1. Understanding Mental Illness A Review of the Disorders

2. Defining Mental Illness Clinical definition : Clinically significant behavioral problemsClinically significant behavioral problems Associated with distress (painful symptoms)Associated with distress (painful symptoms) Causes disability (impairment in functioning)Causes disability (impairment in functioning) A biological illness that responds to treatmentA biological illness that responds to treatment Not to be confused with weakness of characterNot to be confused with weakness of character

3. Facts about Mental Illness  Has nothing to do with intelligence  Can happen to anyone  Chronic but not contagious  Difficult to diagnose and to treat  Treated but not cured  Mentally ill are not all dangerous  Should not be confused with terms psychopath or sociopath

4. General Signs of Mental Illness ObservableObservable ConfusionConfusion DisorientedDisoriented Darting looksDarting looks Talking to selfTalking to self Poverty of SpeechPoverty of Speech Pressured speechPressured speech Poor hygienePoor hygiene Inappropriate attireInappropriate attire Behavior Changes Flat Affect Withdrawn Sad or anxious mood Panic Psycho somatic complaints

5. SchizophreniaSymptoms Brain diseaseBrain disease Includes psychosisIncludes psychosis Impacts 1 out of every 100 people. Does not differentiate across SESImpacts 1 out of every 100 people. Does not differentiate across SES Onset is late teens, early adulthood.Onset is late teens, early adulthood. Positive Symptoms include :Positive Symptoms include : –hallucinations –delusional thinking Negative symptoms includeNegative symptoms include – apathy –withdrawal.

6. Schizophrenia Symptoms in Jail  May appear non compliant  Agitated by voices and delusions -may look and act dangerous  Command hallucinations may actually be dangerous  More likely to respond to clear directions, and reassurance in a kind tone of voice  Poor hygiene - Not aware of their surroundings enough to know that they are not clean

7. Mood Disorders Major Depression Symptoms Affects 5 percent of the general populationAffects 5 percent of the general population Sad mood that lasts 2 weeksSad mood that lasts 2 weeks Loss of interest or pleasure in daily activitiesLoss of interest or pleasure in daily activities Changes in sleep, appetite, decreased energyChanges in sleep, appetite, decreased energy Thought problems affect concentration, memory, decisions, feelings of guilt, worthlessnessThought problems affect concentration, memory, decisions, feelings of guilt, worthlessness Risk of suicide is highRisk of suicide is high Important to differentiate mental health fromImportant to differentiate mental health from physical problems physical problems Responds well to treatmentResponds well to treatment

8. Mood Disorders Major Depression Symptoms in Jail  Loss of interest in food and self care  May not care about legal situation  Suicide risk is real and must be monitored  Risk of suicide may increase after medication

9. Mood Disorders Mania/ Bipolar Disorder Symptoms  Euphoric Mood (elevated, high or happy)  Irritable Mood (touchy)  Three Stages of Mania Hypomania, Acute Mania, Psychosis  Bipolar Disorder - mood swings from depression to mania  Can be Rapid Cycling

10. Mood Disorders Mania/ Bipolar Disorder Symptoms in jail  Jail may be the consequence of the disorder  Mood can swing from entertaining to hostile  Talkativeness can be irritating  If depressed, often cry, feel hopeless, become suicidal  Can be restless, pacing, demanding and destructive  Often non-compliant  Can be professional and well-educated

11. Anxiety Disorders Panic Disorders Symptoms  Prevalence is 1 to 2 percent of the population; Women twice as high as men.  Panic attacks occur without warning  Symptoms include intense fear, heart palpitations,chest pain, shortness of breath, dizziness  Person is concerned that the attacks will strike again Symptoms in Jail  Jail environment and structure of holding can induce symptoms induce symptoms  Referral is indicated

12. Anxiety Disorders Obsessive-Compulsive Disorder Symptoms  Obsessions are recurrent thoughts, images, impulses that cause anxiety. They are illogical,at times repulsive and/or center on violence or harm.  Compulsions are behaviors that are repetitive - attempts at reducing the anxiety created by the obsessions. Symptoms in Jail  Rarely seen in jail and do not pose high risk

13. Post Traumatic Stress Disorder Symptoms  Exposure to an extremely stressful event.  Painful memories, nightmares,, suspicion, anxiety, depression, feelings of guilt and sleep difficulties  Symptoms worsen with exposure to similar events  Substance abuse is a common method to cope Symptoms in Jail  Jail environment can trigger symptoms  Jail inmates and personnel can trigger symptoms  Lack of privacy and loss of control are issues

14. Personality Disorders  Inflexible, maladaptive, ways of coping and relating  Difficulty in holding steady work and relationships  Difficult to change  Can co -exist with other mental illnesses  Behavior problems precipitate jail  Antisocial  Narcissistic  Borderline  Avoidant  Paranoid  Dependent  Schizotypal  Schizoid

15. Personality Disorders  Predominant disorders in jail are Antisocial and Borderline  Jail environment heightens symptoms  Effective management requires consistent limit- setting  Suicidal risk is real and must be monitored  Jail personnel must professionally manage housing unit, inmates and themselves

16. Substance Abuse Symptoms  85% of jail population have substance abuse problems  High correlation of substance abuse and other mental illnesses Symptoms in Jail Monitor risk of OD or withdrawalMonitor risk of OD or withdrawal Monitor abuse of prescription drugsMonitor abuse of prescription drugs Can mimic other Mental illnessesCan mimic other Mental illnesses Long term abuse can cause dementiaLong term abuse can cause dementia

17. Co-occurring Disorders  Presence of both a mental illness and substance abuse disorder  High prevalence rates  60% of persons with a mood disorder also have a substance abuse disorder  50% of persons with schizophrenia also have a substance abuse disorder In Jail - More prone to violence, impulsivity, paranoia and anxiety

18. Common Factors of Mental Illness and Substance Abuse  Brain disorders  Lack of Insight  Chronic  Impacts Family  Shame and guilt  Needs Treatment

19. Dementia and other Cognitive Disorders Symptoms Memory problemsMemory problems ConfabulationsConfabulations Impaired thinkingImpaired thinking Impaired JudgementImpaired Judgement Symptoms in Jail Poor memory and may not follow directionsPoor memory and may not follow directions Treat individual as you would any with a disabilityTreat individual as you would any with a disability

20. Mental Retardation Symptoms  Poor adaptive functioning from birth  Related to intelligence, not thoughts, feelings and behaviors Symptoms in Jail  Not to be confused with mental illness  Requires patience

21. Effective Communication Effective Communication

22. Keys to Communication Empathy Empathy Warmth Warmth Genuine Genuine

23. Promoting Communication  Listening:attend to both verbal and nonverbal cues, hear and observe, and avoid distractions  Clarification: Restate.Repeat, Clarify, Question  Dealing with Silence  Respond Effectively  Maintain Personal Space  Open ended questions  Non verbal Cues

24. Basic Communication Guidelines  Short, clear direct sentences  Simple content  Low stimulation level  Don’t force communication  Be consistent  Don’t take actions or reactions personally

25. Basic Communication Guidelines  Short, clear direct sentences  Simple content  Low stimulation level  Don’t force communication  Be consistent  Don’t take actions or reactions personally

26. Basic Communication Guidelines  Be patient  Person may not “get” all the information  Be pleasant and firm  Praise cooperative behavior  Practice reflective listening  Know your non verbal communication

27. Basic Communication Guidelines  Be patient  Person may not “get” all the information  Be pleasant and firm  Praise cooperative behavior  Practice reflective listening  Know your non verbal communication

28. Basic Communication Guidelines  Short, clear direct sentences  Simple content  Low stimulation level  Don’t force communication if person is withdrawn  Be consistent  Don’t take actions or reactions personally  Person may not “get” all the information you provide  Be patient  Be pleasant and firm  Praise cooperative behavior  Practice reflective listening  Know your non verbal communication

29. Types of Non-Verbal Communication  Body Posture  Facial Expression  Eye Contact  Gestures

30. Crisis Management

31.  Crisis defined  What is crisis intervention  Recognizing a person in crisis – behavioral crisis – behavioral and verbal cues and verbal cues

32. Violence  The incidence of violence is no greater in persons with mental illness than it is in the general population  Incidence increases 60% if the illness is untreated.  Substance use greatly increases violence  Greatest risk, males in late teens to early 20’s  Past behavior best predictor

33. Warning Signs  Tremors  Hyperactivity  Rigid Posture  Clenched jaws and fists  Pulsing arteries  Verbal abuse/profanity

34. Effective Crisis Intervention  Reduce Stress  Force as the last resort  Consider the symptoms of mental illness  Identify precipitating factors  Goal is to de-escalate

35. 5 Stages of Successful Interventions  Immediacy- Intervene as soon as possible. Goal is to reduce anxiety.  Assume Control - via providing the structure the person needs, not be overwhelming them  Assess the situation- let the person talk, watch for nonverbal cues, be a guide and avoid judgements and putdowns  Situation Management  Post crisis intervention

36. 5 Stages of Successful Interventions  Immediacy- Intervene as soon as possible. Goal is to reduce anxiety.  Assume Control - via providing the structure the person needs, not be overwhelming them  Assess the situation- let the person talk, watch for nonverbal cues, be a guide and avoid judgements and putdowns  Situation Management  Post crisis intervention

37. Suicide and Suicide Prevention

38.  Jail suicide is 9 times higher than general pop.  8 of 10 have given prior warnings  Ambivalent about death  Ambivalence is not the same as manipulation  Most jail suicides are not impulsive  Risk does not increase with discussion Facts about Suicide

39.  Prior attempts increases risk by 33%  Mental illness increases the risks -  61% have major depression  48% have personality disorder  40% Alcohol use  10% Anxiety  6% Schizophrenia  Understanding SI behavior increases prevention! Facts about Suicide

40. Why Jails are Suicide Prone Settings  Authoritarian environment  Loss of control over future  Isolation  Shame  Dehumanizing aspects of aspects ofincarceration  Fears  Police and Jail staff immune to arrest and incarceration  Officers and jail staff overlook or misunderstand symptoms

41. Terms related to Suicide  Ambivalence  Ideation  Lethality  Attempt  Gesture

42. Evaluation Tool The Sad Persons Scale  Sex  Age  Depression  Previous Attempts  Ethanol  Rational Thinking Loss  Social Support Losses  Organized Plan  No Spouse  Sickness

43. Why Do People Die by Suicide?  Impulsive  Depressed  Escape from suffering  Communication  Loss of a loved one

44. Understanding Suicidal Thinking  Suicide is a solution to a problem, what is the problem ?  Most suicides are acts to end intolerable feelings  Coping Patterns Fail  “Tunnel Vision” interferes with seeing alternatives  Person feels “unheard”  Ambivalence

45. Recognizing Suicidal Risk In Jail uPsychological Factors uSocial Risk Factors uBehavioral Warning Signs

46. Special Features of Jail Suicide Risk  Legal Status Factors  Time of the year  Long Term Factors

47. Intervening  Create a safe environment  Only one person communicate  Talk about plan  Emphasize positives  Evaluate potential  Refer for treatment  Do not lie

48. Prevention  Admission Screening  Utilize a formal screening worksheet  Develop tiered assessments - intake, supervisor, mental health professional referral  Observe for risk factors, even after intake  Assure treatment

49. Collaboration and The Team Approach

50. Shared Goals  Diversion of inmates from jail to appropriate community care  Assure adequate mental health care while incarcerated  Assure Continuity of Care for those inmates at the time of their release.

51. Steps to Meeting Shared Goals  Screening and identification  EvaluationClassification  Diversion  Crisis Prevention  Provision of emergency mental health services  Assure care  Supervision  Suicide Prevention  Pre release planning

52. Team Approach Options  Employ Mental Health Staff  Formal Contractual Agreements with Providers  Informal Agreements (MOA)

53. Characteristics of a good Working System  Shared Vision, mission and values  Involvement of all stakeholders  Established written documentation  Formal and informal verbal communications  Ongoing Commitment

54. Formal Agreements  Purpose  Range of Services  Time Frame  Remuneration, if applicable  Expectations of the jail re documentation, referrals, medication administration, etc  Confidentiality  Mechanism for review, evaluation and modification

55. Comprehensive Service Array  Diversion  Timely and effective treatment  Placement in programming  Linkage with support groups  Housing assistance  Educational Assistance  Entitlements  Other supports

56. Systematic Planning  Cooperation  Coordination  Collaboration  Integration  Key Issues Identification of problems, barriers and solutions

57. Technical Assistance Resources National Institute for Corrections (Jail Center) 1- 800-995-6429National Institute for Corrections (Jail Center) 1- 800-995-6429 The GAINS Center for People with Co-Occurring Disorders in the Justice System 1-800-311-GAINThe GAINS Center for People with Co-Occurring Disorders in the Justice System 1-800-311-GAIN

58. To contact me: Ray Sabbatine - tykerjs@att.net tykerjs@att.net Cell 859-806-0935 Office 502-868-5595 Fax 502-868-5364