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Warm Line Responder Training 1Mental Health America of Montana.

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1 Warm Line Responder Training 1Mental Health America of Montana

2 I.Introduction, Policies & Procedures II.Boundaries and Frequent Callers III.Values and Feelings IV.Active Listen V.Crisis Theory and Management VI.Cultural Issues VII.Suicide VIII.Mental Health IX.Self Care and Stress Management X.Child and Elder Abuse XI.Sexual and Relationship Violence XII.Addictions 2Mental Health America of Montana

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4  Who is MHA of MT  What is the Montana Warm Line ◦ What is the role of a Warm Line Responder  Training expectations and Activities  Personnel policies, grievance procedures, responsibilities  Scheduling, call log forms, supervision, and team meetings  Code of Ethics 4Mental Health America of Montana

5  Mental Health America of Montana (MHA of MT) is a nonprofit organization whose mission is “educating and advocating for the mental health of all Montanans”  MHA of MT also provide resource referrals and professional education  MHA of MT is the official Montana Outreach Partner for the National Institute of Mental Health (NIMH), and provides informational materials for mental health providers, consumers, family members and the general public. 5Mental Health America of Montana

6  Montana Warm Line and Virtual Drop-In Center  Annual Children’s Mental Health Conference  Mental Health Caucus and Advocacy  Newsletter and Information Dissemination  Information and Referral  Prevention and Reduction of the Incidence of Suicide in Montana (PRISM)  Stigma Reduction  Consultation 6Mental Health America of Montana

7  Consumer run ◦ All responders are mental health consumers who are in recovery (job description) ◦ Responders do the following:  Give back to the mental health community  Are sensitive and re-assuring  Provide supportive active listening  Telephone-based “warm line” ◦ Open 4:00 – 10:00 pm Monday thru Friday ◦ Open 1:00 to 10:00 pm Saturday and Sunday  “Virtual” drop-in center ◦ Blogs ◦ Chat Room 7Mental Health America of Montana

8  Background into state of Montana mental health facts  Purpose of Montana Warm Line  Responsibilities of Responders ◦ Active Listening ◦ Promote caller self-determination and decision-making ◦ Offer encouragement, hope, and re-assurance ◦ Maintain own wellness and recovery ◦ Respond to emergencies appropriately ◦ Maintain supervision with prevention coordinator ◦ Complete call log sheets ◦ Be available during your responder shift ◦ Participate in trainings ◦ Comply with policies and procedures 8Mental Health America of Montana

9  Objectives ◦ Safe training environment ◦ Role plays  Group  Triads  Individual  Self Evaluation process ◦ Understand responder role ◦ Confidentiality Policy ◦ Policy and Procedure manual ◦ Complete responder responsibilities  Call log sheets  Supervision 9Mental Health America of Montana

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11  Volunteer or Employee?? ◦ Employment application ◦ Confidentiality statement signature  Protections  Expenses  Discipline process  MHA of MT Board oversight 11Mental Health America of Montana

12  Warm Line Responder scheduling process ◦ Warm Line hours ◦ Telephone capacity ◦ Accountability to Prevention Coordinator  Call log sheet ◦ Hard copy/Soft Copy ◦ On-line access ◦ Quantification of log sheet data  Quarterly reporting  Continual learning process 12Mental Health America of Montana

13  The primary responsibility of a WLR is to help peers achieve their own needs, wants, and goals.  WLRs will maintain high standards of personal and professional conduct.  WLRs will conduct themselves in a manner that fosters their own recovery.  WLRs will openly share with peers, other WLRs and non-peers their recovery stories from mental illness or co-occurring disorders as appropriate for the situation in order to promote recovery and resiliency.  WLRs at all times will respect the rights and dignity of those they serve.  WLRs will never intimidate, threaten, harass, use undue influence, use physical force, use verbal abuse, or make unwarranted promises of benefits to the individuals they serve.  WLRs will not practice, condone, facilitate, or collaborate in any form of discrimination on the basis of ethnicity, race, sex, sexual orientation, age, religion, national origin, marital status, political belief, mental or physical disability, or any other preference or personal characteristic, condition, or state. 13Mental Health America of Montana

14  WLRs will promote self-direction and decision making for those they serve.  WLRs will respect the privacy and confidentiality of those they serve.  WLRs will promote and support services that foster full integration of individuals into the communities of their choice.  WLRs will be directed by the knowledge that all individuals have the right to live in the least restrictive and least intrusive environment.  WLRs will not enter into dual relationships or commitments that conflict with the interests of those they serve.  WLRs will never engage in sexual or intimate activities with peers they serve.  WLRs will not use illegal substances under any circumstances.  WLRs will keep current with emerging knowledge relevant to recovery and will share this knowledge with other certified peer specialists.  WLRs will not accept gifts from those they serve. 14Mental Health America of Montana

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16  What are boundaries ◦ How to recognize ◦ How to set them with self and callers  Supporting callers ◦ What helps ◦ What hinders/hurts ◦ Know your own signals  Physiology  Emotions  Thoughts  Actions 16Mental Health America of Montana

17  Outline for calls ◦ How to introduce yourself ◦ How to get to the need(s) of the caller ◦ How to be strength based ◦ Ending a call ◦ Complete the call log  Supervision about calls ◦ Do a follow up call the next day with your supervisor ◦ Have a specific call to discuss ◦ Answer your questions 17Mental Health America of Montana

18  It’s not necessarily a bad thing (you or we must be doing a good job)  Boundaries you can set: ◦ Time ◦ Scope of the Warm Line ◦ Code of Ethics ◦ What doesn’t feel good to you  Your comfort ◦ Identify what is out of your boundary (anger, trauma, substance use, harmful thinking) ◦ Learn to re-direct 18Mental Health America of Montana

19  What’s inappropriate for me? ◦ Use supervision and FYI sessions to establish your comfort level ◦ Ask for help  Prevention Coordinator  Warm Line Responders  Executive Director 19Mental Health America of Montana

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21 Your role on the WL is not to change callers’ values, or even to talk about your own values. It is to help callers think through their individual situations and make the best decision for themselves based on their own beliefs, values, and circumstances.  What WLRs value: ◦ Acceptance ◦ Non-judgment ◦ Balance ◦ Realism ◦ Awareness ◦ Self-determination 21Mental Health America of Montana

22  Feelings are neither good nor bad; they just are.  Everyone has the right to his or her own feelings.  Everyone has the responsibility for his or her own feelings.  Feelings make sense when considered in the context of the individual’s world view  Denying a feeling does not make it go away. 22Mental Health America of Montana

23  Categories of Feelings: ◦ Desire ◦ Anger ◦ Happiness ◦ Sad ◦ Fear ◦ Depressed ◦ Guilt ◦ Anxiety ◦ Inadequate 23Mental Health America of Montana

24  Religious Fanatic  Pregnant Teen  Promiscuous Female  Welfare Recipient  Professionals  Child Abusers  Volunteers  Promiscuous Male  Child Molester  Spouse Abuser  Drug Abuser  Psychotic  Minorities  Alcoholics  Hysterical People  Abortion  GLBT  Extramarital Affairs  Senior Citizen  Pro-wrestling 24Mental Health America of Montana

25  Basic human needs ◦ Security ◦ Love and belonging ◦ Power ◦ Freedom ◦ Fun  Intrinsic vs. extrinsic psychology ◦ Stimulus response ◦ Choice theory 25Mental Health America of Montana

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27  Be fully present – communicate genuine interest, positive regard  Be fully present – eliminate external distractions  Be fully present – eliminate internal distractions  Be fully present – eliminate internal personal judgments  Be fully present – practice empathy understanding 27Mental Health America of Montana

28  Be fully present – actively listen for understanding  Be fully present – use reflective and empathic responses  Be fully present – facilitate clarification and concreteness  Be fully present – encourage exploration of deeper meaning 28Mental Health America of Montana

29  Evaluating and/or judging  Jumping to conclusions  Assuming (remember the old adage)  Know it all behavior  Short attention span  Hearing what we want  Talking when we ought to listen  Thinking we know better  Fearing change 29Mental Health America of Montana

30  I see  I’m not sure I understand – do you mean…  Oh  You hate that  Mm hmm  You’re confused that  Interesting  Let’s discuss it  Seems you’re know…  You’re really clear about that  You feel lonely right now  I’d be interested in your point of view  Go ahead – I’m listening  You’re upset  Tell me the whole story 30Mental Health America of Montana

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32  Definition: A crisis is any situation for which a person does not have adequate coping skills. It is “self-defined”. 32Mental Health America of Montana

33  Defined: Crisis intervention is “emergency first aid” for mental health.  Purpose: Assist the person and/or group to return to a pre-crisis level of functioning 33Mental Health America of Montana

34  Primarily home or community-based  Focuses on assessment of strengths, adaptation of existing coping skills, and development of new ones  Seeks to restore people to pre-crisis levels of functioning  Accepts content at face value  Validates the appropriateness of reactions to the event and its aftermath and normalizes the experience  Has a psycho-educational focus 34Mental Health America of Montana

35  Recognition ◦ The person realizes she/he is not coping  Attempted Resolution ◦ Person strives to solve problem ◦ Person involves others to help  Emotional Blockage ◦ Emotions become overwhelming ◦ Intensity and duration of frustration impact the physiology of the person ◦ Self-doubt grows ◦ Self-talk is defeating 35Mental Health America of Montana

36  Step One: Listen  Step Two: Assess  Step Three: Develop an action plan  Step Four: Close 36Mental Health America of Montana

37  Elements of listening  Establish rapport and trust  Identify precipitating problems  Help the person deal with, identify, and diffuse feelings  Techniques for listening  Use first names; ask if it OK to use the person’ first name  Use content questions  Ask or use feeling questions or statements 37Mental Health America of Montana

38  Elements of Assessing ◦ Determine the severity of the crisis ◦ Assess potential lethality or physical harm to the person or others ◦ Identify coping patterns, strengths, and resources  Techniques for Assessing ◦ Find out if the person is suicidal, homicidal, or both ◦ Find out to what extent the crisis has disrupted the person’s normal life pattern  Daily routines with family, friends, work, etc. 38Mental Health America of Montana

39  Techniques for Assessing ◦ Find out if the level of tension has distorted the perception of reality ◦ Find out how the person deals with anxiety, tension, or depression – have they been proactive ◦ Find out what coping methods were used in the past – do they have a variety ◦ Find out if family and social resources are potential resources – positive or negative ◦ Find out what the person used as support systems in the past – WRAP or traditional system 39Mental Health America of Montana

40  Elements of Developing an Action Plan ◦ Selectively choose and use appropriate approaches to action planning ◦ Assist in modifying previous inadequate coping skills ◦ Negotiate a contract or action plan ◦ Select appropriate referral resources ◦ Plan for immediate action and implementation  Techniques for Developing an Action Plan ◦ Use three basic approaches: 1)Start by being non-directive 2)Be collaborative by working together on a joint plan 3)Be directive if the person does not or will not make a plan 40Mental Health America of Montana

41  Techniques for Developing an Action Plan ◦ When making an action plan, keep it simple and manageable ◦ Keep the action plan short-term – 24 hours to three (3) days ◦ Keep the action plan achievable and focused ◦ Plan for follow-up provisions ◦ KISS method  Keep it simple stupid 41Mental Health America of Montana

42 In order to successfully assist a person to resolve the crisis, a helper must begin, not at the start of the situation, but at the end, with the overwhelming emotions. Deal with the person’s feelings Develop coping skills and alternatives People in crisis are easily influenced Personalize the solutions Empathize your understanding of what the situation means to the person Encourage the person to identify the problem 42Mental Health America of Montana

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44  To describe culture is to describe the values, beliefs, behavioral norms, and social structures common to a group of people.  Culture is learned from the following: ◦ Children’s caretakers ◦ Religious ceremonies ◦ Community celebrations ◦ Art ◦ Literature ◦ Stories passed down from generation to generation 44Mental Health America of Montana

45 1.Value Diversity 2.Have the capacity for cultural self- assessment 3.Be conscious of the “dynamics” inherent when cultures interact 4.Institutionalize cultural knowledge 5.Develop adaptations to service delivery reflecting an understanding of diversity between and within cultures 45Mental Health America of Montana

46  Develop Awareness ◦ Admit personal biases and prejudices ◦ Value diversity  Acquiring Knowledge ◦ Attend classes ◦ Read about other cultures  Developing and maintaining Cross-Cultural Skills ◦ Develop diverse friends ◦ Learn another language ◦ Overcome fears 46Mental Health America of Montana

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48  Over 32,000 people in the U.S. die by suicide each year  A person dies by suicide every 16 minutes in the U.S.  90% of all people who die by suicide have a diagnosable psychiatric disorder  There are four male suicides for every female suicide, but twice as many females as males attempt suicide  Suicide is the fifth leading cause of de3ath among those years old  Suicide is the third leading cause of death among those 15 – 24 years old  The suicide rate for men rise with age, most significantly after age 64  More than 30% of persons suffering from major depression report suicidal ideation 48Mental Health America of Montana

49  Psychiatric disorders  Past history of attempted suicides  Genetic predisposition  Neurotransmitters  Impulsivity  Demographics 49Mental Health America of Montana

50 A suicide crisis is a time-limited occurrence signaling immediate danger of suicide. The signs of crisis are: ◦ Precipitating event ◦ Intense affective state in addition to depression ◦ Changes in behavior ◦ Changes in speech ◦ Changes in actions ◦ Deteriorating in functioning 50Mental Health America of Montana

51  Observable signs of serious depression  Increased alcohol and/or other drug use  Recent impulsiveness and taking unnecessary risks  Threatening suicide or expressing a strong wish to die  Making a plan  Unexpected rage or anger 51Mental Health America of Montana

52  Take it seriously ◦ 75% of all suicides give some warning to a friend or family member  Be willing to listen ◦ Ask what is troubling them ◦ Ask if the person is suicidal ◦ Let them know you care  Seek professional help ◦ Be active in encouraging the person to seek professional help ◦ Use your knowledge of resources in the community  In an acute crisis 52Mental Health America of Montana

53  In an acute crisis ◦ Get the person’s name, phone #, and address ◦ Tell them you are going to get them help ◦ Call 911  Follow-up on treatment ◦ Call the person back until help arrives ◦ Take an active role in assuring the person is helped 53Mental Health America of Montana

54 1.Know that you are not responsible for a successful suicide 2.Pay attention to the following: i.Actions- the caller may mention to you: Giving away possessions Withdrawal Loss of interest in hobbies Abuse of alcohol or drugs Reckless behavior Extreme behavior changes Impulsivity Self-mutilation 54Mental Health America of Montana

55 2.Pay attention to the following: ii.Feelings(desperate, angry, worthless, lonely, sad, hopeless, and helpless) iii.Thoughts/Phrases I won’t be needing this anymore I can’t take it anymore The world would be better off I wish I could go to sleep and never wakeup iv.Physical Lack of interest in appearance Loss/change in sex interest Disturbed sleep/appetite Physical complaints Increase in energy 55Mental Health America of Montana

56 2.Pay attention to the following: v.Reviewing the risk Ask if they have a plan – the more specific a plan the higher the risk Explore their pain level – is it unbearable Explore their personal resources – the less resources the higher the risk Explore background factors – is there a history of suicide 3.Prioritize safety i.Determine if they have taken steps to harm themselves If yes – call Mental Health America of Montana

57 3.Prioritize safety ii.Determine if they have taken steps to harm themselves – if not Assess high or low risk by going back to whether there is a plan iii.Ask about their thinking on suicide – the gains and the losses iv.Determine ways to dismantle the suicide plan with the caller How can we flush the pills down the drain Where can you put the knife so it is not accessible Who can you connect them to at this moment 57Mental Health America of Montana

58  Do: ◦ Take a positive strength-based approach ◦ Be calm and understanding ◦ Use constructive – information giving questions ◦ Define the problem – remove confusion ◦ Reframe, rephrase, and restate what the person has shared ◦ Mention the person’s personal ties – family/friends ◦ Emphasize the temporary nature of the problem 58Mental Health America of Montana

59  Don’t: ◦ Sound shocked by anything the person shares ◦ Stress the shock and embarrassment that the suicide would be to the family before you are certain that isn’t exactly what she/he hopes to accomplish ◦ Engage in a debate with the suicidal person because you may only lose the debate, but also the person. You do not want them to be in a position to defend suicide (teeter-totter metaphor) 59Mental Health America of Montana

60  Establish good contact  ASK about suicide  Collaborate  Assess the risk  Discuss supports available  Agree on an intervention  Debrief and self-care 60Mental Health America of Montana

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62  Approximately 26% of Montanans have a diagnosable mental health disorders  Mental Illness is the leading cause of disability in persons  Females adults have higher rates of serious mental illness (6%, compared to men at 4%)  In 2006 Americans spent over $57 billion dollars on mental health services ($8.9 billion was spent on children) 62Mental Health America of Montana 1

63  Serious mental health disorders include: ◦ Major Depression ◦ Schizophrenia ◦ Bipolar Disorder ◦ Borderline Personality Disorder ◦ Social Anxiety Disorder ◦ And Post-Traumatic Stress Disorder ◦ Among others  Mental Illness like EVERY other illness can be treated  Despite popular/current opinion people with mental illness are more likely to be victims of violent crime rather than the perpetrator 63Mental Health America of Montana

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65  Psychological and physiological response to events that upset our personal balance in some way.  Biological stress response is meant to protect and support us.  Stress response feels like: ◦ Heart pounding in the chest ◦ Muscles tensing up ◦ Breaths coming faster ◦ Every sense is on “red alert” 65Mental Health America of Montana

66  The nature of the stressor  A crisis experience  Multiple stressors of life changes  Your perception of the stressor  Your knowledge and preparation  Your stress tolerance  Your support network 66Mental Health America of Montana

67  Statement I’m able to adapt to change easily I feel in control of my life I tend to bounce back after a hardship I have close, dependable relationships I remain optimistic and don’t give up I can think clearly and logically I see the humor in situations I am self-confident and strong I believe things happen for a reason I can handle uncertainty I know where to turn for help I like challenges and change  Check If You Agree 67Mental Health America of Montana

68  Get connected  Use humor and laugh  Learn from your experiences  Remain hopeful and optimistic  Take care of yourself  Accept and anticipate change  Work toward goals  Take action  Learn new things about yourself  Think better of yourself  Maintain perspective 68Mental Health America of Montana

69  Burnout: a defensive response to prolonged occupational exposure to demanding interpersonal situations that produce psychological strain and inadequate support  Counter-transference: occurs when a helping person’s unconscious or unresolved issues resurface when working with a client with similar issues  Vicarious trauma: a disruption of the helping person’s unique internal response in reaction to repeated exposure to traumatic material 69Mental Health America of Montana

70  Take a bath, light some candles, use relaxation techniques  Turn phones or lights off for 30 minutes  Take at least 30 minutes for “alone time”  Listen to music, watch a favorite TV show, buy a new outfit  Journal, paint, or draw  Indulge in your favorite ice cream  Get a massage, soak your feet, get a facial  Join a local gym, book club or church group  Sign up for a class  Exercise – walk, bike ride  Call or visit a friend  Celebrate yourself  Take a swim, plan a picnic, lay out in the sun 70Mental Health America of Montana

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72  Elder care, sometimes referred to as long-term care, includes a wide range of services that are provided over an extended period of time to people who need help to perform normal activities of daily living because of cognitive impairment or loss of muscular strength or control.  Elder care can include rehabilitative therapies, skilled nursing care, palliative care, and social services, as well as supervision and a wide range of supportive personal care provided by family caregivers and/or home health care agencies.  Elder care may also include training to help older people adjust to or overcome many of the limitations that often come with aging.  Elder care can be provided at home, in the community, or in various types of facilities, including assisted living facilities and nursing homes.  Long term elder care is may not be paid for by Medicare and additional conditions may apply, regardless of where it is provided. 72Mental Health America of Montana 2

73  The Department of Health and Human Services administers a wide variety of senior based services for Montana residents who are age 60 or older.  Programs and services are primarily delivered by a network of 10 Area Agencies on Aging which reach all geographic areas of the state. Their goal is to provide services that allow seniors to remain independent.  More information on those programs can be found at  The Long Term Care Ombudsman program (LTCOP), established in all states under the Older Americans Act (Title 7), works on behalf of residents in long term care facilities and Assisted Living facilities.  A listing of Ombudsmen locations by Area Agency on Aging can be found at  To report elder mistreatment contact Mental Health America of Montana73

74  Child care (or "childcare" or "babycare" or "daycare") means caring for and supervising children usually from 0–8 years of age.  The three main types of child care options for most American working families include in- home care, family child care, and child care centers. Mental Health America of Montana74

75  The Montana Department of Public Health and Human Services administers a variety of programs aimed at expanding access to and improving the quality of care and education for preschool children.  Choosing child care is one of the most important decisions a family can make. Here are some factors you may wish to consider: ◦ Is the facility licensed or registered by the State of Montana? ◦ Does the caregiver seem warm and friendly? Does he or she seem to enjoy children? ◦ Is the caregiver knowledgeable about children’s emotional and physical development? ◦ Does the caregiver serve nutritious meals and snacks? ◦ Does the caregiver plan age-appropriate activities? ◦ Does the home or facility employ appropriate safety measures? ◦ Does the caregiver respect your family and cultural values? Mental Health America of Montana75

76  To search for a licensed or registered child-care provider in Montana by name or city, visit sanswrite.hhs.mt.gov/MontanaPublic/ProviderSearch.aspx sanswrite.hhs.mt.gov/MontanaPublic/ProviderSearch.aspx  For help in selecting a child-care provider, contact the Montana Child Care Resource & Referral Network at (866) or by visiting  To get help paying for child care visit the DPHHS website at ◦ The Department offers Best Beginnings child-care scholarships to qualified low- income families who send children to licensed child-care centers, registered group or family child-care homes, or legally unregistered child-care providers. ◦ Each family participates in the cost of that care by making a co-payment based on family income. ◦ Scholarships are also available to families who get cash assistance through the Temporary Assistance for Needy Families (TANF) program while they participate in Family Investment Agreement activities and demonstrate a need for child care.  To report a possible case of child abuse or neglect, call toll-free Mental Health America of Montana76

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78  1 out of every 6 American women has been the victim of an attempted or completed rape in her lifetime. 1  17.7 million American women have been victims of attempted or completed rape. 1  9 of every 10 rape victims were female in Mental Health America of Montana

79  About 3% of American men — or 1 in 33 — have experienced an attempted or completed rape in their lifetime. 1  In 2003, 1 in every ten rape victims were male. 2  2.78 million men in the U.S. have been victims of sexual assault or rape. 1 79Mental Health America of Montana

80  15% of sexual assault and rape victims are under age ◦ 29% are age ◦ 44% are under age 18.3 ◦ 80% are under age 30.3 ◦ are the highest risk years.  Girls ages are 4 times more likely than the general population to be victims of rape, attempted rape, or sexual assault. 3  93% of juvenile sexual assault victims know their attacker 4 ◦ 34.2% of attackers were family members. ◦ 58.7% were acquaintances. ◦ Only 7% of the perpetrators were strangers to the victim. 80Mental Health America of Montana

81  Victims of sexual assault are: ◦ 3 times more likely to suffer from depression. ◦ 6 times more likely to suffer from post-traumatic stress disorder. ◦ 13 times more likely to abuse alcohol. ◦ 26 times more likely to abuse drugs. ◦ 4 times more likely to contemplate suicide. Mental Health America of Montana81

82  National Sexual Assault Hotline ◦ HOPE  National Sexual Assault Online Hotline ◦  MT Domestic Violence/Sexual Assault 24 hr Crisis Line ◦ or ◦  Friendship Center (Helena) ◦ Hotline: ◦ Website:  The Voice Center (Bozeman) ◦ ◦ Mental Health America of Montana82

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84  Substance abuse affects an estimated 25 million Americans.  In terms of people who are affected indirectly such as families of abusers and those injured or killed by intoxicated drivers, an additional 40 million people are affected.  Alcoholism is a progressive disease and afflicts 10 million adults and 3 million children.  An estimated 12.5 million Americans are addicted to other drugs such as sedative- hypnotics or barbiturates, opiates, sedatives, hallucinogens and psychostimulants. 84Mental Health America of Montana 1

85  Warning Signs/Symptoms ◦ Using the substance on a regular basis (daily, weekends or in binges). ◦ Tolerance for the substance. ◦ Failed attempts to stop using the substance, ◦ Physical and/or Psychological dependence. ◦ Withdrawal symptoms (delirium tremens, trembling, hallucinations, sweating and high blood pressure), and in some cases dementia. 85Mental Health America of Montana 1

86  Alcohol and Drug Services of Gallatin County Intake: or  Boyd Andrew Community Services Transitional Living Facility (Helena) Intake: or  Montana Chemical Dependency Center  Al-Anon ◦ AL-ANON or  Alcoholics Anonymous ◦ or  A.A. Helena  The Drinker’s Check-Up an anonymous self-guided online tool that allows you to develop a better understanding of your drinking and the risks involved. Mental Health America of Montana86

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