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Assisting individuals affected by mental illness with special emphasis on those experiencing homelessness
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Assisting individuals affected by mental illness with special emphasis on those experiencing homelessness


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Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Tim Welsh …

Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Tim Welsh
Many homeless individuals experience mental health problems that impact their ability to maintain stability.
This presentation will explore the issue of mental illness and help participants develop engagement and
intervention skills for working with individual who are experiencing a mental illness.

Published in: Health & Medicine

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  • 1. Assisting IndividualsAffected by Mental IllnessWith Special Emphasis on Those ExperiencingHomelessnessDeveloped by: Tim Welsh LCSWPhoenix Health Center: Louisville KY
  • 2. 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
  • 3. OVERVIEW• Building Rapport• Wants vs. Needs• Safety• ABC’s of working with people with lack ofinsight into their mental illness• Outreach• Complicating Factors• Housing First
  • 4. Build RapportLISTEN, LISTEN, LISTEN• “Theres actually been two [studies] that … doctors letpatients talk for an average of 20 seconds before theyinterrupt - sometimes even less. In the most recent study,some doctors let a patient talk for only three secondsbefore they interrupted.” Lisa Sanders MD on NPR radio August 13, 2009.• Many homeless individuals suffer from many things whichprevent 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 feelvalued and respected we must listen to their story andthereby discover their needs & wants…
  • 5. Wants vs. Needs• What the Client Wants-These are the reasons theclient talks with you and the reasons they willcontinue to come back and see you– Housing– Clothing– Bus Fare– Hygiene items– Etc.Versus:
  • 6. Wants vs. Needs• What You/Court/Family Members thinkthe Client Needs-May or may not be the same thing asthe client’s “want” list. You may see needsthat the client has which the client may notprioritize highly or even see as a need at all.– Psychiatric Medication– Stop Drinking Alcohol/Using Illicit Drugs– Get into Housing
  • 7. Wants vs. NeedsMeet clients more than half way.Remember:• Self Determination• Your Role: Work alongside the clients to achieve theirgoals• Normalizing Items» Ex. Hair Dye» Hygiene Items
  • 8. Safety! Safety!! Safety!!!
  • 9. Safety: Initial Contact/Meeting• Determine whether there is an immanent risk to self orothers• 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?
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. ALARM CODES• Have a code system and make sure everyoneknows the codes and what to do when codesare called (Specified people have clearlydefined objectives in the event of a code).• Someone to call 911• Someone to handle the other clients• Someone on standby to ensure the persondealing with the crisis is not alone• Clear the waiting room/area/house• Avoid areas with potential weapons
  • 14. 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• MIWQPR SUICIDE PREVENTION TRAININGS
  • 15. The ABC’s of working withindividuals with lack of insight intotheir mental illness
  • 16. Building a Relationship with Clients with lack of insightPart I• You may want to wait before you “push” theidea 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?
  • 17. Building a Relationship with Clients with lack of insightPart II• If you determine the client was formerly onmedications or that they obviously need thembut the client is adamant that they do notneed/want any, you can ask symptom-relatedquestions:• “Do you have any trouble with sleep?”• “Your situation sounds very stressful. Are you havingany trouble with your nerves?”
  • 18. Building a Relationship with Clients with lack of insightPart IIIFor psychotic clients:• If they are not an imminent risk to self or others, youmay want to simply focus on building the relationshipso that you can closely monitor them.– Over time they may come around to the idea of medications ifthey feel safe– If their symptoms worsens you can take out a Mental InquestWarrant
  • 19. Building a Relationship with Clients with lack of insightPart IV• For psychotic clients: Base your reactions totheir delusions/hallucinations on the amountof insight the patient has into theirdelusions/hallucinations.– If the patient believes their delusions or hallucinations arereal, you may simply want to listen and not confront thedelusions (at least not initially).
  • 20. Outreach• Campsites– Do not go alone– Avoid if possible –Instead go to public places where individuals who arehomeless 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
  • 21. 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.
  • 22. 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
  • 23. Complicating Factors• Personality DisordersRemember that personality disorders are ultimatelyways of coping and surviving that theindividual learned in childhood usually dueto abuse or neglect.Think: “What has happened to you?”Instead of “What is wrong with you?”
  • 24. 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 forhomeless clients:– Strict appointment enforcement– Complicated medication regimens– Drug/Alcohol Abstinence• Some rules must be firm– SafetyComplicating Factors
  • 25. Mental Inquest Warrants• 202A.026 Criteria for involuntary hospitalization.No person shall be involuntarily hospitalized unlesssuch person is a mentally ill person:(1) Who presents a danger or threat of danger toself, 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 restrictivealternative mode of treatment presently available.Contact local County Court House for details
  • 26. 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 threatenedperson resides/as well as the police dept. where theperson making the threats is located.• Attempt to contact the threatened person to warnthem of the threat
  • 27. Duty to WarnResponsibilities of Qualified Mental Health Professionals• 645.270 Duty of qualified mental health professional to warn intended victim ofpatients 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 apatients 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 thepatients and the victims 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.
  • 28. 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
  • 29. Housing FirstHelpful Strategies:• Support Groups• Counseling• Psychiatric Home Visits
  • 30. REMEMBERThe most valuable thing we offer is simplyproviding compassionate interaction for thoseliving on the outskirts of our society, therebyallowing them to slowly reconnect, and just asimportantly, feel human again.
  • 31. Tim Welsh LCSWtwelsh@fhclouisville.org502 569 1662