Living Safely with Mental Illness: Preventing and responding to - - PowerPoint PPT Presentation

Living Safely with Mental Illness: Preventing and responding to crises

Joel A. Dvoskin, Ph.D. University of Arizona College of Medicine joelthed@aol.com

The Truth about Violence and Mental Illness (Swanson et al)

• The vast majority of people with mental illnesses

never commit acts of serious violence.

• People with SMI are much more likely to be victims

than perpetrators of violence.

• Only a very small proportion of violence is

attributable to people with mental illnesses.

• If mental illnesses were completely eliminated as a

violence risk factor, the population prevalence of violent acts toward others would go down by…… wait for it………..

4%

The Epidemiology of Violence: (Note: None of these are caused by SMI)

• Family violence
• Neighborhood violence
• Institutional violence
• Racism and cultural violence
• Poverty and violence
• The violence of poverty
• Situational emotional crisis
• Intoxication

Are You a Violent Person?

• Are you sure?
• Could any situation lead you to become

violent?

• What situation were you just thinking of?
• How did it make you feel?
• The special role of fear, anger, and despair

When It Comes to Violence, Mental Illness Is Not the Problem

• The problem is crisis
• The problem is despair
• If you want to prevent violence, spend your

efforts on preventing and responding to life crises

• This is true whether or not the person has SMI
• The importance of housing

The Decimation of the Public Mental Health System

• During the past 12 years, the public MH system has

been decimated by budget cuts

• Drastic reductions in timely and competent response

to emotional crisis

• Inability to use Medicaid dollars for housing
• We must restore and enhance the ability of public

mental health and public safety systems to respond to crises in a competent and timely manner – This requires adequate funding

People in Emotional Crisis?

• People who feel sad, angry, disconnected,

and insignificant probably won’t kill a bunch of strangers

• But they might commit suicide, or become

addicted, or end up in jail

• It’s impossible to identify murderers in

advance…

• …But it’s easy to identify people in crisis.

Crisis: An ounce of prevention…

• The best time to respond to a crisis is long

before there is a crisis

• Crisis planning with your client
• What knocks people off the wagon?
• Housing
• It‘s all about skills

Effective Crisis Services

• CIT
• Mobile crisis outreach teams
• Crisis triage settings
• Peer-run “warm lines”
• Drop-in centers

Effective Crisis Services

• Help to reduce the criminalization of mental illness by

diverting people in crisis to treatment instead of jail

• Providing appropriate management and care for

people with SMI in the CJS

• Provide an effective way to de-escalate crisis

situations

• Prevent violence
• Prevent suicide
• Keep people with SMI out of jail or prison

Crisis Services and Law Enforcement

• CIT is a game changer

– Changes police attitudes toward people with SMI – Changes police attitudes toward people in crisis – Changes community attitudes toward the police

• Pre-booking diversion
• Suicide prevention
• Violence prevention
• Can enhance adherence to treatment
• Don’t forget other first responders

Crisis Services in Jails and Prisons

• Prevent decompensation
• Prevent escalation of violence
• Reduce the use of seclusion and segregation
• Reduce suicide attempts
• Reduce victimization of inmates with SMI
• Services include medication, special watch

procedures, counseling and therapy, information, case management services

• Value of staff training – especially CIT

What CIT Is and Isn’t

• CIT is a way of making better decisions:

– Arrest or not arrest – Jail vs. MH Crisis Service or ER

• But CIT does not create more options
• Thus, the success of CIT is largely dependent

upon the quality and quantity of community MH services

• It is not a handoff of MH responsibility to the

police

Benefits of CIT

• Better training in verbal de-escalation

techniques

• Decrease in arrests and use of force
• Increase in identifying underserved consumers

more quickly and connecting them with appropriate services.

• Fewer injuries to citizens and officers
• A different view of time

Assessing the Immediate Risk of Violence or Suicide

• The Dvoskin Test: Ask them
• Ask them why
• Ask respectfully
• Ask matter-of-factly
• Don’t assume they’re a good talker
• The value of optimism
• “I’m here to keep you safe”
• The dangers of threats…by us
• People generally don’t enjoy being in crisis

Protective Factors

• Why don’t people use violence?
• Why now?
• What would get them to walk away?
• Don’t be a dream-killer
• Something to lose?

De-escalation

• Awareness
• Calmness
• Be genuineness
• Empathy
• Non-judgmental
• Respect
• Keep your hands to yourself
• Space: the final frontier

Recipient Focus

• Active partnerships

–Roles and responsibilities of all parties –Include all in safety planning

• Integrity and respect

–Saving face –Focus on the person

• The importance of courtesy

–Polite requests

Cultural Competence and Safety

• What is cultural competence?
• Am I ever going to achieve it?
• Language is key
• Contrasting cultures
• All you can reasonably hope for

–Respect –An open mind –Admit your ignorance

Aspects of Culture That Can Affect Safety

• Personal space
• Need for autonomy
• Privacy - letting outsiders in
• Expression of emotions (anger)
• Visiting another person’s neighborhood
• A “man’s” home is his castle
• The many meanings of eye contact
• Respect - how demonstrated
• Authority and/or gender issues?
• Beliefs about mental illness
• Maybe it’s “stress”

Luckily for us….

• … People will cut us slack if we quit acting like

we know everything.

Secondary Trauma Among Mental Health Workers and First Responders:

Helping them doesn’t have to hurt you.

A Sea of Trauma

• Child abuse
• Torture
• Spousal violence
• Ravages of untreated mental illness
• Natural disasters
• Officer-involved shootings
• Poverty
• “Not you again!”
• When calls go bad

Trauma

• Most stress is not traumatic
• Traumatic stressors are extreme, unusual,

intense, and often prolonged

• Your body and mind are hard wired for
• ccasional traumatic stress, but…
• Your stress is not occasional

Human Response to Trauma

• Arousal Continuum

– Calm – Vigilance – Alarm – Terror

• Fight or Flight
• Adrenalin, high blood pressure, and a quick pulse

– Lucrative – if you play running back in the NFL – For a 60 year old psychologist, maybe not so much.

Effects of Trauma

• Symptoms can include:
• Nightmares
• Flashbacks
• Fight or flight
• Dissociation
• Cutting
• Hyperarousal
• Misinterpretation of cues
• Overreaction

Effects of Trauma

• Alarm System as a Survival Mechanism
• Extreme or frequent threats can damage the

alarm system

• With chronic trauma, the alarm system is too

easily triggered and too slow to shut down

• Over-interpretation of and overreaction to

signs of danger

Managing Your Own Emotions

• Nothing scares a client more than scared mental

health workers or officers

• Scared people are more likely to be violent
• The more scared they are, the more likely you are to

get hurt

• Pretending not to be scared never fools anyone.
• Manage your emotions

Secondary Trauma

• Symptoms Identical to PTSD

– Recurring and Intrusive Recollections and Ideations – Avoidance of Reminders of the Trauma – Numbing – Physiological Hyperarousal

• Can Result From One Event
• Causal Event Is Different Only Because It

Happened to Somebody Else

Why Are You At Risk?

• What makes you effective makes you

vulnerable –Empathy –Ability to feel someone else’s pain

• Insufficient recovery time
• Unresolved personal trauma
• Isolation and system fragmentation

Impact on Families

• The Dangers of Silence
• “I Don’t Want to Burden My Family”
• Family Violence

–Child Abuse –Spousal Violence

• Drugs and Alcohol
• Divorce
• Suicide

Physical Coping Mechanisms

• Sleep Well
• Eat Well
• Exercise – Private versus team
• Play well
• Beware of thrill seeking
• The Dangers of drugs, alcohol, and gambling
• The Joy of Sex

Psychological Coping Mechanisms

• Self-reflection: “Check yourself before you

wreck yourself.” – Ali G.

• Do things that bring you joy
• Enjoy your kids
• Get away from your kids (see “The Joy of
• Smile
• Solitude versus loneliness

Emotional Coping Mechanisms

• Spend time with friends
• Don’t hide when you need them most
• Cry with people
• Laugh with people
• Good and bad humor

Rational Coping Mechanisms

• Think about your limitations
• Humility is your friend
• Think about the lives you saved
• Think about your own needs
• Empathize with your family – Is silence

really what they want from you?

• Learn about secondary trauma
• Be an incrementalist

Workplace Coping Mechanisms

• When one victory has to outweigh ten defeats
• Set limits
• Peer support
• Vacations
• Get and take supervision
• Give each other a break
• It may not take a village, but it sure takes a

team!

How Can Mental Health Workers Remain Safe While Serving Difficult Clients?

The Most Important Protective Factors

• Clinical relationship and therapeutic alliance
• Respect
• Your receptionist matters
• Instillation of hope
• Your own good common sense

Don’t Be Afraid to Ask

• We have learned that asking about suicide

doesn’t cause suicide; it prevents it

• So why don’t we ask about violence?
• Nobody knows more about a person’s feelings

and intentions than they do

• Ask early, respectfully, and non-judgmentally
• Heed the advice of the great psychologist Alex

Trebec

Three things that Get Us Hurt

• Fear
• Anger
• Despair
• Pay special attention to these affective states

in your client… and yourself.

Be Trauma-Informed

• “What has happened to you?”
• The dangers of intimacy
• Key Principals

–Safety and trust –Choice –Collaboration –Empowerment

Empathy

• “There but for the grace of God…”
• “How can I help you?”
• “Try to see it my way….” - Communicate a

sincere desire to understand the person’s choices

• Consider the possibility that they’re doing the

best they can

Face

• The most dangerous place in the world
• What is face?
• How big is your face?
• How to know when you’re in your client’s face

Try Not to Make Things Worse

• If you’re scared, find a respectful way to get
• ut of there, or at least back off
• When we panic, we stop being good

communicators

The Greatest Gift

• You help people in despair because they need help.
• If you do it often enough, you’ll prevent tragedies…
• …but you’ll never know it.
• Despair is the enemy.
• Hope is the solution.
• The best gift we give our clients is hope for a better

life.

• Hopeful people don’t commit acts of senseless

violence.

Some General Observations about CIT and Crisis Services

• The worst thing about this work is you don’t get to

know what you prevented

• You learn the most from failure
• But you are not allowed to fail, ever
• Stakes are too high
• There is no stress like perfection
• CIT and other crisis services have demonstrated an

ability to make America safer for people with serious mental illnesses, and to provide them with kindness and help instead of arrest and incarceration.

This Can Be Thankless Work

• You are often the first responders to

psychiatric and emotional crises.

• You seldom receive the praise you deserve

when you quietly and skillfully help a person who is in trouble

• You are too quickly and unfairly blamed when

an encounter goes wrong.

So from all of us to all of you…

…Thank You

• Thanks for coming.
• Thanks for honoring me with you attention.
• Thanks for the people who aren’t here to say

thanks.

• Thanks for the work you do.