host:
So when someone has reached an emotional or psychological breaking point, what should be the first 24 to 72 hours of care? What should that look like in a best practice modern health system?

Purcell Dye, PhD:
Wow, that's a really big question. I really appreciate it. In the modern care system, we do have—when I say we, I'm speaking of the hospital setting, specifically crisis facilities within the Las Vegas Valley—opportunities for individuals who are in psychiatric distress, and that looks different in various patients. An individual in psychiatric distress typically is identified as an individual who is suicidal, homicidal, or in acute psychiatric distress, where the decisions that they make are putting them in harm's way, and they are not able to make those clear decisions. I believe that it's most critical within that short period of time for a support system to be identified. Now, that support system waxes and wanes, depending on the individual, and best case scenario, you'd want those people very close to you to identify whether or not this person is safe. Expanding that viewpoint, you're going to identify various support resources throughout the community. Law enforcement, ambulatory services, school settings. Workplace environments also play a role in that as well. However, it is a community effort. And also, I'd like to just add that it's not mental illness. We're not talking about mental illness because, an individual, you know, treatment is a broad spectrum. But for individuals in acute psychiatric distress, identifying those supports, those resources, and identifying what access looks like to getting those individuals into a hospital or a psychiatric treatment center as soon as possible is critical.

Host:
So, you're really talking about loved ones being aware of the right support systems.

Purcell Dye, PhD:
More importantly, loved ones identifying whether or not this person is in acute distress. And the issue, Cheryl, with loved ones is that they're so close to you that they might not identify what acute distress is. For example, a family member could look at a loved one and say, "You know what? They're just acting out," or, you know, "They need to settle down or relax or get some sleep." So, identifying what those precursors are or those acute signals are are critical. So, of course, we're talking about awareness. We're talking about education. We're talking about nurturing and understanding as to, "You know what? This is beyond the scope of what Purcell usually does. This is something that we've never seen before," and identifying that we need to probably get Purcell in front of somebody, a professional, psychiatrist, a nurse, an ED doc, as soon as possible.

Host:
I'm glad you brought up warning signs. That's my next question. What are those key warning signs that a person is moving from severe stress or burnout into an actual mental health crisis that requires urgent intervention?

Purcell Dye, PhD:
Oh, that's another really good question, because those identifiers that are going to basically identify whether or not this individual is in crisis waxes and wanes again. For males, I'll use as an example because there is a difference at times. For the most part, men carry it differently—carry it, when I say it, I mean the psychiatric distress—you might identify an individual who is isolating. Potentially, they're not conversating or they are not around their typical social settings. In others, you might see a person who is not eating, not sleeping. And while, you know, we build up defense mechanisms so that the people on the outside don't recognize what's going on, a person who's close to you would identify, "You know what? Something's off." And you don't want to take that for granted. You don't want to take those signals for granted. And a more acute component, you could identify an individual who is responding to internal stimuli, who's identifying that voices are becoming louder; voices with commands are a typical signal of a person who is slowly moving into psychiatric distress at the severe level. Individual who also is voicing suicidality, individual who has had some severe loss or trauma, specifically when it comes to jobs, finances. Relationships are also a huge indicator. So, when a person's very close to these individuals, you're identifying that these compounded stressors are starting to weigh in on a person. You don't want to take any signal for granted. So, it definitely takes that loved one to get that person in front of a professional as soon as possible, Cheryl.

Host:
Any warning signs that you see in women more so than men?

Purcell Dye, PhD:
Well, in women you're looking at more—and this is all statistical, to be frank—but women you're looking they verbalize their intentions a lot more. So, you might identify a woman who is saying that they're going to do something or reporting to loved ones that they, you know, can't handle life or these stresses. And the issue with this is a close person might say, "Well, you know what? This is just their behavior," or "They're just acting out." But you don't want to take that for granted. Whereas of men, they typically isolate. They stop talking. They stop moving around in these social settings. They don't want to talk about it. Typically, substance use also plays a key role in this. Both male and female tend to go to alcohol or some sort of way to self-medicate to try to alleviate the stress. But we all know that that potentially exacerbates the issue as well.

Host:
So in an emergency department or crisis clinic, how do clinicians decide whether a person needs hospital admission, intensive outpatient care, or can be safely supported at home?

Purcell Dye, PhD:
Right. How does it? Well, firstly, the individual who is facing or completing this assessment or facing that individual in distress needs to be trained, okay? So, we're starting with an individual who has that baseline training of you're going to see individuals who have MSWs, they're licensed LCSWs. Also, you have high-level training within the law enforcement department, those ED nurses. You don't want to take anything for granted, all right? And I'll use a specific example. In the Las Vegas Valley, you have a high rate of homelessness, right? With that, you're going to see patients or individuals, who are saying, "You know what? The stress of not having shelter is one that's making me not want to live." And I speak to this with my employees. You know, if I was in a point in my life where I didn't have a shelter, and it's 120 degrees outside. And I didn't have anybody to call, I can't say that I'd be sitting in front of you being as articulate as I could be. I might be in a space where, you know what? These burdens are a lot more heavier than I can bear, and death is an option. You know, me ending my life is an actual option. And it takes a trained person to look at the history of this individual, look at the trauma of this individual, hear the inflection in a person's voice, look at their affect, identify how destitute they actually are, if there's no support. And the aggregate usually weighs in very heavily as to whether or not this person meets inpatient criteria.

Host:
So for families and general practitioners, what are the practical steps to take immediately after a crisis has been de-escalated to support safety and reduce the risk of another crisis?

Purcell Dye, PhD:
Now, post-discharge is critical, right? An individual has been stabilized, you know, they've gone into a facility like Spring Mountain Treatment Center. They have been treated by a psychiatrist. One of the phenomenal things about our facility is that each patient sees an actual psychiatrist. We definitely are proud of that. They also have groups. You know, they're having social work groups. They're having process groups. At the same time, we're talking about each person who was admitted has a medical diagnosis. So, orders are given for medication. So, that stabilization is a multifaceted and dynamic process. Post-discharge, you're looking at a safety crisis plan. So, each patient that gets discharged, there are specific identifiers that highlight who do I call if I'm in distress, if the situation lands on my lap again? What do I do? Are there breathing techniques? Is there somebody that I can call? Is there a way that I can circumnavigate my thoughts in a way where I'm healthy? In addition to that, each discharge, each person who is discharged rather, they are lined up with a psychiatrist and a treatment in a therapeutic environment. So, both appointments are actually—that's mandatory. And those appointments need to be made within seven days. Not those appointments, but those actual engagements need to be had within seven days of discharge. So, we're not waiting two weeks or a month before this patient sits in front of a psychiatrist or a counselor. Those appointments are made immediately in addition to a family meeting. So, those things are done post-discharge immediately, and they're documented. So, each patient that leaves our hospital, they have all of those things in place.

Host:
That's great. So, what are the differences between short-term stabilization like in the ER or a crisis unit and then long-term recovery? And then, how can patients and families tell whether real progress is being made?

Purcell Dye, PhD:
Well, there's a huge difference between the two when we talk about short-term and the long-term process. One, the short-term is addressing the acute intense component that's more so linked with safety, right? Purcell is not safe in the community. Purcell is not safe at home with his kids. I need to get Purcell into a place where he can become stabilized from a medical perspective and a therapeutic perspective immediately. All right? And that's going to identify opportunities that when he comes out, he's going to be able to take care of himself, he's going to be able to manage his medications, and he's going to be able to thrive. Now, once I'm discharged from said facility, now there's an opportunity for a partial program, which is a day program. Individuals can step down and go to a five-day a week program that lasts from potentially 9:00 to 3:00 PM, where they have groups that are more so DBT, dialectical behavioral training or cognitive behavioral therapy, which is an area that individuals can identify certain things like distress tolerance, which is critical; mindfulness, being present in the moment; and emotional regulation, which are also extremely critical when they talk about how I can manage my life post-discharge. And these are also things that are taken up in the intensive outpatient program, which is more so like a throughout the week, three hours throughout the week. And we also have counselors that are meeting these patients at that level as well.

Host:
And how can loved ones tell whether real progress is being made?

Purcell Dye, PhD:
Well, real progress is being made in time. Patience is probably the biggest tool. And a great corollary argument would be a lot of these issues didn't happen overnight. They were subtle. They were creeping. They were things that took decades to build. And it very well might be a lifelong process when you talk about the treatment and healing process. Relapse is also a big component, not being able to regulate. Medication, medication changes. Stressors change the chemical nature of the brain, and these things are always dynamic and changing. So, an individual who has a consistent and sustained relationship with their outpatient provider is critical, as well as family members and support who can ask those tough questions. "How are you doing? How are you sleeping? What's going on? You know, I'm noticing this has changed." Those kind of questions need to be sustained throughout the relationships between the provider and the loved ones.

Host:
You touched on this a little bit about safety plans. What role does safety plans and crisis response plans play after someone has reached their breaking point? And then, what are the key elements that should always be included?

Purcell Dye, PhD:
Well, the key elements are critical when you talk about the safety crisis plan. I remember, and this is something that I actually speak about as well as my new employee orientation, when a person is in psychiatric distress or suicidality, having a phone number, having one person pick up that phone completely changes the trajectory of those outcomes. So when we talk about the safety crisis plan, identifying who is actually going to be able to commit to being this person's support, and those support components are going to be lined up. So, that's key in that safety crisis plan. Another component is just identifying, "Who's in my social network that I feel safe talking to?" Just because somebody's close to me, say a partner or a family member, I might not necessarily consider this person to be the safest person I can talk to. So on that safety crisis plan, there's an opportunity for that patient to say, "You know what? There's a person that nobody would even know that I feel comfortable and safe speaking to because the people closest to me might not be the support that should be."

Host:
That's great. Anything else you wanted to add on this vital topic?

Purcell Dye, PhD:
Thank you so much, Cheryl. Yeah, I do want to just add that I'm proud of the effort that has taken place throughout the last decade when it comes to lowering the stigma of mental health and mental health crisis. Identifying that those conversations are necessary. Not just at the therapeutic level, but also on a familial level as well. Having those conversations that talk about what happens when you can't bear it, what happens when things do happen, and coming to the table, a family support component or just being able to speak about it without the shame overlapping and looking at mental illness and stress as you would any body part that needs to be taken care of and nurtured. And so, I'm really proud of what's been happening, not just within the Las Vegas Valley, but throughout the country when it talks about mental health stigma.

Host:
Dr. Purcell Dye, it's obvious that you are passionate about your calling. Thanks for taking the time to educate us on the best practices to get from crisis to stability. Very informative. Thank you.

Purcell Dye, PhD:
Thank you, Cheryl.

Host:
For more information, visit our website, valleyhealthsystemlv.com. If you found this podcast helpful, please share it on your social media and check out our podcast library for other topics of interest to you. This is Health Talk with the Valley Health System, presented by the Valley Health System. Thanks for listening.