When Someone in Need is Refusing Help: Navigating the IEA Process

Presenters:

Pierre Brazeau, Family Member
Kimberly Goldberg, Director of Acute Services, Lakes Region Mental Health Center
Mohammed ElSayed, MD, Msc, Clinical Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth, New Hampshire Hospital

Transcript:

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Michelle Wagner, NAMI NH (she/her): Good afternoon. We’re just gonna take a few seconds here while folks enter the zoom room. We have quite a few people registered.

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Michelle Wagner, NAMI NH (she/her): I am Michelle Wagner, and I’m with Nami, New Hampshire, working on the first episode psychosis, early, serious mental illness, initiative. Thank you for joining us for today’s webinar titled. When someone in need is refusing help navigating the Iea process. This presentation is being recorded.

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Michelle Wagner, NAMI NH (she/her): oops. I think someone might need to mute.

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Michelle Wagner, NAMI NH (she/her): and you’ll be able to find it on the education page of Onward nh, org.

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Michelle Wagner, NAMI NH (she/her): in the next couple of days you’re gonna receive a follow up email with links to both an evaluation and the recording. This is a Zoom Webinar. That means your camera folks who are watching us and Mike, your camera and microphone are off the QA. Is working, so please enter any comments or questions you have there. My colleague, Karen Prevay, is with us to help field your questions.

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Michelle Wagner, NAMI NH (she/her): We have a great panel today to talk with us about the involuntary emergency admission process, and I’m gonna have them introduce themselves. I’ll start with Pierre then Mohammed and Kimberly. Pierre.

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Pierre Brazeau: Hi! My name is Pierre Brazil. I’m the father of a loved one, and I have work with the process to

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Pierre Brazeau: in the past, and have been involved in a recent panel of looking at future ways of online processes with the State of New Hampshire.

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Michelle Wagner, NAMI NH (she/her): Thank you, Pierre Mohammed.

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Mohamed W. ElSayed, MD, MSc: Hi! My name is Mohammed. I’m one of the psychiatrists at New Hampshire Hospital and an assistant professor at Dartmouth. I’ve been involved with in patients, and and outpatients, and the ie. Classes for the last 2 and a half years. And I’m also one of the newer members with the Board of Directors at naming New Hampshire.

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Michelle Wagner, NAMI NH (she/her): Kimberly.

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Kimberly Goldberg: Hi! I’m Kimberly Goldberg. I am the director of the acute services program with Lakes, region, mental health. I have worked with them for the past 8 years. All in acute services. So I am very familiar with the Ia process.

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Michelle Wagner, NAMI NH (she/her): Thank you, Kimberly, and I, too, like Pierre. I’m a family member. So I have been on the other side of that Iea process trying to get one filled out and not sure how to navigate the whole very convoluted process. And we’ve heard that from many folks who call into our information and resource line at Nomi, New Hampshire.

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Michelle Wagner, NAMI NH (she/her): What do we do? What are the next steps? What does this look like? So we decided, even though we had a webinar whoops, Mohammed, I’m just gonna mute. You cause we’re getting some feedback.

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Michelle Wagner, NAMI NH (she/her):  we had had a webinar back in June of 2022 with Judge King to talk about the judicial view of filling out that paperwork. We had a lot of folks on that call, but we know that we need a more, step by step, process sort of soup to nuts.

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Michelle Wagner, NAMI NH (she/her): So that’s why we’re here today. And with that I’m gonna turn to you, Kimberly.

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Michelle Wagner, NAMI NH (she/her): can you just give us an overview? What does this process look like? You’re you’re in the out in the field doing this. So what does it look like?

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Kimberly Goldberg: So the Ia process is is not an easy one. I think that’s a great place to start. Michelle. It can be

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Kimberly Goldberg: difficult to not only fill out the actual paperwork itself. But generally when you’re filling this paperwork out, that means you’re dealing with a loved one who’s in crisis which can compound all of those things you know so much? Because how do you manage that and try and do this very serious legal paperwork? And I think that’s a really important

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Kimberly Goldberg: hard to to bring up is this is legal paperwork that we’re dealing with, and we’re dealing with the process of taking away somebody’s right to be free. So it’s something that

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Kimberly Goldberg: that friend family member loved one should they? Take very seriously, and it’s one that the teams that you’ll be dealing with either at the community, Mental health center or hospital. Also take very seriously.

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Kimberly Goldberg: But all that being said. Please remember that there are people. There are teams out there that can help you with actually completing this paperwork. You don’t have to do it alone. Please, you know, reach out to us. That is part of our jobs to help

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Kimberly Goldberg: folks who are completing this paperwork. With not only understanding how to fill it out, but the reasons we can and can’t fill it out, which are another. It’s a that’s another big piece of this is making sure that the reasons that we’re trying to actually ie. Somebody or involuntary emergency admission in case we don’t know that acronym acronym

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Kimberly Goldberg: so making sure that they know that this is a a good and valid reason to be filling out that paperwork, and that’s that’s the place I always start with. Whoever is filling out the paperwork is making sure that they know if the reasons that they’re

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Kimberly Goldberg: attempting to get this person I aid are valid reasons and reasons that will uphold in a a court. Because this

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Michelle Wagner, NAMI NH (she/her): okay? And can you tell us what those reasons are?

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Kimberly Goldberg: Sure. So the biggest ones that people probably may know are threats to kill oneself or take one’s own life. And actual attempts to take your own life.

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Kimberly Goldberg:  The inability to care for yourself.

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Kimberly Goldberg:  and homicidal ideation. is is the another one. There’s all these reasons to have to connect back to a mental health reason. So it has to relate back to the fact that this is being caused by a mental health condition.

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Kimberly Goldberg:  so those are the

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Kimberly Goldberg: the top reasons that people end up usually being. I aid the reason I mentioned that it needs to be related to a mental health condition is one of the things that we can see on a fairly regular basis is somebody. Who’s I aid for solely

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Kimberly Goldberg: substance use reasons, and maybe they don’t have a diagnosis of a mental health condition. And that’s one of the reasons, or one of the things that we cannot actually, ie. Somebody for is just due to

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Kimberly Goldberg: substance use only and that’s, you know, one of the the educational pieces that we often have to discuss with family members when you know they see a loved one who’s struggling with their own substance use.

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Kimberly Goldberg: But those first steps that we take are going over the form with folks. and

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Kimberly Goldberg: it is quite a lengthy form.

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Kimberly Goldberg: Thankfully. There’s you don’t have to fill the whole thing out as a petitioner. And that would be your your

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Kimberly Goldberg: title kind of within this paperwork. If you’re completing one. you would be the petitioner.

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Kimberly Goldberg: One of the things that I wanna make sure people always know is making sure that you have a valid

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Kimberly Goldberg: phone number where somebody can reach you a valid email address where somebody can reach you. Thank you. Michelle. Michelle’s putting up the the website for where you can access the actual Ia paperwork and all of this. So much of this can be done online now, which is a whole new process and makes it a little bit easier for folks. Not super easy, but a little bit easier. And that’s something.

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Kimberly Goldberg:  so yeah. So having that valid phone number and address are really important. Because, as I said earlier, this is going to be a court process.

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Kimberly Goldberg: once this goes through its initial kind of validation with the at the hospital. Usually the emergency department setting. Then. That’s when the court process happens. But, as you can see here, this is the first page of the Ia. Thank you so much. So you can see right there where it says Petitionee’s information. So that would be the person that you’re attempting to have. I aid

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Kimberly Goldberg: and the petitioners. Information would be the person who’s actually filling out this information. Down at the bottom there, where it says hospital and certificate information. That’s information that would be completed

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Kimberly Goldberg: once. The patient is, seen by a mental health clinician or professional in the emergency department setting. So you wouldn’t need to fill that out necessarily, initially, but it would need to get filled out once we’ve identified that this is valid information.

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Kimberly Goldberg: So

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Kimberly Goldberg: already right there, I think you can tell like this isn’t. This is a lot of information you’re gonna be putting in so that’s why I always recommend getting in contact with your local community mental health center, who? Is very willing enable to help you fill this information out, and that can be done in a multitude of ways. So sometimes we ask people to come into our office. Sometimes we help them out through telehealth or just over the telephone.

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Kimberly Goldberg: But one of the easiest ways to access help with this is utilizing the

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Kimberly Goldberg: New Hampshire rapid response access point at

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Kimberly Goldberg: (833) 710-6477, and they can connect you to the Community Mental Health Center. Who will give you a call back and help you walk through this process. So

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Kimberly Goldberg:  in our next part of completing this. We’re looking at the petitioner statement. And Michelle, if you wouldn’t mind pulling up page 2 for me.

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Kimberly Goldberg: Awesome

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Kimberly Goldberg: and a lot of this stuff is pretty straightforward, as far as you know who you are as the petitioner, and that’s going to be your name and what your relationship is to that person? And then the person that you’re actually attempting to have. I aid.

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Kimberly Goldberg: Now you can see about halfway down the page we see within the past 40 days, and there’s a checkbox there, and that’s you know, the checkbox that you would use if somebody had actually attempted to take their own life. You can check more than one box.

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Kimberly Goldberg: The biggest thing you need to remember is you need to have the information to back up all of that info that you’re going to, that you’re identifying has been the the safety concern, or what I always identify as the imminent danger, because it has to be imminent, has to be happening

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Kimberly Goldberg: in this moment. This person is going to be a danger if they don’t get this help. Not next week week, not next month. It has to be

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Kimberly Goldberg: in, you know, the very, very near future any any information that you’re including in this petition statement, for whatever category you’re choosing, has to be within the last 40 days. So we ask that people make sure that they’re not including any historical data in when they’re completing the Iea petition because it’s it won’t be valid or relevant to this particular incident.

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Kimberly Goldberg: So the

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Kimberly Goldberg: one of the most difficult things that I find for loved ones who are completing this paperwork

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Kimberly Goldberg: is having to stick right to the facts. And leave out a lot of the emotions that can be associated with such a difficult time in there. Relationship with this with the petition or petitioner or petitionee. Excuse me.

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Kimberly Goldberg: So you know, because this is legal paperwork, we want to make sure that we’re just sticking to the facts. We’re only including the information that’s relevant to how they actually attempted to hurt themselves hurt somebody else, or how they’re not taking care of themselves. You know it’s it.

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Kimberly Goldberg: A lot of times family members will put in information about the person’s emotional state, you know, stating things like they’ve been very sad. Which is very relevant to maybe the clinician that might be doing an evaluation later, but not necessarily for the legal paperwork. And that’s kind of a difficult area to navigate when you’re trying to complete this paperwork.

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Kimberly Goldberg: So if we look on

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Kimberly Goldberg: the additional pages, you can see that there’s

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Kimberly Goldberg: areas like, Be here at the top. You could say within the past 40 days is threatened to inflict serious bodily injury. So that would be if somebody had actually threatened to take their own life. But hadn’t actually acted on that yet. This is, that’s the box you would check for that one and you can see as you go through. There’s the multitude of options that we talked about, or that I spoke about earlier.

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Kimberly Goldberg: And then when you come to page

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Kimberly Goldberg: 7

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Kimberly Goldberg: you’ll see that. There is a signature page right there.

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Kimberly Goldberg:  and I like to point this out because the we do get quite a few of these that come in without signatures. And we need that signature for this to be a valid form. So just a little highlight there, making sure that you remember, if you have to fill these out to to sign that statement as well.

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Kimberly Goldberg: There is an option on the next page, and it looks very similar to the petition statement to add a witness statement. So if there is anybody else who has that same information that, or some additional information about why this person is an imminent danger. Risk? Then we want to have them included in this information. The other thing I should mention is.

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Kimberly Goldberg: we we like to have the person with the first hand information. Fill that this paperwork out as often as we can.

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Kimberly Goldberg: There we, the the law does allow us to have firsthand hearsay, which is like one level away from the person who originally experienced that. So let’s say,

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Kimberly Goldberg: a sister. Here’s their brother. Makes suicidal statements, but they’re not able to fill out the paperwork for some reason. But the sister says that, or tells the all the information very clearly to the to the clinician, and the clinician would be able to fill out that information for you.

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Kimberly Goldberg: And that would be a legal way to to utilize that information. Without getting too far away from the actual source itself.

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Kimberly Goldberg: So the nice thing is that is the only those are the only pages that you would need to fill out as either the petitioner or

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Kimberly Goldberg: or witness. So you wouldn’t have to do anything after that.

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Kimberly Goldberg: Anything after that should stay blank until the person is actually transferred to the emergency department.

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Kimberly Goldberg: and those last pages are completed by the staff at the hospital. Whether that’s a mental health clinician. A physician. Apr, N. There’s a array of of folks that can actually do that and their job at that point is to make sure that all the information that’s been put in the

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Kimberly Goldberg: petition statement is valid is real, is, you know, an actual meets the actual criteria for completing this Iea.

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Kimberly Goldberg: So you know, I say that because sometimes we get information that doesn’t meet the criteria, or we find to be invalid for some

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Kimberly Goldberg: reason, whatever that may be. And we aren’t always able to keep that person in the hospital. If we can’t validate that information, or, if the information included, is not valid reasons for completing an iea so there is always a chance that even if you filled this out

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Kimberly Goldberg: perfectly, and you know it’s all correct that this person will remain in the hospital. They may end up going home if we don’t have the the criteria met.

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Kimberly Goldberg: So that’s why these next pages get filled out afterwards, because we have to validate all that information. Because anybody can fill out a an Ia. You don’t need any level of degree, or or training, or anything like that. Anybody can fill these out. So it’s really important for us on the other side to make sure that this is getting filled out in a

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Kimberly Goldberg: a valid way, and and not being completed, for you know

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Kimberly Goldberg: nefarious reasons, I suppose.

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Kimberly Goldberg:  So once

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Kimberly Goldberg: somebody. So some of you may be asking, okay, how do I get this person to the hospital because they don’t want to go. They don’t recognize that they’re having

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Kimberly Goldberg: you know, if that they’re causing an imminent danger to themselves or somebody else. So in those cases we use a form called a complaint formally known as a complaint and prayer. And that document has to always be associated with an Ia. You can’t have it individually by itself. It has to be with an Ia

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Kimberly Goldberg: an ia can be done and completed by itself, and you don’t necessarily need a complaint, but you always need an Ia if you’re gonna do a complaint. And that complaint is a short and Michelle, do you have that to pull up by any chance?

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Kimberly Goldberg:  a short document that needs to be notarized by a justice of the peace

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Kimberly Goldberg:  And once that’s completed, it’s brought to the emergency or the sorry. The police department with where the patient lives with the the Ia paperwork and the police will then go and get that person and bring them to the emergency department for the evaluation. So this is the complaints.

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Kimberly Goldberg: as you can see it. It does have some information that needs to be filled out in here, but much less than the Iea paperwork.

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Kimberly Goldberg: So you would need this to make the transfer to the emergency department a legal transfer.

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Kimberly Goldberg:  if somebody’s already in the emergency department like, I said, you don’t necessarily always need this this piece of paperwork, but it’s good to know if you ever do need it.

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Kimberly Goldberg:  So the once somebody actually gets to the emergency department, as I said. They’ll be evaluated by a mental health professional when they’re there.

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Kimberly Goldberg: And they determine if this information is all valid, all good. Then the rest of the paperwork gets filled out. That’s another reason why we need to make sure that we have a valid phone number for you, because we will be calling, whoever the petitioner is, and the witness if it’s

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Kimberly Goldberg: If as long as their information is valid on this paperwork, if we can’t get a hold of you. We may not be able to validate that information, so please make sure that that’s a number we can absolutely reach you at

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Kimberly Goldberg: the other thing that may happen is the person may get to the emergency department and say, Hey.

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Kimberly Goldberg: I recognize now that I’m having a mental health concern. And I need hospitalization. So that may be a time where we end up hospitalizing somebody voluntarily because they’re able to consent to that, and they’re willing to consent to that which is always what we would rather do as opposed to actually

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Kimberly Goldberg: having to take away that person’s right to be free like, I said before, so you know that is also a possibility, and something that we keep in mind. If we feel like that person’s continues to be a danger to themselves or somebody else and or that they can’t consent to a voluntary hospitalization, we may still proceed with the Ia process.

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Kimberly Goldberg: So once we found that everything is valid in here, and we’ve completed the last few pages of the Ia all of that gets sent to New Hampshire hospital and the court and the court sets a court date for a hearing based on the information that’s in the Ia.

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Kimberly Goldberg: And that needs to be done within 72 h, so not counting Sundays and holidays.

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Kimberly Goldberg: So those. So please keep that in mind that if you turn this in on Friday you may get a call or an email saying, 8 Am. Monday morning is a hearing, so please be aware of that, because if you do not attend that hearing. Likely the case will be thrown out, and the person will be discharged because they have the right, just like in any other hearing. They have the right to, you know.

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Kimberly Goldberg: Discuss what’s going on versus what’s being said in the Iea

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Kimberly Goldberg: they will also be appointed a lawyer just like they would for any other court case as well. So that’s an important piece to keep in mind for. Any family member that you know, you will actually be speaking with a lawyer. And yeah, and in the court, thankfully, 99% of these hearings are by phone and the patients are usually there by telehealth.

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Kimberly Goldberg: so don’t necessarily need to be have to drive to court, or anything like that which is great. So usually that makes for an easier process, and most people can attend that

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Kimberly Goldberg: so once that if that Ia is upheld

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Kimberly Goldberg: by the court, then there we are. We hope that that patient gets transferred to a hospital at that point.

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Kimberly Goldberg: Excuse me, an inpatient hospital.

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Kimberly Goldberg: and they are they are able to stay there for 10 days. Unless there’s another reason why they need to stay longer. Which doctor, I’m sure talk about

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Kimberly Goldberg: and if they don’t need to or if it’s not upheld, then we need to discharge that person, or we need to figure out another reason why

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Kimberly Goldberg: that person needs to be, ie. So we can complete another Iea, if that information has, you know, has already been used, we’ll need new information. To complete a new IA

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Kimberly Goldberg:  and that is a really summarized version of what the process looks like for completing an Ia

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Michelle Wagner, NAMI NH (she/her): that was fabulous, Kimberly. And of course we’ve had loads of questions and comments come in. So Leah asks, is there a difference between an IEA. And an IEH.

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Kimberly Goldberg: I am unfamiliar with the term, ie. H. So I apologize, but II don’t know.

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Michelle Wagner, NAMI NH (she/her): I am not familiar with that term, either, so wish we could help. But and then bj, is saying, wouldn’t it make sense to change that sud? So substance use disorder, exception, since sud is so often a way to medicate untreated mental health. And since inhibitions that might be present without the sud aren’t there when using, there’s definitely a correlation between the 2, can you speak to that a little bit.

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Kimberly Goldberg: Oh, I definitely don’t disagree with you that usually there is a mental health concern when somebody is using substances or reviewing substances I don’t generally see that in a vacuum by itself. That being said,

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Kimberly Goldberg: substance use disorders are considered medical disorders. Not necessarily mental health disorders, which may be a little confusing because they are, you know, it designated in the Dsm, I’m hoping most people know what that is. But they are technically medical conditions, which is why they’re not considered under an Ia. But I do. Do think that this is a very valid concern and a very valid point.

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Michelle Wagner, NAMI NH (she/her): Thank you. Samantha says, is Ieaa only for adults or for youth as well.

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Kimberly Goldberg: Technically it is for anyone. However, if somebody’s under the age of 18, or they have a guardian. You can actually hospitalize somebody as a voluntary by guardian, and generally we would utilize that

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Kimberly Goldberg: for anybody under the age of 18 the exception to the rule. Maybe if that parent or guardian doesn’t understand the severity of the the child’s mental illness and doesn’t feel that they need to be hospitalized when a clinician, in fact, does feel like that’s a valid concern.

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Michelle Wagner, NAMI NH (she/her): Thank you. Megan helped us out with ie. H. She says police departments often use the term ie. H. Involuntary Hospital Involuntary emergency hospitalization.

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Michelle Wagner, NAMI NH (she/her): Thank you, Megan. Thanks. Many of us have learned something. and

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Michelle Wagner, NAMI NH (she/her): Ebony had said. What does the petitioner do if they report the harmful behavior? But when the person is evaluated they say they aren’t going to act on this behaviour. So they’re sent home, and then they’d be engaged in the behaviour again. This becomes a frustrating process, because we have to fill out a new, IEA, over and over.

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Kimberly Goldberg: Yeah. So sometimes, when we see a pattern like that, it helps us with being able to actually end up keeping that person

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Kimberly Goldberg: a lot of times. You know, we

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Kimberly Goldberg: unfortunately are not mind readers. We can’t predict the future. So sometimes it’s about the way the information is presented. Sometimes it’s about the way that the person the petitionee presents when they’re in the emergency department. And you know, if it’s something that we can’t necessarily prove because, again, this is legal paperwork. We may not be able to keep somebody even if it’s, you know.

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Kimberly Goldberg: information that seems valid in the moment.

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Michelle Wagner, NAMI NH (she/her): Yeah, there’s a lot of legalities involved here for sure.

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Michelle Wagner, NAMI NH (she/her):  And what we like to tell families is, keep notes, you know. Keep keep notes, keep track of what’s going on with your loved one date, it time it.

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Michelle Wagner, NAMI NH (she/her): describe it in detail. So then, you have this information to do have to fill out an iea really important to have the data cause you’re not. Gonna remember, you’re in crisis.

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Kimberly Goldberg: absolutely, you know. Another recommendation I would give is, you know, if this, if there’s Facebook messages or text messages, or anything like that, keep copies of those print those out. Bring those with you, and you’re filling out this paperwork. So we have that proof right in front of us, and you know we can see. Oh, that yesterday, at 5 20, they said, this thing. You’re you’re building a case, and it’s to protect your loved one. Exactly

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Michelle Wagner, NAMI NH (she/her): so. Megan says. I work for Cmhc. And we’ve had Ieaas overturned for First Level hearsay, depending on the hearing officer.

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Michelle Wagner, NAMI NH (she/her): So in our experience, having the person who directly witnessed heard the information supporting imminent imminent risk is a stronger petition.

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Kimberly Goldberg: It’s always our preferred method. It’s just once in a while we have reasons why we can’t do that. Sometimes it’s about the relationship between the petitioner and petitionee.

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Kimberly Goldberg: That causes us to, you know. Fill it out ourselves. Sometimes. It’s just that person’s out of state, and we don’t. We can’t get them here to give us that information, so we’ll we’ll do it ourselves. But yes, we always want first hand, if at all possible.

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Michelle Wagner, NAMI NH (she/her): And Bj. Says, I work for a municipality

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Michelle Wagner, NAMI NH (she/her): we had a man here that our mental health agency recommended. We complete an Iea, for they refused to see him because of how dangerous they believed he was, and they said they don’t have the ability to serve him. What do we do in that case?

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Kimberly Goldberg: Is that the police that

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Kimberly Goldberg: refuse to do that. I’m not sure who refused to see him because of how dangerous they believed he was. Yeah, absolutely.

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Kimberly Goldberg: Sometimes with. Well, once somebody’s in the emergency department there would be very little reason why somebody wouldn’t be seen. It may be delayed because somebody needs to be, you know.

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Kimberly Goldberg: medicated, for whatever reason. Maybe they’re being aggressive. But eventually we would end up seeing that person. We can’t. You know the police aren’t going to cause a more dangerous situation.

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Kimberly Goldberg: You know, like they’re not necessarily gonna break down somebody’s door unless they know that somebody’s actively trying to hurt themselves. So that may be

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Kimberly Goldberg: part of the concern that’s happening. It could be, you know, this is a known person to them, and they know they have firearms, and it and

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Kimberly Goldberg: they’re worried about, you know.

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Kimberly Goldberg: being hurt themselves. But I can’t really speak for the the police departments as much. So bj, did qualify. No, the Mental Health Agency wouldn’t see this person.

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Michelle Wagner, NAMI NH (she/her): Yeah, I’m not sure about that, so I can’t really think of reasons, but there may be intricacies there that I’m not aware of.

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Pierre Brazeau: I have to great

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Pierre Brazeau: in the case.

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Pierre Brazeau: The health Agency, maybe, but the hospitals are so. Police are bringing an individual to the hospital emergency department. They have the capability of handling that kind of individual

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Pierre Brazeau: versus the agency, not being equipped to see someone that would make sense. That’s where the compulsory and the Ia and using police to transfer individual to a secure location, the pod where they can get appropriate medication and be managed

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Pierre Brazeau: and evaluate it appropriately.

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Michelle Wagner, NAMI NH (she/her): Thank you, Pierre, for adding in So we’ll go back to the questions

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Michelle Wagner, NAMI NH (she/her): I wanted to get on as many of them as we could, because people are very engaged. So, Mohammed, Dr. El Sayed, what does it look like on your end? What are you doing at New Hampshire Hospital?

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Mohamed W. ElSayed, MD, MSc: Well, before I talk about what happens in New Hampshire Hospital, let me just talk about the last part of the Iea that gets filled out by the psychiatrist and the medical doctor. Can you bring the ie. Back to the screen, please. Thank you.

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Mohamed W. ElSayed, MD, MSc: Thank you.

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Mohamed W. ElSayed, MD, MSc: So after the ie. Gets filled out by the additional and the client goes to the emergency department. That doesn’t mean that this goes to the hearing. There’s still some part that needs to be filled out by the physician with the Apollon in the emergency department.

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Mohamed W. ElSayed, MD, MSc: That includes first physical examination, and it’s just a complete physical examination to make sure that what whatever the patient is experiencing is not because of a medical problem that needs to be and the patient needs to be that needs to be admitted to the medical floor.

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Mohamed W. ElSayed, MD, MSc: So this is just a complete physical examination. Sometimes they do some blood work, and sometimes they do intoxicology. Just to make sure that, as Kimberly said.

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Mohamed W. ElSayed, MD, MSc: this is not substance use is considered part of medical problems. So just to make sure that this is also not a substance, use problem.

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Mohamed W. ElSayed, MD, MSc: After the physical examination there comes the mental status examination.

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Mohamed W. ElSayed, MD, MSc: and that that can be filled out by clinician does not need to be a psychologist or an Api, but needs to be a clinician. So if, after the clinician goes and examines the patient, either in the Mental health center or in the emergency department. They fill out the the whole document, stating how they saw the patient

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Mohamed W. ElSayed, MD, MSc: and usually the the the examination. Also talks about how the patient is presenting danger. So if the patient is, is experiencing any suicidal thoughts or homosexual thoughts, adding this to the mental status, examination would strengthen the ie.

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Mohamed W. ElSayed, MD, MSc: And then going to the

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Mohamed W. ElSayed, MD, MSc: so so that was need to be filled out. So that last piece need to be filled out by either the psychitis BA, or an Apo end. And this this is when we say, okay? So I, the psychologist or the clinician, examine the patient, and then we think that the patient needs to go to on an iea to that place which we call it. I designated the receiving facility.

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Mohamed W. ElSayed, MD, MSc: It just means that a facility that can that has an inpatient psychiatric hospital.

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Mohamed W. ElSayed, MD, MSc: Most of the time these hospitals are locked, so patients cannot go out. That one most of the time when people fill out with the application. It just states New Hampshire Hospital. As a standard, because this is well, this is the main State facility will be. Patients can be here in an involuntary on an involuntary status

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Mohamed W. ElSayed, MD, MSc: as Spa said, or most of the hospitals that have involuntary admissions or have can receive patients. They do have staff that can support

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Mohamed W. ElSayed, MD, MSc: a patient who is in danger either to them themselves or the others. So all the emergency departments have more staff that can support this and these patients and thin their needs, and also New Hampshire hospitals. So we have enough staff. So if someone becomes in danger to themselves, or try to do something to themselves or to other people. We have enough staff that can support the patient at that moment, and make sure that this does not happen.

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Mohamed W. ElSayed, MD, MSc: So once once the the IEA gets signed.

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Mohamed W. ElSayed, MD, MSc: This is when we have from the date of signature of that of this page. We have 3 days until the put hearing

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Mohamed W. ElSayed, MD, MSc: that Kimberly talked about after the good healing

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Mohamed W. ElSayed, MD, MSc: and the quote here just states, if there is a need or cause a coral cause for the patient to go to an impatient psychiatric facility for 10 days, so all the cost stays. Either there’s a probable cause, or or there’s no probable cause for the patient to go to the hospital.

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Mohamed W. ElSayed, MD, MSc: If there is a plow cause found. then the patient gets on what we call a cue.

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Mohamed W. ElSayed, MD, MSc: So the one of them

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Mohamed W. ElSayed, MD, MSc: problems with the mental health system in New Hampshire is we have. We don’t have enough bets for everyone who is in the Ed to get to the hospital. So this is why

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Mohamed W. ElSayed, MD, MSc: sometimes sometimes pitching get right away. So sometimes there is no queue. The patient is the first in the law. And first online we have a better New Hampshire hospital, and the patient gets transferred right away. That doesn’t always happen. And I well, let me briefly, is that that does not happen like anymore. So most of the time patients usually stay in the Ed waiting for a bed to be available.

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Mohamed W. ElSayed, MD, MSc: Once a bed is available, the patient gets cancelled to a New Hampshire hospital.

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Mohamed W. ElSayed, MD, MSc: We have up to 10 days to to see the patient, to examine the patient and understand what’s going on.

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Mohamed W. ElSayed, MD, MSc: Let’s say that. Well, 10 days were more than enough, and we see that all the time we so someone came into the hospital. They were in an acute, stressful situation in their life, and this is why they wanted to end their life. But right now they stayed in the hospital. They worked with the team. They worked with the staff and they feel they get. They feel better than how they work before they wanted to. The to the Ed.

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Mohamed W. ElSayed, MD, MSc: Then that’s it. We ask the quote. Well, we the other quote, well, there’s no need to keep the patient in the hospital anymore. They can go back to their lives, and before they go back to their lives we make sure that the patient gets and has an appointment to see someone outside just to follow

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Mohamed W. ElSayed, MD, MSc:  and other times, if someone is oh, we can, you can take the screen off, and I think I think that’s that’s all for the iea.

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Mohamed W. ElSayed, MD, MSc: Thank you, Michelle.

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Mohamed W. ElSayed, MD, MSc: In other times. 10 days are not are not enough to work with the patient. Sometimes some patients don’t want to talk to us, for

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Mohamed W. ElSayed, MD, MSc: most of most of the 10 days. Sometimes beaches

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Mohamed W. ElSayed, MD, MSc: still have symptoms, and if used to to work with the staff, either working with psychosis like myself in in starting on medications or or working with staff and talking to Staff about how they feel. And this is when we think, or the patient needs to stay longer than 10 days. And this is when we apply for a process called cobain

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Mohamed W. ElSayed, MD, MSc: apobe, is a process that allows us to keep the patient in the hospital more than the designated 10 days by the law.

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Mohamed W. ElSayed, MD, MSc: and it can be extended to a commitment for outpatient treatment as well.

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Mohamed W. ElSayed, MD, MSc: Not everyone who gets on a cobate hearing does get a commitment could order to be an outpatient treatment. It just means the patient needs to stay longer than the inpatient.

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Mohamed W. ElSayed, MD, MSc: Sometimes this is all that they need, or some well, so some patients do require 11 days rather than 10 days. So this is how we can legally extend the presence in the hospital.

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Mohamed W. ElSayed, MD, MSc: and then, after they leave the hospital, they they still get to the appointments without without any commitment, without any quote orders.

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Mohamed W. ElSayed, MD, MSc:  Do I need to talk about the do you? Do you mean? Do you need me to talk about the quote orders, too? Or is that

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Michelle Wagner, NAMI NH (she/her): I think we’re good. That’s terrific, and we’ll see what come through for questions. We’ve got a lap of Pierre. We want to loop you in here. This process. You’ve been through this in years past. It’s a brutal process from a parent’s perspective. And you’ve been on a committee to help improve that.

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Michelle Wagner, NAMI NH (she/her): Share your perspective with us if you will.

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Pierre Brazeau: Yeah, I think

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Pierre Brazeau: you know one thing we need to be aware of, it’s it’s it’s a learning experience. It’s typically the very first time it’s in a high stress scenario.

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Pierre Brazeau: There’s efforts underway to make the process easier and make it online to provide some how to

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Pierre Brazeau: how to fill up the form support.

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Pierre Brazeau: And, as been indicated, it’s important that you start documenting

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Pierre Brazeau: information in advance of an Iea. If you think you’re headed in that direction. Sometimes it’s not clear that your loved ones gonna need an iea until something drastic happens.

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and then you look into it and say, Okay, this is the process.

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Pierre Brazeau: I think now it’s easier to find the forms.

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Pierre Brazeau: It’s still a challenge to find a justice of the peace. And I think, Kimberly, you said, you know some of your people on your staff are Jps now.

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Pierre Brazeau: That’s always a challenge. Some police departments have a Jp on site, and we’ve used that in the past.

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Pierre Brazeau: Substance. Use and co-occurring.

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Pierre Brazeau: Very early on we were challenged with that is it a substance? Use issue versus a mental health issue?

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Pierre Brazeau: And we went through the process of you know, our son voluntarily admitting himself. And they say, Well, we’re we’re still not sure because there’s substance use in the background here.

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Pierre Brazeau: So it took a period of time to really understand that it was, in fact.

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Pierre Brazeau: an evolving mental health issue. And once that was documented, it was much easier and subsequent. I used to say, Yes, there is substance use occurring, but there’s an underlying mental health issue at play here.

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Pierre Brazeau: and so it that can be a very frustrating process.

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Pierre Brazeau: and all I can say is that you know my wife and I, you have to remain committed to the process and understand it can be challenging. It can be frustrating.

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Pierre Brazeau: But you’re there to advocate for your loved one, and that’s the biggest key is to continue this, you know. Stand up and say, but there’s something else here.

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Pierre Brazeau: we talked about, you know. Sometimes they recant statements. And that can be challenging unless you have documentation like messages, text messages, Facebook, or as a loved one, you may know

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Pierre Brazeau: things that trigger them. And you can say, Well, ask them about this situation.

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Pierre Brazeau: and oftentimes

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Pierre Brazeau: that triggers something in in a loved one. And now they’re willing to disclose some of their mental health issues.

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Pierre Brazeau: and it becomes more apparent.

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Pierre Brazeau: There is an underlying issue here. When you say, well, ask them what happened that night, like, what are they thinking about? When they stated, helicopters were flying over the house, surveilling us. And there they’ve been recanting and recancing, and all of a sudden they go.

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Pierre Brazeau: They relive that experience, and they are able to share in a way what’s going on in your mind. And now a mental health clinician can see and help them. So that. That’s another way to try. And you know, advocate for your loved one.

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Pierre Brazeau: it! I think the process has gotten better.

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Pierre Brazeau: I think. Now. There’s a lot of police forces

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Pierre Brazeau: in the past. We’ve done Ias, and they were inexperienced in executing an Iea or dealing with mental health crisis. But there’s been a lot of initiatives. My wife’s been involved in one of them, which is the, you know, crisis intervention training for police departments and

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Police departments have gotten better at getting all of their staff trained. So they understand

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Pierre Brazeau: how to work with mental health patients that they didn’t 10 years ago. So challenges that we had 10 years ago.

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Pierre Brazeau: Hopefully, people are experiencing that today with Ieaas. But it’s it’s always situational dependent. And you know, every every person involved has to look at their own personal safety as well. So it’s it’s a challenge. And and some people, some police officers, some

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Pierre Brazeau: Some individuals, are just

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more adapt

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Pierre Brazeau: at dealing with mental health crisis than others.

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Pierre Brazeau: And and sometimes you just have to look for the right situation.

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Pierre Brazeau: it. It’s a challenge, and it’s and it can be really frustrating as a parent

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Pierre Brazeau: and heartbreaking cause. At the same time, you’re trying to do this, and you’re also dealing with your own emotional distress

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Pierre Brazeau: avoid seeing happen to your loved one, and that can can be very challenging and also cloud. You know this.

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Pierre Brazeau: how you fill these arms up, putting too much of your own personal feelings in and not

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Pierre Brazeau: sticking with the facts. And that’s just because you yourself are in crisis as well because you’re seeing someone you love

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Pierre Brazeau:  dealing with mental health illness that

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Pierre Brazeau: you know is challenging and significant in their life, and and that

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has an impact on you as an individual as well.

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Michelle Wagner, NAMI NH (she/her): Thank you, Pierre, for that perspective. It’s an important one.

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Michelle Wagner, NAMI NH (she/her): We had have a whole bunch of questions that have come in. What? Where does the Mse get recorded? I’m not sure what that acronym is.

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Michelle Wagner, NAMI NH (she/her): Oh, got it! Yes, I do know what that is. Good Lord, so where does that get recorded?

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Mohamed W. ElSayed, MD, MSc: It gets recorded in the ie. And one of the pages that we showed right after the physical examination.

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Michelle Wagner, NAMI NH (she/her): Yeah, perfect, perfect, perfect. Mitchell asks, what types of places will accept Ieaas? Is it only hospital Er’s or other types of treatment centers or medical centers?

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Michelle Wagner, NAMI NH (she/her): And we did bring that up. Drfs right? The designated receiving facilities. And there was the list

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Michelle Wagner, NAMI NH (she/her): on the form. So

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Michelle Wagner, NAMI NH (she/her): yeah.

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Pierre Brazeau: I think the designated receiving facilities are for people to be transferred from. Yeah er. But

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Pierre Brazeau: that’s different than the question of Iea. Some. Where will the patient be taken if you execute an Iea who will do an Iea that’s could be a hospital. That’s not a designated receiving facility. Maybe Mohammad or Kim really can expand on that.

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Michelle Wagner, NAMI NH (she/her): I think it was, except I eas.

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Kimberly Goldberg: So I don’t think it was. Yeah, I think it was. If we’re talking about it after the court process, then it would be a designated receiving facility prior to that court process. It would be an emergency department.

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Kimberly Goldberg: I can’t think of a time when it wouldn’t be an emergency department.

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Michelle Wagner, NAMI NH (she/her): Got it?

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Michelle Wagner, NAMI NH (she/her): Shawn asks or says on old Iea prayer complaints. There would be a place for Petitionee’s address, so police would know where to go to pick them up. There doesn’t be appear to be a spot for that anymore.

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Michelle Wagner, NAMI NH (she/her): Any ideas comments on that.

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Kimberly Goldberg:  There is a spot on the complaint. For that information, I believe

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Kimberly Goldberg: pretty confident there is. Now I’m questioning, but

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Michelle Wagner, NAMI NH (she/her): but at the very top, isn’t there, doesn’t it?

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Michelle Wagner, NAMI NH (she/her): Let’s take a look at the yeah. Let’s take a look at the form together. How’s that?

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Kimberly Goldberg: So if somebody’s already in the emergency department, they wouldn’t necessarily

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Kimberly Goldberg:  need that address?

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Kimberly Goldberg: But if they were filling out this this part of it, then there would be I.

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Kimberly Goldberg: 8, 5, 8, 6, 3.

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Pierre Brazeau: As one thing I can add as a petitioner when you complete complaint in the Iea often times you’re the one who’s bringing it to the police.

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Pierre Brazeau: And they’re asking you, where is this individual? And you’re saying at this moment, in time, I believe he’s in downtown by this area, or he’s at our house right now, or because they can be.

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Pierre Brazeau: they can be in motion, and in some cases

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Pierre Brazeau: When our son was not living at our house he was transient. And so it’s a matter of well, where is he right now? Well, we’re not sure but these are areas that he

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Pierre Brazeau: there’s an interaction that often occurs that provides that additional information.

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Pierre Brazeau: to the police department to execute the order.

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Michelle Wagner, NAMI NH (she/her): Yeah.

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Michelle Wagner, NAMI NH (she/her): perfect. Thank you, Pierre. We only have 8 min left a bunch of questions. So Christine asked, do the court hearings take place? If they have not moved to New Hampshire Hospital?

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Kimberly Goldberg: Yes, they will. It’ll take place via telehealth or by phone.

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Michelle Wagner, NAMI NH (she/her): and within the 72 HI she had added that on. Yeah, we got that with the increasing number of patients boarding in Eds. Are they holding court in ers. We just said that. And how does this affect the 10 days? If it’s upheld? If there aren’t any beds available

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Kimberly Goldberg: person will will still receive treatment in the emergency department while they’re there. And I think there was a question about treatment. What does treatment actually look like

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Michelle Wagner, NAMI NH (she/her): kashlyn asks so if they are staying in the local hospital? Is the patient medicated according to previous history, medications, etc., properly, or do they need to wait until a bed is available at the State Hospital to get that treatment.

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Mohamed W. ElSayed, MD, MSc: They do start medications in in the hospitals, sometimes patients if you use them, but if there’s a situation where the patient is in danger, then they can force medications.

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Michelle Wagner, NAMI NH (she/her): And bj, let us know that justice of the peace lists may be available at town clerk’s offices.

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Michelle Wagner, NAMI NH (she/her): because we know this has been an issue in the past. People have gone to J. P’s, and the JP. Says, I’m not comfortable doing this, although we know from you folks that this is what they’ve signed on for when they agree to be a justice of the peace. Correct?

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Michelle Wagner, NAMI NH (she/her): Okay. Let’s see guardians regarding guardians.

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Michelle Wagner, NAMI NH (she/her): What about adults with guardians through the office of public guardians? Can that guardian voluntarily admit an adult against their will.

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Mohamed W. ElSayed, MD, MSc: Yes.

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Michelle Wagner, NAMI NH (she/her): and this is parents parent of a youth. If a parent of a youth is unable to get the child to

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Michelle Wagner, NAMI NH (she/her): to go voluntarily to the hospital for evaluation. Would the parent follow the Iep application and complaint process to get assistance in getting the child to the emergency department?

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Kimberly Goldberg: I’m guessing they mean I sorry I was reading. And yeah, she corrected. Down below. It could be used. It’s so. II don’t know that I’ve ever seen it actually happen. But

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Kimberly Goldberg: technically the answer is, yes.

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Michelle Wagner, NAMI NH (she/her): BJ. Asked. People who don’t do this every day aren’t as good with the documentation. Is there a template we can give to people to help them in filling that out.

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Kimberly Goldberg: So the new website that the State is using for the Ia paperwork walks you through it pretty well, and I believe that

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Kimberly Goldberg: there at least was a a Powerpoint presentation that helps with that as well

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Kimberly Goldberg: was available.

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Michelle Wagner, NAMI NH (she/her): James is saying, how does one manage when legal guardian does not respond to initial call from clinician, nor the guardian who is on call.

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Michelle Wagner, NAMI NH (she/her): That becomes a sticking point.

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Mohamed W. ElSayed, MD, MSc: Yeah, become stuff. If even if they’re getting on, call is not answering, then their physician can respond to the situation. That’s dangerous at the moment, or if there’s an imminent medical emergency at the moment. But they can’t take long term decisions for the patient.

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Michelle Wagner, NAMI NH (she/her): Okay.

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Michelle Wagner, NAMI NH (she/her): let’s see.

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Michelle Wagner, NAMI NH (she/her): So Catalina was saying, we now have recovery support workers in Carroll County who have become Jps for this purpose. Going back to our Jp. Question encourage recovery, support organizations to consider this. So that’s a great way to get more Jps available.

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Michelle Wagner, NAMI NH (she/her): And does it have to be a family member filling out the Iea? If there is a person within the community who doesn’t have family, but is clearly in crisis. Can anyone witness to the dangerous behavior?

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Kimberly Goldberg: Anyone can complete an Iea?

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Michelle Wagner, NAMI NH (she/her): Let’s see, it can be very frustrating as a clinician when NHH. Defers a patient, and there is a difference of opinion that the patient requires inpatient mental health hospitalization

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Michelle Wagner, NAMI NH (she/her): a any thoughts on that?

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Michelle Wagner, NAMI NH (she/her): Because this happens right?

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Michelle Wagner, NAMI NH (she/her): Differing opinions.

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Mohamed W. ElSayed, MD, MSc: Yeah, it it does happen. And II guess

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Mohamed W. ElSayed, MD, MSc: the stronger you make your argument, and why this patient is an iea.

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Mohamed W. ElSayed, MD, MSc: This is. This is how you can get the ie. Through and well, even if well, sometimes we have conflict cases here in hospital that we would like to Eis, and we have different opinions in the same case. So just try to make you argument as long as possible.

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Michelle Wagner, NAMI NH (she/her): Great, thank you for that.

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Michelle Wagner, NAMI NH (she/her): Cathy says. Is there any effort being made to not require handcuffs behind the person’s back for a person that are known to the police. That might be outside of the scope of this group.

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Pierre Brazeau: I do know. There as a parent is. We’ve experienced both scenarios.

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Pierre Brazeau: The crisis intervention, training, and individuals who

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Pierre Brazeau: have experience with mental health crisis

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or more, opt to be able to work with a patient

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Pierre Brazeau:  for a potential patient, but it it’s a challenge, and we’ve seen both. And it’s it’s heartbreaking.

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Pierre Brazeau: so I

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Pierre Brazeau: you know I we have our own personal opinions on it, but it’s it’s a challenge. And all I can say is that the training

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Pierre Brazeau: is helpful

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Pierre Brazeau: for individuals involved, like police officers and learning how to de escalate

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Pierre Brazeau: and transfer patients safely without having to resort to, you know, a more safety approach of handcuffs. But

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Pierre Brazeau: I it’s up to that individual. I guess, and whether they feel safe or not, and how they’re handling the pay. So it’s heartbreaking, and we’ve

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Pierre Brazeau: seen both scenarios and

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Michelle Wagner, NAMI NH (she/her): yes, and things are improving. I do an early psychosis, 50 min workshop at all of our C, it programs that we have. So

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Michelle Wagner, NAMI NH (she/her): we’re educating and helping. And we are at time. It’s 1259. So I just wanna let folks are. I wanna thank our panel. Who was here? This was a fabulous discussion. We missed a couple of questions, but we got to most of them. So thank you so much for your expertise

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Michelle Wagner, NAMI NH (she/her): and a reminder that the recording of today’s the discussion will be posted on the Education page of Onward Nhorg, you’re going to receive an email in the next couple of days which will include links for the website along with the evaluation. Once you’ve completed the survey, you’ll automatically receive a certificate of attendance, and for questions or comments please reach out to me, M. Wagner at Nami Nhorg. We look forward to seeing you next time. Until then. Take care, everybody.

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Kimberly Goldberg: Thank you. Alright.

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