Living Safely with Mental Illness: Preventing and responding to crises

Transcription

1 Living Safely with Mental Illness: Preventing and responding to crises Joel A. Dvoskin, Ph.D. University of Arizona College of Medicine

2 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..

3 4%

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

5 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

6 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

7 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

8 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.

9 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

10 Effective Crisis Services CIT Mobile crisis outreach teams Crisis triage settings Peer-run warm lines Drop-in centers

11 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

12 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

13 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

14 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

15 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

16 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

17 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?

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

19 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

20 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

21 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

22 Luckily for us. People will cut us slack if we quit acting like we know everything.

23 Secondary Trauma Among Mental Health Workers and First Responders: Helping them doesn t have to hurt you.

24 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

25 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

26 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.

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

28 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

29 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

30 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

31 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

32 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

33 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

34 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

35 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

36 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

37 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!

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

39 The Most Important Protective Factors Clinical relationship and therapeutic alliance Respect Your receptionist matters Instillation of hope Your own good common sense

40 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

41 Three things that Get Us Hurt Fear Anger Despair Pay special attention to these affective states in your client and yourself.

42 Be Trauma-Informed What has happened to you? The dangers of intimacy Key Principals Safety and trust Choice Collaboration Empowerment

43 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

44 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

45 Try Not to Make Things Worse If you re scared, find a respectful way to get out of there, or at least back off When we panic, we stop being good communicators

46 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.

47 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.

48 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.

49 So from all of us to all of you

50 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.