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 occasional 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
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