How Do We Help Families Stay Safe as Caregivers?

Transcription

1 How Do We Help Families Stay Safe as Caregivers? Nancy Pierce, MA, LCSW Mental Health Crisis Consultants Sara Hausser, Daughter of Jane Skalitzky How Do We Learn? As adults we learn from experiences of others Hope to gain a better understanding of what family caregivers face As crisis professionals we can learn how to help by recognizing and responding to risk families face in their care giving role Help family access resources, gain knowledge and build skills to better understand how they can reduce the risk inherent in care giving Hindsight Bias Thinking No if onlys or woulda, coulda, shouldas Instead we wish we could/would have Second guessing or blaming/shaming If we had been there or involved Judging what was done then and basing on what we know now (which is everything) Yes, to learning from this family s experience Thank you for allowing us opportunity to learn 1

2 Sara s Story Risk of Violence and Mental Illness/Disorders Most people who are violent are not mentally ill; Most people who are mentally ill are not violent 2

3 Myths of Dangerousness Mentally ill are dangerous Automatic association between mental illness and dangerousness (media, myths, stereotypes) Could snap at any minute without warning Should all be locked up or kept out of most communities Myths create negative stereotypes which may lead to misinterpretation and stigma Facts and Stats of Violence Persons with severe mental illnesses (bipolar disorder, schizophrenia, major depression) 2-3x more likely to be assaultive as general population Lifetime prevalence of violence among the mentally ill is 16% vs. 7% in general population People who abuse alcohol and other drugs are 7x more likely to be assaultive 3%-5% of violent acts can be attributed to individuals living with a serious mental illness What Do Facts and Stats Mean? Very few people with mental illness are violent Very few violent people are mentally ill Low risk no risk Most acts of violence committed by individuals with serious mental illness are carried out when they are not being treated and/or using substances We equate violence with the mental illness instead of untreated symptoms 3

4 Mental Illness Risk for Violence Substance abuse Personality disorders Antisocial Borderline Narcissistic Psychotic disorders Mania in manic-depression/bipolar disorder Schizophrenia Developmental disability/brain injury or illness Traits, Characteristics, Contexts Impulsive or can t regulate hostility/irritability Unable to regulate negative affect due to illness Paranoid thinking/angry personality style Difficulty problem solving/decision making Consequence defiant, resistant, unaware Co-occurring disorders may risk Contexts/circumstances Not taking meds, keeping appointments, etc. Abusing substances, toxic peers/environments History is Best Predictor Past violence and impulsive behavior Family history Similar circumstances and contexts Off medications Using substances Losses/crises: housing, food, money, supports Trauma 4

5 Recognize Signs and Symptoms Uncooperative, hostile/suspicious Agitation/tension-excitement Disturbed/disorganized speech/thinking Violent command hallucinations with associated delusions* Threat/control override: mind and body controlled by forces outside of their control* Identify De-stabilizers Not in treatment Stopped medications or not taking regularly Acute psychotic symptoms Substance abuse and/or withdrawal Loss of housing, food, money Loss of social supports Arrest/incarceration Being victimized or abused/trauma Active Symptoms of Psychosis and Violence 5

6 Acting on Command Hallucinations Delusions related to auditory hallucinations Knowing voice s identity Believing voices to be real and good/caring Having few strategies to deal with voices Not feeling in control of voices Are you feeling driven to obey voices? Threatened Feel threatened not being under own control Under control of external force that determines person s actions Mind dominated by forces beyond their control Thoughts being put into their head not their own Being followed by others plotting to ruin, poison, do harm, drive them insane What would you do if you have contact with people who wish to do you harm? Control Others control my movements Others can insert thoughts into my head/mind My thoughts are dominated by external force Others can determine my thoughts Others have control over me My life is being controlled by something or someone other than me What might you have to do to regain control? 6

7 Active Symptoms and Violence Paranoid, persecutory, control delusions Perceived threat of harm by others (2x) Perceived threat from thoughts/behaviors being controlled by external forces (2x) Risk increases when evidence to support 8 to 10 x more likely when psychotic symptoms are in combination with substance abuse Command hallucinations Are part of delusional system Familiar voices Driven to obey Who is Most at Risk? People with severe mental illnesses over 10x more likely to be victims of violent crime than general population Often not believed or considered credible witnesses or victims Families and caregivers most at risk especially mothers/parents 7

8 Hard to Ask for Help (Clients and Families) Why is it Hard to Ask for Help? May not seek or want help and live in fear of loved one with mental illness May not know how or where to get help May be reluctant to use tough love approach or set boundaries May be understandably concerned about involving police, courts/legal system May struggle to recognize when they are not safe and need outside resources Right to Refuse Treatment People have the right to refuse treatment Symptom of severe mental illness impairs ability to understand and perceive their illness Affects part of brain involved in self-reflection 50% with schizophrenia, 40% with bipolar disorder Reason why people with schizophrenia and bipolar disorder refuse or don t seek treatment Without awareness of illness, refusing treatment appears rational no matter how clear need for treatment might be for others 8

9 Lack of Insight = Anosognosia Recognizing anosognosia = poor insight Anosognosia vs. denial Severe and persistent over months/years Beliefs are fixed and don t change even with overwhelming evidence Illogical explanations attempting to explain away the evidence Symptom of brain dysfunction, not the person LEAP= how families can help find person s own reasons for accepting treatment LEAP* Core Tools Listening reflectively To understand person s point of view and reflect your understanding back to them Without commenting, disagreeing or arguing Empathy Considering person s point of view Respond to feelings not content Agreeing by finding common ground On those things you can agree on Agreeing to disagree about others Partnering to achieve goals you share Ally vs. adversary *Xavier Amador, Ph.D Commitment Statutes Outpatient Commitment 9

10 Chapter 51 Wisconsin Statute Wisconsin Alcohol, Drug Abuse, Developmental Disabilities and Mental Health Act Civil Commitment Process What families can expect Provides legal procedures for voluntary and involuntary admission Treatment and rehabilitation of individuals (adults & minor children) with mental illness, developmental disability, drug dependency, or alcoholism Chapter 51-Mental Health Crisis Emergency Detention: police + crisis unit Petition for Examination or 3 party petition Fifth Standard Treatment Directors Hold Person may be placed under Chapter 51 civil commitment Outpatient commitment: most of the mental health treatment is outpatient Fifth Standard Petition Similar to Three Party Petition, but person must have history of receiving treatment and inability to understand benefits of treatment while suffering from mental illness Different from other involuntary civil commitment statutes because it requires a finding that the person suffering from a mental illness is in need of treatment and there must be a finding that the person is incompetent to refuse medication Does not require finding of dangerousness to be immediate/overt as it is with the first four standards 10

11 Outpatient Commitment Outpatient treatment conditions must be followed by persons under Chapter 51 commitment Keeping appointments, taking medications as prescribed, not using alcohol/drugs, refraining from acts of harm to self/others Treatment conditions are court ordered so viewed as involuntary or forced/coerced by the person County monitors 51 commitments to ensure person is following terms of outpatient conditions and mental health services are made available to them Return to More Restrictive If person under commitment does not follow outpatient treatment conditions, they may be returned to more restrictive setting like hospital All efforts are made avoid return and help the person to follow terms of outpatient commitment Meet with person to learn about any challenges or obstacles preventing them from following treatment conditions Assisted Outpatient Treatment/AOT AOT laws allow courts to order certain individuals with major mental illness to comply with treatment while living in community Allows courts to commit mental health systems to provide treatment Programs reject serving those with serious illness or don t follow up if client fails to show up for services Meant to help and not punish Way to get mental health services to those who refuse voluntary treatment 11

12 AOT Criteria 18 years or older Suffer from a mental illness Unlikely to survive safely in community without supervision History of non-compliance with treatment Significant factor in being in hospital, prison or jail at least twice within past 36 months or Resulted in one or more acts, attempts or threats of serious violent behavior towards self or others within the last 48 months Unlikely to voluntarily participate in treatment Advantages Allow persons to be ordered into treatment without ordering them into hospital Criteria to place someone in AOT are easier to meet than imminent dangerous standard No need to wait until person becomes dangerous to self or others, as in the inpatient standard. Under AOT you can start procedures to prevent a relapse that could lead to dangerousness. Do AOT Laws Work? AOT working in some states, but not in others Families report law is on the books, but not being implemented Counties describe AOT law as confusing and difficult to implement Strained mental health resources Lack of enforcement resources Allowing judges to force psychiatric treatment remains deeply controversial as a violation of a person s civil rights 12

13 How to Reduce/Manage Risk for Family/Caregivers Professional Guidelines to Reduce Risk Treat active mental illness Consider civil commitment (chapter 51) Enforce compliance with medications Address and treat substance abuse Manage modifiable risk factors in the client Increase the frequency of sessions or check-ins Change focus of treatment to anger/impulse control Include collateral treatments and supports Involve others including community police officers What Do Families Need to Know? How to recognize signs of risk How to ask about symptoms of risk Consult and alert providers and/or authorities Don t worry alone Boundaries and love We don t believe people we love will hurt us We often don t know the people we love Crisis units can help with risk issues 13

14 Do We Inform Families about Risk? Are we worried about increasing fear or stigma/stereotyping if we discuss risk? Inform families about possible risk of violence Relationship between mental illness and violence, but unclear if it is cause and effect Symptoms/circumstances when risk is elevated Safety planning for family before risk event Skills to recognize signs & ask about symptoms Reduce access to weapons or lethal means Safety Planning for Family Increase case management to monitor/manage risk Alert crisis unit before crisis Home visit to assess possible emergency detention May involve neighborhood or mental health officer Planned respite care for both client and family Crisis stabilization facilities Hospital diversion/care center Hospitalization for safety, medication management to reduce active symptoms of psychosis What to Report and To Whom? Increased frequency and intensity of psychotic symptoms interfering with functioning Evidence or reports stopped/erratically taking medications Substance abuse or withdrawal Not sleeping Feeling frightened, trapped, threatened/threatening Agitation and aggression Report to providers/case managers, crisis unit If immediate risk, 911/police 14

15 Police Response Police respond to restore order and safety Trained to take charge Not looking to criminally charge or arrest CIT officer trained in crisis intervention Patrol or beat officer = welfare checks Mental health officer checks to monitor psychotic behaviors and safety concerns Community deputies provide community support services in rural areas Admission vs. Arrest Recommend hospital admission over arrest if violent behavior/s are result of untreated symptoms of major mental illness Police regularly consult with crisis units Voluntary preferred over involuntary admit If person is taken to jail, alert jail mental health team, jail nurse or jail supervisor about mental health needs including risk If there is risk, determine if bail should be posted or if person can bail out themselves Community-Based Treatment Assertive Community Treatment Community support programs/csp Daily contacts with case manager and/or team Medication management Social and vocational skills groups Comprehensive Community Services/CCS Psychosocial services to facilitate recovery Crisis plans co-authored by client and providers Supported housing + case management services Payees 15

16 Role of Medications Medications alone won t treat the negative or cognitive symptoms of mental illness Side effects Daily medication pick up/observation If possible, not family care givers Delivery and observation Reduced doses and dosing Injection with longer intervals helps with adherence Peer Specialist Consumer of mental health services in recovery as part of the support system Lived experience of mental illness Provide support, socialization and connection Serve as model of hope, self-determination and recovery Family Advocacy in Crisis Work Families are taking on more of the responsibility of care for their loved ones living with mental illness in community Crisis professionals need to be vigilant regarding the safety of family caregivers As part of our community mental health services, it is essential to recognize and respond to the risks associated with untreated mental illness/substance abuse 16

17 Make a difference Please share your thoughts and ideas of what you learned today and how you might apply them to your clinical work setting when you return home Write your ideas twice: one for Sara and her family and one for you to bring back to incorporate into your crisis work 17