Christina Andersson has left her shoes at the door. She sits with her feet folded under her on a futon in the narrow, cluttered apartment. The woman across from her laughs, embarrassed, as she twists a ragged tissue in her hands, her eyes still wet. But her voice breaks and she starts to cry again as she tells Andersson about her long fight for custody of her children, her difficulty finding permanent housing and a medical condition that leaves her in chronic pain.
On a mirror behind her she’s taped a carefully lettered note, reminding herself that her children need her, and that she has to survive for them. It’s a good sign that the woman still cares about her life, Andersson says.
“Right away when I sat down, I saw her note,” she says. “We talked about her kids. That’s the reason she wants to keep fighting.”
Earlier that morning, the woman called the Department of Health ACCESS line, telling dispatchers she was feeling overwhelmed and desperate. Less than an hour later, Andersson, with Aloha House’s Crisis Mobile Outreach team, knocked at her door. The program sends a case worker in person to help someone who’s suicidal, experiencing a psychotic break, or just feeling hopeless, within 45 minutes of a call for help.
Once the woman has calmed down, Andersson takes out her paperwork. She writes a short assessment of the woman’s condition, and fills out forms to sign her up for follow-up case management and a peer support specialist. It’s not the first time the woman has been through the program, and that should be a reason to hope, Andersson reminds her.
“The good thing about that is that you know you’ve had the strength before,” she says. “That’s your baseline.”
“It can happen again,” the woman agrees.
When they’re on-call, case workers for the crisis response team never know who or what they’ll see next. It could be someone with schizophrenia who’s off her medication and wandering through a shopping center, or a distraught father who’s lost his job and his family and is considering suicide.
“It could be a parking lot, the hospital, someone’s house,” Andersson says.
Fellow team member Tina Boteilho says her heart starts pounding when her phone rings for a crisis call. It’s sometimes “scary” not knowing the situation she’s heading into, she says, but in a field where mental health care is often scheduled, structured and sterile, it’s also exciting to be helping clients right when they need it, right where they are.
“I like that drop-everything-and-go,” she said. “That rush is good.”
Boteilho said her approach is to start building a connection with the client and de-escalating the situation right away, sometimes before she even gets to the scene.
“If they’re really high risk, you try to keep them on the phone, so by the time you get there, they feel like they know you already,” she said.
Once there, she has four hours to talk the client through the crisis, help him or her calm down and figure out what is needed. If someone’s having a psychotic breakdown, that client might need to be taken to Maui Memorial Medical Center’s Molokini Unit for medical treatment, while another person might need a stay at the Aloha House crisis shelter for intensive counseling and support. Someone else might be fine going home and seeing a counselor the next day. If the person needs housing assistance, counseling, medication or other help, Boteilho will start setting that up too.
“We try to link them as fast as possible with as many services as possible,” she says.
Aloha House contracts with the state Department of Health to run the Crisis Mobile Outreach program, along with a 30-day follow-up Crisis Support Management program and an eight-bed crisis shelter. Holding contracts to provide long-term mental health case management are Aloha House, Care Hawaii, and Maui Youth and Family Services, which subcontracts through Mental Health Kokua.
While she might love the excitement of her job, Boteilho acknowledges it can also take a toll on case workers.
“You don’t want to be pessimistic, but it seems like the problems people have are getting worse and worse,” she says. “That’s the hardest part, seeing the desperation.”
When the troubles she sees start to weigh her down, Boteilho says she tries to remind herself that what her client is going through aren’t her problems. But sometimes that can be hard to remember, especially when the client’s story strikes close to home.
“You know there’s not that much difference between you and them,” she says. “For all of us, those are the ones that are really hard, the ones that are close to being you. Those are the ones where you have to remind yourself, ‘this is not my experience.’”
For Vince Nubla, fatigue compounds the regular job stresses. As team leader, Nubla is on call 24 hours a day, seven days a week. He can be paged any time, whether it’s a case worker who needs his input on a difficult call in the middle of the night, or an ACCESS dispatcher telling him he’s got 45 minutes to get out of bed and get to the scene of a crisis.
Asked the last time he got a full night’s sleep, Nubla thinks for a long time.
“I get calls every night,” he finally says, shrugging.
Last year, his doctor told him lack of sleep had caused him to develop painful gout in his hand.
But Nubla says he loves his job and insists it doesn’t make him anxious to never know when his phone will ring with the latest crisis.
“Just making sure I get there in 45 minutes, or my case manager gets there,” he says. “That’s all I care about.”
Besides, he says, the rewards of the job make the sacrifices worth it. Sometimes all it takes is medication and someone to talk to for a client to transform.
“They feel more confident, not as afraid. They start to pick themselves up,” he says. “Wow — that’s rewarding.”
Program specialist Marlene Nagata knows clients have turned a corner when she sees them start showing up for appointments wearing clean clothes or makeup. They start dating again, or talk about new friendships or activities. They’ve begun to care again — for themselves and for life — after being in the dumps, she says.
“You see them down and out, at their very worst,” she says. “Then the next time you see them, they’re different.”
Andersson remembers one woman who was “catatonic” the first time she saw her. She helped her get medication, and spent months talking and building trust, slowly breaking through the shell, before helping her move into a group home.
“Now she’s got her son back and is working full time,” she says. “She’s a different person. I love that.”
Today, Andersson sits across from her client in a booth at the Tasty Crust while her client tucks into a plate-sized pancake. He’s one of her long-term clients. They’ve met at least once a week to discuss his goals and progress, and talked on the phone multiple times a day for the past year.
“I have unlimited minutes,” she says.
He takes out the new dentures she’s helped him get, covering them them discreetly with a paper towel. He’s not used to eating with them.
She sips tea and watches him eat, steering the conversation with brief questions, taking in his answers with the quiet attention of a practiced listener. Is he taking his medication? How much is he drinking? Did he update the Housing Division with his new address? Where is the new room he’s planning to rent?
“If this is the place I’m thinking of, there’s a lot of marijuana there,” Andersson warns him.
He shrugs. “I don’t mind the potheads. It’s the ice that bothers me.”
The man deals with a combination of mental health issues, including post-traumatic stress disorder and substance abuse. Sometimes it’s a relief just to have someone to talk to, he says. “She helps keep me sane.”
He finishes his pancakes, wipes his mouth and hunches over to slip the dentures back in. Sitting up, he grins. The teeth transform his face into a young man’s.
While the team sees all kinds of cases, PTSD is a common one, says case Manager Jessica Brazil. Many are people still traumatized by childhood abuse. Others are coping with mental illness like depression or schizophrenia. Some are people who’ve simply become overwhelmed by their struggles with work, housing or family. But those problems can be compounded when people are too ashamed or embarrassed to seek help.
“There’s so much stigma from lack of understanding about mental illness that a lot of people don’t ask for help until they’re fairly acute,” she says.
Boteilho agrees. “You tell your mom, ‘I don’t feel well,’ and she says, ‘aww’ (and takes care of you),” she laughs. “You tell her, ‘I’m depressed,’ and she says, ‘Oh, just go to work,’”
But Boteilho says she’s learned that the people she sees in crisis are just like everybody else.
“I have a couple of consumers where the difference between me and them is one paycheck, one experience in life,” she says. “I look at them and think, wow, you went left when I went right.”
• Ilima Loomis can be reached at iloomis@mauinews.com.
