Assisting Individuals Affected by Mental Illness

With Special Emphasis on Those Experiencing Homelessness

Developed by: Tim Welsh LCSW Phoenix Health Center: Louisville KY

About Phoenix Health CenterLouisville, Kentucky

• Physical Health Care• Dental Care• Mental Health Care

• Counseling• Psychiatric Nurse Practitioner

• Social Services• Assist w/Disability Process• Drug/Alcohol Treatment• Work w/Families who are Homeless

OVERVIEW

• Building Rapport• Wants vs. Needs• Safety • ABC’s of working with people with lack of

insight into their mental illness• Outreach • Complicating Factors • Housing First

Build Rapport

LISTEN, LISTEN, LISTEN• “There's actually been two [studies] that … doctors let

patients talk for an average of 20 seconds before they interrupt - sometimes even less. In the most recent study, some doctors let a patient talk for only three seconds before they interrupted.” Lisa Sanders MD on NPR radio August 13, 2009.

• Many homeless individuals suffer from many things which prevent them from trusting others

• Paranoia • Trauma• Mistreatment by others (at shelters, government agencies, in public, etc.)

• Everyone desires to be heard. In order for them to feel valued and respected we must listen to their story and thereby discover their needs & wants…

Wants vs. Needs• What the Client Wants-These are the reasons the

client talks with you and the reasons they will continue to come back and see you– Housing – Clothing – Bus Fare– Hygiene items– Etc. Versus:

Wants vs. Needs• What You/Court/Family Members think the

Client Needs-May or may not be the same

thing as the client’s “want” list. You may see needs that the client has which the client may not prioritize highly or even see as a need at all.– Psychiatric Medication– Stop Drinking Alcohol/Using Illicit Drugs– Get into Housing

Wants vs. NeedsMeet clients more than half way.

Remember:• Self Determination • Your Role: Work alongside the clients to achieve their

goals• Normalizing Items

» Ex. Hair Dye » Hygiene Items

Safety! Safety!! Safety!!!

Safety: Initial Contact/Meeting

• Determine whether there is an immanent risk to self or others

• Location (Clinic, Street, Apartment)• Be aware of your environment

• Home Visits• Tell others where you are going • Go in pairs• Go in the morning • Cell phone at the ready

– Have others call you at specified time• Know your surroundings• Know when to leave/say goodbye • What has worked for you before?

Safety: Be Familiar With…– Common symptoms• Psychosis• Mania• Sadness/Suicidal Ideation• Anger/Homicidal Ideation

– What to expect • With people with mental health issues• With people who are high/intoxicated

KNOW YOUR OPTIONS

• 911• Hospitals• Mental Inquest Warrants• Crisis Stabilization Units• Close Follow-Up– Dispense Medications Weekly/Daily

• Safety Contracts• No Tolerance for Violence– Barring Process

EXITS • Know all EXITS from the room(s) you are in• Do not let client get between you and EXIT • Set up furniture so you have access to EXIT

ALARM CODES

• Have a code system and make sure everyone knows the codes and what to do when codes are called (Specified people have clearly defined objectives in the event of a code).

• Someone to call 911• Someone to handle the other clients • Someone on standby to ensure the person

dealing with the crisis is not alone• Clear the waiting room/area/house• Avoid areas with potential weapons

Suicide• Know risk factors

– Does the Client have a Plan?– Are they hopeless or intenting ending their life?

– Scaling– What does your gut instinct– Consult supervisor/colleagues

• Know what to do in case – Someone is actively suicidal

• Contract for Safety• Hospital • MIW

QPR SUICIDE PREVENTION TRAININGS http://www.kentuckysuicideprevention.org

The ABC’s of working with individuals with lack of insight into

their mental illness

Building a Relationship with Clients with lack of insight

Part I• You may want to wait before you “push” the

idea of psychiatric medications. – Test the waters by asking:• Are you on any medications now?

– Avoid asking “Are you on any psychiatric medications?”

• Have you been on medications for blood pressure, sleep, or depression before?

Building a Relationship with Clients with lack of insight

Part II• If you determine the client was formerly on

medications or that they obviously need them but the client is adamant that they do not need/want any, you can ask symptom-related questions:

• “Do you have any trouble with sleep?”• “Your situation sounds very stressful. Are you having

any trouble with your nerves?”

Building a Relationship with Clients with lack of insight

Part III

For psychotic clients: • If they are not an imminent risk to self or others, you

may want to simply focus on building the relationship so that you can closely monitor them. – Over time they may come around to the idea of medications if

they feel safe – If their symptoms worsens you can take out a Mental Inquest

Warrant

Building a Relationship with Clients with lack of insight

Part IV

• For psychotic clients: Base your reactions to their delusions/hallucinations on the amount of insight the patient has into their delusions/hallucinations. – If the patient believes their delusions or hallucinations are

real, you may simply want to listen and not confront the delusions (at least not initially).

Outreach• Campsites

– Do not go alone– Avoid if possible –Instead go to public places where individuals who are homeless

congregate

• Public areas where people who are homeless congregate– Day Shelters– Soup Kitchens– Parks– Libraries

• Word of mouth• Build Trust• Provide

– Food– Clothes/Shoes– Socks/Underwear– Hygiene Items

Complicating Factors• Dual Diagnosis

– Dangers of drinking/using illegal substances & taking medications– Dangers of drinking/using while sleeping outside– Increase in assaults/homicide of the homeless.

• Previous poor mental health experiences• Paranoia• Word of mouth “Aren’t you the ‘crazy’ doctor”• Physical Health Issues • (Mis)Perceptions

• Clients see people, who are on psychiatric medications, look like zombies.– Clarify that there are many medications available.– Clients do not know all details of other client’s mental health issues.

• Fear of Hospitalization– Important to be clear about why someone would be hospitalized.

Complicating Factors• Personality Disorders– Monitor your emotional reactions – Set FIRM Boundaries– Avoid Tug-of-War

• Agree to Disagree

– Beware/Plan for Triangulation• Get releases of information signed

– Consequences• Explain what will happen if client acts/threatens• Ensure that you follow through on plan/rules

Complicating Factors• Personality Disorders

Remember that personality disorders are ultimately ways of coping and surviving that the individual learned in childhood usually due to abuse or neglect.

Think: “What has happened to you?”Instead of “What is wrong with you?”

Rules = Hoops

• Ways around Hoops:– Review rules/status quo to see if they are barriers to service – Outreach – Educate Front office/Frontline staff

• Some rules may create unnecessary boundaries for homeless clients:– Strict appointment enforcement– Complicated medication regimens – Drug/Alcohol Abstinence

• Some rules must be firm– Safety

Complicating Factors

Mental Inquest Warrants

• 202A.026 Criteria for involuntary hospitalization. No person shall be involuntarily hospitalized unless

such person is a mentally ill person: (1) Who presents a danger or threat of danger to

self, family or others as a result of the mental illness; (2) Who can reasonably benefit from treatment; and

(3) For whom hospitalization is the least restrictive alternative mode of treatment presently available. Contact local County Court House for details

Homicidal Threats/Duty to WarnResponsibilities of Qualified Mental Health Professionals

• Upon hearing a threat against someone else– Determine the immediate risk– Intent– If the threat appears possible• Call the police department where the threatened

person resides/as well as the police dept. where the person making the threats is located.• Attempt to contact the threatened person to warn

them of the threat

Duty to WarnResponsibilities of Qualified Mental Health Professionals • 645.270 Duty of qualified mental health professional to warn intended victim ofpatient's threat of violence.(1) No monetary liability and no cause of action shall arise against any qualified mental healthprofessional for failing to predict, warn or take precautions to provide protection from apatient's violent behavior, unless the patient has communicated to the qualified mental healthprofessional or person serving in a counselor role an actual threat of physical violence against aclearly identified or reasonably identified victim, or unless the patient has communicated to thequalified mental health professional or other person serving in a counselor role an actual threatof some specific violent act.(2) The duty to warn or to take reasonable precautions to provide protection from violentbehavior arises only under limited circumstances specified in subsection (1) of this section. Theduty to warn a clearly or reasonably identifiable victim shall be discharged by the qualifiedmental health professional or person serving in a counselor role if reasonable efforts are madeto communicate the threat to the victim and to notify the law enforcement office closest to thepatient's and the victim's residence of the threat of violence. If the patient has communicated tothe qualified mental health professional or person serving in a counselor role an actual threat ofsome specific violent act and no particular victim is identifiable, the duty to warn has beendischarged if reasonable efforts are made to communicate the threat to law enforcementauthorities. The duty to take reasonable precautions to provide protection from violent behaviorshall be satisfied if reasonable efforts are made to seek civil commitment of the child under KRSChapter 645.(3) No monetary liability and no cause of action shall arise against any qualified mental healthprofessional or person serving in a counselor role for confidences disclosed to third parties in aneffort to discharge a duty arising under this section.

Housing First

• Pros– Gets people into housing/off streets fairly quickly– Can help people stabilize – Help rebuild sense of normalcy

• Challenges– Possibility of Increased drug/alcohol use– Mental Health symptoms increase initially– Keeping Mental Health appointments decreases

Housing First

Helpful Strategies:• Support Groups• Counseling• Psychiatric Home Visits

REMEMBER The most valuable thing we offer is simply

providing compassionate interaction for those living on the outskirts of our society, thereby allowing them to slowly reconnect, and just as importantly, feel human again.

Tim Welsh LCSW

twelsh@fhclouisville.org502 569 1662