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.

1. Assisting Individuals
Affected by Mental Illness
With Special Emphasis on Those Experiencing
Homelessness
Developed by: Tim Welsh LCSW
Phoenix Health Center: Louisville KY

2. About Phoenix Health Center
Louisville, 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 of
insight into their mental illness
• Outreach
• Complicating Factors
• Housing First

4. Build Rapport
LISTEN, LISTEN, LISTEN
• “There's actually been two [studies] that … doctors let
patients talk for an average of 20 seconds before they
interrupt - sometimes even less. In the most recent study,
some doctors let a patient talk for only three seconds
before they interrupted.” Lisa Sanders MD on NPR radio August 13, 2009.
• Many homeless individuals suffer from many things which
prevent 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 feel
valued and respected we must listen to their story and
thereby discover their needs & wants…

5. Wants vs. Needs
• What the Client Wants-These are the reasons the
client talks with you and the reasons they will
continue to come back and see you
– Housing
– Clothing
– Bus Fare
– Hygiene items
– Etc.
Versus:

6. Wants vs. Needs
• What You/Court/Family Members think
the Client Needs-
May or may not be the same thing as
the client’s “want” list. You may see needs
that the client has which the client may not
prioritize highly or even see as a need at all.
– Psychiatric Medication
– Stop Drinking Alcohol/Using Illicit Drugs
– Get into Housing

7. Wants vs. Needs
Meet clients more than half way.
Remember:
• Self Determination
• Your Role: Work alongside the clients to achieve their
goals
• 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 or
others
• 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 everyone
knows the codes and what to do when codes
are called (Specified people have clearly
defined objectives in the event of a code).
• Someone to call 911
• Someone to handle the other clients
• Someone on standby to ensure the person
dealing 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
• MIW
QPR SUICIDE PREVENTION TRAININGS
http://www.kentuckysuicideprevention.org

15. The ABC’s of working with
individuals with lack of insight into
their mental illness

16. Building a Relationship with Clients with lack of insight
Part I
• You may want to wait before you “push” the
idea 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 insight
Part II
• If you determine the client was formerly on
medications or that they obviously need them
but the client is adamant that they do not
need/want any, you can ask symptom-related
questions:
• “Do you have any trouble with sleep?”
• “Your situation sounds very stressful. Are you having
any trouble with your nerves?”

18. Building a Relationship with Clients with lack of insight
Part III
For psychotic clients:
• If they are not an imminent risk to self or others, you
may want to simply focus on building the relationship
so that you can closely monitor them.
– Over time they may come around to the idea of medications if
they feel safe
– If their symptoms worsens you can take out a Mental Inquest
Warrant

19. Building a Relationship with Clients with lack of insight
Part IV
• For psychotic clients: Base your reactions to
their delusions/hallucinations on the amount
of insight the patient has into their
delusions/hallucinations.
– If the patient believes their delusions or hallucinations are
real, you may simply want to listen and not confront the
delusions (at least not initially).

20. Outreach
• Campsites
– Do not go alone
– Avoid if possible –Instead go to public places where individuals who are
homeless 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 Disorders
Remember that personality disorders are ultimately
ways of coping and surviving that the
individual learned in childhood usually due
to 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 for
homeless clients:
– Strict appointment enforcement
– Complicated medication regimens
– Drug/Alcohol Abstinence
• Some rules must be firm
– Safety
Complicating Factors

25. Mental Inquest Warrants
• 202A.026 Criteria for involuntary hospitalization.
No person shall be involuntarily hospitalized unless
such person is a mentally ill person:
(1) Who presents a danger or threat of danger to
self, 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 restrictive
alternative mode of treatment presently available.
Contact local County Court House for details

26. Homicidal Threats/Duty to Warn
Responsibilities 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 threatened
person resides/as well as the police dept. where the
person making the threats is located.
• Attempt to contact the threatened person to warn
them of the threat

27. Duty to Warn
Responsibilities of Qualified Mental Health Professionals
• 645.270 Duty of qualified mental health professional to warn intended victim of
patient's threat of violence.
(1) No monetary liability and no cause of action shall arise against any qualified mental health
professional for failing to predict, warn or take precautions to provide protection from a
patient's violent behavior, unless the patient has communicated to the qualified mental health
professional or person serving in a counselor role an actual threat of physical violence against a
clearly identified or reasonably identified victim, or unless the patient has communicated to the
qualified mental health professional or other person serving in a counselor role an actual threat
of some specific violent act.
(2) The duty to warn or to take reasonable precautions to provide protection from violent
behavior arises only under limited circumstances specified in subsection (1) of this section. The
duty to warn a clearly or reasonably identifiable victim shall be discharged by the qualified
mental health professional or person serving in a counselor role if reasonable efforts are made
to communicate the threat to the victim and to notify the law enforcement office closest to the
patient's and the victim's residence of the threat of violence. If the patient has communicated to
the qualified mental health professional or person serving in a counselor role an actual threat of
some specific violent act and no particular victim is identifiable, the duty to warn has been
discharged if reasonable efforts are made to communicate the threat to law enforcement
authorities. The duty to take reasonable precautions to provide protection from violent behavior
shall be satisfied if reasonable efforts are made to seek civil commitment of the child under KRS
Chapter 645.
(3) No monetary liability and no cause of action shall arise against any qualified mental health
professional or person serving in a counselor role for confidences disclosed to third parties in an
effort 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 First
Helpful Strategies:
• Support Groups
• Counseling
• Psychiatric Home Visits

30. REMEMBER
The most valuable thing we offer is simply
providing compassionate interaction for those
living on the outskirts of our society, thereby
allowing them to slowly reconnect, and just as
importantly, feel human again.

31. Tim Welsh LCSW
twelsh@fhclouisville.org
502 569 1662