CMI15 Handbook

Your Law Practice:
Understanding Clients with

Mental Illness
Thursday, October 1, 2015
8:45 a.m.–4:30 p.m.
5.75 General CLE credits and

1 Ethics credit
YOUR LAW PRACTICE: UNDERSTANDING CLIENTS WITH MENTAL ILLNESS
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Copyright © 2015
OREGON STATE BAR

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Your Law Practice: Understanding Clients with Mental Illness ii

TABLE OF CONTENTS
Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1. We All Know Someone . . . So What Exactly Is Mental Illness? . . . . . . . . . . . . . . . . 1–i

— Joe Hromco, Ph.D., Western Psychological and Counseling Services PC, Tigard, Oregon
2. Teaching Materials from NAMI Family to Family Class 8: Communication Skills

Workshop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2–i
— Adam Davis, Family to Family Health Information Center, Portland, Oregon
3A. Multnomah County Drug Court; Multnomah County Mental Health Court . . . . . . . . 3A–i
— The Honorable Angel Lopez, Multnomah County Circuit Court, Portland, Oregon
3B. Involuntary Civil Commitment Hearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3B–i

— The Honorable Kenneth Stewart, Clackamas County Circuit Court, Oregon City, Oregon
3C. Investigator’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3C–i

— Mark Niederkorn, Mental Health Specialist, Clackamas County, Oregon City, Oregon
4A. Representing Clients Affected by Mental Health Challenges . . . . . . . . . . . . . . . . 4A–i

— Kyra Hazilla, Oregon Attorney Assistance Program, Portland, Oregon
4B. The Ethics of Representing Clients with Mental Illness . . . . . . . . . . . . . . . . . . . .4B–i

— Helen Hierschbiel, Oregon State Bar, Tigard, Oregon
5. Attorney Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–i

— Michele Veenker, Executive Director, National Alliance on Mental Illness Clackamas
County (NAMI-CC), Clackamas, Oregon
— Maeve Connor, Peer Support and Development Director, National Alliance on Mental
Illness Clackamas County (NAMI-CC), Clackamas, Oregon
Your Law Practice: Understanding Clients with Mental Illness iii

Your Law Practice: Understanding Clients with Mental Illness iv
SCHEDULE
8:00 Registration
8:45 We All Know Someone . . . So What Exactly Is Mental Illness?

F Signs
F Symptoms
F Statistics
Joe Hromco, Ph.D., Western Psychological and Counseling Services PC, Tigard
9:45 Break
10:00 In Their Own Voices: Mental Illness from the Inside

F Hear from people living with a mental health disorder and those who love them.
Janie Marsh, Director, Peer Support Services, Mental Health America of Oregon, Portland
Angela Rheingans
11:15 Communicating with Someone in a Crisis
F Communication strategies for people with delusions, hallucinations, and anosognosia
F Trauma-informed communication
F How to manage threatening behavior
F Suicidal or suicide ideation: what is the difference?
Tim Connor, Psy.D., Oregon State Hospital, Portland
Adam Davis, Family to Family Health Information Center, Portland
Noon Lunch
1:00 Mental Health and the Law

F Mental health and drug courts
F Civil commitment
F HIPAA
F Jail and prison systems
F Guilty Except for Insanity pleas
F Peer support
Moderator: Chris Bouneff, Executive Director, National Alliance on Mental Illness (NAMI) Oregon,
Portland
The Honorable Angel Lopez, Multnomah County Circuit Court, Portland
The Honorable Kenneth Stewart, Clackamas County Circuit Court, Oregon City
Tim Connor, Psy.D., Oregon State Hospital, Portland
David Madigan, Cooney Cooney & Madigan LLC, Tigard
Janie Marsh, Director, Peer Support Services, Mental Health America of Oregon, Portland
Mark Niederkorn, Mental Health Specialist, Clackamas County, Oregon City
2:30 Break
2:45 Legal Ethics When Representing Individuals with Mental Illness

Kyra Hazilla, Oregon Attorney Assistance Program, Portland
Helen Hierschbiel, Oregon State Bar, Tigard
Your Law Practice: Understanding Clients with Mental Illness v
SCHEDULE (Continued)
3:45 Attorney Resources

F Where can attorneys, clients, friends or family go for help?
F Gaps in the system
Michele Veenker, Executive Director, National Alliance on Mental Illness of Clackamas County
(NAMI-CC), Clackamas
Maeve Connor, Peer Support and Development Director, National Alliance on Mental Illness of
Clackamas County (NAMI-CC), Clackamas
4:30 Adjourn
Your Law Practice: Understanding Clients with Mental Illness vi

FACULTY
Chris Bouneff, Executive Director, National Alliance on Mental Illness (NAMI) Oregon, Portland.
Maeve Connor, Peer Support and Development Director, National Alliance on Mental Illness of Clackamas
County (NAMI-CC), Clackamas. Ms. Connor decided to pursue a career in nonprofits because of her
interest in social justice. She has also worked at Oregon Foundation for Reproductive Health and
Death with Dignity National Center and chairs the Living Room, a safe haven for GLBTQQ youth in
Clackamas County.
Tim Connor, Psy.D., Oregon State Hospital, Portland. Dr. Connor has worked at the Oregon State Hospital
since 2007 in both the civil and forensic programs. He earned his Psy.D. degree from Pacific University
in Forest Grove. He has practiced in Oregon and Idaho.
Adam Davis, Family to Family Health Information Center, Portland.
Kyra Hazilla, JD, MSW, CCTP, Oregon Attorney Assistance Program, Portland. Ms. Hazilla is an Attorney
Counselor whose experience includes crisis intervention, working with victims of sexual assault, drug
and alcohol dependency, and helping domestic violence survivors and their children. She was a public
defender practicing juvenile law for most of her legal career, advocating for children and families
struggling with myriad challenges.
Helen Hierschbiel, Oregon State Bar, Tigard. Ms. Hierschbiel is General Counsel of the Oregon State Bar,
where, among other things, she gives ethics guidance to lawyers. She joined the Oregon State Bar in
December 2003 in the Client Assistance Office, reviewing and investigating complaints against lawyers.
While at the bar, she has written numerous article and given dozens of presentations regarding lawyers’
ethical obligations. Prior to joining the Oregon State Bar, she worked in private practice in Portland and
for DNA–People’s Legal Services on the Navajo and Hopi reservations in Arizona.
Joe Hromco, Ph.D., Western Psychological and Counseling Services PC, Tigard. Dr. Hromco is a psychologist
and vice president of Western Psychological and Counseling Services. He received his Ph.D. in Clinical
Psychology from Northwestern University. With over 25 years of experience in the field, Dr. Hromco has
served in clinical and administrative capacities spanning the array of behavioral health programs. He
has been appointed faculty at Pacific University’s School of Professional Psychology and the OHSU’s
Department of Public Health and Prevention.
The Honorable Angel Lopez, Multnomah County Circuit Court, Portland. Judge Lopez was appointed to
the bench in 2009 by Governor Theodore Kulongoski. Judge Lopez is past president of the Oregon State
Bar and a member of the Bench/Bar Professionalism Committee, the Oregon Historical Society, and the
Oregon Hispanic Bar Association. He is a recipient of the Paul DeMuniz Professionalism Award and
the Mercedes Deiz Award for his contribution to the Oregon State Bar’s affirmative action efforts.
David Madigan, Cooney Cooney & Madigan LLC, Tigard. Mr. Madigan represents a wide variety of
health care professionals in all aspects of their practice. As a health care attorney, his practice focuses
on defending board complaints, advising health care practices on state and federal regulations. He is
a frequent speaker to health care providers on issues pertaining to board discipline, HIPAA privacy
and security compliance, insurance audits, and law and ethics relating to medical and mental health
providers and risk management. He is licensed to practice in both Oregon and Washington.
Your Law Practice: Understanding Clients with Mental Illness vii
FACULTY (Continued)
Janie Marsh, Director, Peer Support Services, Mental Health America of Oregon (MHAO), Portland. Ms.
Marsh joined MHAO in 2014 and is Director of MHAO’s EVOLVE Peer Delivered Services. She has
worked as a Peer Support Specialist, Forensic Peer Specialist, QMHA, and Community Support &
Integration Teams Coordinator for Yamhill County Behavioral Health. She has been involved in
program development and has provided individual support in a variety of ways such as mental health
and addictions recovery, physical health and well-being, with Supported Employment, and Early
Assessment and Support Alliance. She spent one year in Lewis and Clark’s Professional Counseling
Mental Health & Addictions graduate school program in 2014/2015 and then transferred to Portland
State University’s Master of Public Administration: Health Administration program in the fall of
2015. Ms. Marsh has experienced recovery from IV drug addiction, alcoholism, and a diagnosis of
schizophrenia as well as all types of systems and institutional involvement that can accompany such
life experiences.
Mark Niederkorn, Mental Health Specialist, Clackamas County, Oregon City. Mr. Neiderkorn works as a
civil commitment investigator for Clackamas County Behavioral Health. He has a Masters Degree in
Counseling Psychology.
The Honorable Kenneth Stewart, Clackamas County Circuit Court, Oregon City. Judge Stewart is
a Circuit Judge Pro Tem and Judicial Hearings Referee for the Circuit Court of Clackamas County.
Among other duties, he handles the bulk of civil commitment hearings for the court. Prior to becoming
a judicial officer, Judge Stewart was a Clackamas County Deputy District Attorney from 1972 to 1977
and practiced law in Clackamas County for 27 years, predominantly in family and criminal law.
Michele Veenker, Executive Director, National Alliance on Mental Illness of Clackamas County (NAMI-
CC), Clackamas. In 2004, Ms. Veenker began volunteering for the National Alliance on Mental Illness of
Clackamas County (NAMI-CC), serving as its Public Policy Liaison and later a board member. After
NAMI-CC received its first grant in 2010, Ms. Veenker was hired as its first employee. She has added
several new programs and classes, including basics for parents and primary caregivers of children with
mental illnesses, peer-to-peer wellness classes taught by and for people with mental illnesses, Parents
and Teachers as Allies teacher training, the Open Minds Open Art Studio, and the Peer Resource
Connections (PeRC) program for people with mental illnesses and their families. She also brought In
Our Own Voice presentations into area high schools.
Your Law Practice: Understanding Clients with Mental Illness viii

Chapter 1
We All Know Someone . . . So What
Exactly Is Mental Illness?
Joe Hromco, Ph.D.
Western Psychological and Counseling Services PC
Tigard, Oregon
Contents
Resources on Mental Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–1
Presentation Slides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–3
Chapter 1—We All Know Someone . . . So What Exactly Is Mental Illness?
Your Law Practice: Understanding Clients with Mental Illness 1–ii

This presentation is focused on providing an overview of the most common adult mental health
conditions. In lieu of duplicating multiple pages of materials that define each mental health
condition, here are links to internet information which is reputable, updated, and useful.
National Alliance on Mental Illness

NAMI.org has excellent brief overviews of the most common mental health conditions at:
http://www.nami.org/Learn-More/Mental-Health-Conditions
The NAMI website also contains news, resources, and other information about mental health
conditions. The website for NAMI Oregon also contains more local information, including
classes and support groups available:
http://www2.nami.org/MSTemplate.cfm?Site=NAMI_Oregon
Depression and Bipolar Support Alliance

The Depression and Bipolar Support Alliance similarly has excellent information on these
disorders. http://www.dbsalliance.org/site/PageServer?pagename=education_landing
National Institute of Mental Health

The federal Department of Health and Human Services’ National Institute of Mental Health
(NIMH) provides a good overview of the consensus regarding mental health conditions at:
http://www.nimh.nih.gov/index.shtml
PsyWeb
The website PsyWeb provides an overview of information on mental health conditions, as well
as articles on new and emerging research or treatments. The site also contains interactive
activities regarding mental health at www.psyweb.com
American Psychiatric Association

The American Psychiatric Association is the national organization of psychiatrists (physicians
who specialize in psychiatry). Their website provides an overview to mental health at:
http://psychiatry.org/patients-families
Your Law Practice: Understanding Clients with Mental Illness 1–1

American Psychological Association

The American Psychological Association is the national organization of psychologists (those with
a doctoral level training in psychology). Their “Topics” section covers diagnoses as well as many
other relevant psychological issues (e.g., suicide, responding to disasters or trauma, sexual
issues, dealing with pain, etc.): http://apa.org/topics/index.aspx
Western Psychological & Counseling Services

These and other links can be found at the Western Psychological and Counseling Services
website at: http://www.westernpsych.com/contact/links/

Joe Hromco, Ph.D.

Western Psychological & Counseling Services
Agenda
 What is meant by “mental illness”?
 Overview of most common mental
health conditions
Joe Hromco, Ph.D. Western Psychological &

Counseling Services

Why does this matter to an

attorney?

Counseling Services
What is “mental illness”?

 Medical
 Are there biological markers?
 Does it require heritability?
 Statistical
 What is unusual (i.e., not normal)?
 Socially determined or political
 What do we think is abnormal or dysfunctional?
 Legal
 Includes risk to self/others
 Psychological
 Is there a common “why”?

Counseling Services

Mental illnesses tend to be…

 Syndromes
 Collections of symptoms that seem to go
together
 Effect on functioning
 Requiring intervention
 Research or long-term clinical support
 Different terms: Conditions, illnesses,

behavioral health, mental health

Counseling Services
Mental Health Conditions

 Schizophrenia
 Bipolar Disorder
 Depression
 PTSD
 Anxiety Disorders
 OCD
 ADHD
 Borderline Personality

Counseling Services

Schizophrenia(s)
 Delusions
 Hallucinations
 Disorganization
 Often includes:
 Anosognosia
 Affect that is flat
 Anhedonia- feeling little pleasure
 Ambivalence
 Apathy

Counseling Services
Schizophrenia(s)
 1% of the population
 Cross cultural
 Clearly a biological/heritable condition
 Very likely “Epigenetic” (environment turns
on the genes for the disorder)
 Treatment:
 Medications have the most dramatic effect
 Other supports do matter
 Early intervention may be key

Counseling Services

Schizophrenia(s)
NAMI and Schizophrenia

Counseling Services
Bipolar Disorder
 Mania- Combination of intense
symptoms such as racing thoughts,
pressured speech, little sleep, expansive
ideas, impulsive behavior, over a period
of time (e.g., several days)
 Depression- Persistently low mood and
energy

Counseling Services

Bipolar Disorder
 Person to person variation
 Bipolar I, Bipolar II, Cyclothymia
 Not short-term fluctuations or moodiness
 2.5% of population
 More cross cultural variation than
Schizophrenia
 NAMI and Bipolar

Counseling Services
Depression
 Low mood, low energy
 Ranges from
 Major Depression
 Dysthymia
 “Mild Depression”
 Most prevalent (10% of the USA)
 High cross cultural variability
 Cause ranges:
 Combination of biology, psychology,
environment

Counseling Services

PTSD
 What is the most common response to
trauma?
 Response to significant trauma including
hypervigilance, nightmares/flashbacks,
avoidance, existential issues
 “Trauma-informed care”

Counseling Services
PTSD
 3.5% of USA
 Very high variation across cultures
 Obviously, environment based
 Though may be heritability factors
 Treatments can be very effective
 Primarily psychotherapy

Counseling Services

Anxiety Disorders
 Panic Disorders: 2.7% of adults
 Agoraphobia- 1%
 Generalized Anxiety- 3.1%
Also-
 Obsessive Compulsive Disorder- 1.0%

Counseling Services
ADHD
 Two types:
 with hyperactivity and
 without hyperactivity

Counseling Services

ADHD prevalence estimates as a function of year of study publication.
Guilherme V Polanczyk et al. Int. J. Epidemiol. 2014;43:434-

442
© The Author 2014; all rights reserved. Published by Oxford University Press on
Joe Hromco, behalf
Ph.D. of the Psychological &
Western
International Epidemiological Association
Counseling Services
ADHD
 People don’t usually grow out of ADHD
 Likely a social cascade due to childhood
ADHD

Counseling Services

Borderline Personality Disorder

 One of four “personality disorders” with
some practical application (along with
Antisocial, Narcissistic and Obsessive
Compulsive)
 Wide variation in conceptualization.
Usually involves:
 Intense emotional reactivity
 Intense interpersonal ups and downs (“I hate
you-I love you”)

Counseling Services
Borderline Personality Disorder

 1.4% of population.
 Highly female
 Narcissistic and Antisocial are highly male
 Very high “co-morbidity”
 PTSD
 Depression

Counseling Services

Mental Health Conditions

 Schizophrenia(s)
 Bipolar Disorder(s)
 Depression(s)
 PTSD
 Obsessive Compulsive Disorder
 ADHD
 Borderline Personality
 Others: Substance use, autism, eating
disorders, phobia, learning disorders,
personality disorders, etc.

Counseling Services


Chapter 2
Teaching Materials from NAMI Family to Family
Class 8: Communication Skills Workshop
Adam Davis
Family to Family Health Information Center
Portland, Oregon
Chapter 2—Teaching Materials from NAMI Family to Family Class 8: Communication Skills Workshop

Notes to Teachers
1. This is the second Skill Workshop. Again, be sure to allow time to prepare
thoroughly for this class. Be familiar with the lecture script and with “running” each
skill exercise. Most of your attention will need to go to the family participants in the
exercise, so it’s important for you to know where you are and what you’re doing.
Also, your Co-Teacher has important tasks in this class, so pay attention to the
Teacher Instruction boxes.
2. As workshop leader, play your part in the Instrumental Leader mode. Stay right up
near the chair used for the various dialogues and role-plays. “Hover” a bit until each
pair of volunteers is clear about what to do; then step back as they “enact” the
scene. This is “street theater”: You’re never quite sure how people will react, and
the best part of the group process can’t be scripted. Stay alert, stay in the moment
and have fun.
3. Both Co-Teachers need to stay extra sensitive to any reluctance on the part of
people in your class to participate in the various exercises. If anyone signals they
want to “sit out,” make them feel comfortable with this choice.
4. The same protection needs to be maintained regarding the exercises themselves.

Ask people to check the “voices/noises” message on their blue card to see if it’s OK
for them to read. If not, give them another card. Occasionally someone will gain a
flash of insight during this exercise and break down. Give them lots of hugs.
Note: Do not run the Voices Exercise twice (i.e., have “patients” and “voices”
change places.) It is too stressful, and the net effect is anti-climactic.
5. In the Reflective Response exercise, don’t give a “Hot Potato” to someone who is
upset about that same issue in their own lives if at all possible. Change to another
set of dialogues.
In the Reflective Response exercise, you will find many family members will “go
blank” when they get the Hot Potato. It is okay to coach at this point. Tell them, “I
know the words are upsetting. But try to focus on the feeling being communicated.
When a person says there’s nothing to do all day in a Day Program, they are feeling
what? (WAIT) . . . that’s right, bored (or, when they say the Mafia is after them, they
are feeling . . . scared). Have your response relate to the boredom or the fright they
are experiencing; don’t respond to the words, etc.”
However, if folks continue to struggle, or they are showing any signs of

discomfort, immediately tell them to turn the card over. This is the point of the
exercise: We try a response first, and then we get to see the answer.
8.a NAMI Family-to-Family

Education Program: 2013

Family members can come up with some hilarious responses on their own. There is
typically a lot of laughter and shared understanding in this class.
Be sure to invoke the principle that “You can’t know what no one has told you” if you
think it’s necessary. Also, tell family members that “This stuff is hard to do with
someone with mental illness.” They’re right: It is.
6. Be fully prepared for the “de-briefing” sessions in this class. Whenever we ask
families to do something that puts them under some degree of emotional stress, we
stop and ask how the exercise went for them. This way we can tend to their feelings
“in the moment.” De- briefing occurs after the Empathy Exercise and again
after the Reflective Responses Exercises.
Reminders:
• Time: This class moves rapidly. Start your class promptly and proceed. You will
have time to do everything the script calls for.
• Distribute Agenda, Class Handouts and Additional Resources
• You will be on your feet in this class, so you may want to staple your script for ease
of handling.
• Be sure to have your Blue Cards in order and your I-Statement/You Statement
scripts folded in half and ready for use
• The 6 Reflective Response Exercise dialogue cards are reproduced in the front
section as well, so you can read them over and become familiar with them. Be sure
your blue Dialogue Cards are in proper order before the class starts. (You can well
imagine what will happen if they get mixed up!)
• There are 6 blue cards (3 “voices,” 3 “mental environment”) for the Empathy
Exercise. People must pair up to read the cards; this way you have enough cards
for 12 people in the “voices/noises” chorus.
• Remind the local Support Group Facilitators of the date of your Class 12 Party and
confirm their attendance.
• It’s also a good idea at this time to confirm the speakers for Class 10 and Class 11.
• Contact the State Program Director to order the Course Certificates for Class 12.
Send Program Director the names of class participants as you wish them to appear
on the certificates.
• Have the Emotional Stages chart posted
8.b NAMI Family-to-Family


Materials Needed for this Class:
 Same materials as previous classes, plus easel, pad, marking pens

 3 x 5 cards and pens for “patients;”
 blue Cue Cards for those playing “voices” and “mental environment,” in proper order
 Volunteer #1 and #2 scripts for I-Statement and You-Statement Exercise, folded in
half
 Blue Cards (Scripts #1 through #6) for Reflective-Response Exercise, properly
arranged by threes, face down
 Positive Request and Positive Feedback chart.
8.c NAMI Family-to-Family


Class 8: Empathy Exercise
3 x 5 cards and pens for “patients”

Blue Cards for those playing “voices”* and the “mental environment”**.
Blue Cards for “Voices” (separate cards):
1. “Don’t trust the person doing this exercise. She is trying to trick you so they can lock
you up... They are all trying to make it look like you are crazy” (repeat until the
exercise stops)
2. “You’ve got to get away. If you stay here in this room they will hurt you! Hurry! You
can get out now while they’re not looking!” (repeat until the exercise stops)
3. “This person is evil. The devil has sent this person to get you to do bad things:
Don’t do what they are asking you. You will go to eternal damnation.” (repeat
until the exercise stops)
Blue Cards for “Mental Health Environment” (3 separate cards):
1. “I looked in on the patient today and he still seems psychotic. He’s not
responding fully to the medication... let’s take the dose up to the next level.”
(repeat until the exercise stops)
2. “This is your weather station with morning weather on the hour. The barometer is
rising and today will be milder with a high of 55; cloudy tomorrow.” (repeat until
the exercise stops)
3. “Hello, dear! I wanted to call to see how you are doing. How’s the Zyprexa working?
We sure hope it will help. Do you need any clean clothes? We’re coming over
Sunday.” (repeat until the exercise stops)
8.d NAMI Family-to-Family


Class 8: I-Statement Exercise
Script for Volunteer # 1 (Family Member)
I-Statements
#1: I get angry when you don’t bring the car back on time.
#2:
#1: I know we have that arrangement. But I get upset when you don’t get back at the
time we agreed upon.
#2:
#1: I think if you can’t handle time, then I can’t agree to let you have the car. I need
to know you can follow through on our bargain.
#2:
#1: I don’t agree. It’s up to you. If you are late again, I will cancel our agreement. If
you’re on time, then I will stay with our deal.
********** (fold) **********
You-Statement Exercise
#1: You make me angry when you don’t bring the car back on time.
#2:
#1: You’ve been late several times. You agreed to have the car home by 6.
#2:
#1: You shouldn’t be driving a car if you can’t remember the time. You never know
what time it is. By now you should be able to keep track of the time.
#2:
#1: Me? It’s you that’s irresponsible. You never do anything you promise to do...
#2:
8.e NAMI Family-to-Family


Class 8: I-Statement Exercise
Script for Volunteer # 1 (Relative with Mental Illness)
I-Statements
#1:
#2: But you said I could borrow the car.
#1:
#2: Well, I lost track of the time.
#1:
#2: Well, you’re just being unreasonable. You don’t want me to have a good time.
# 1:
********** (fold) **********
#1:
#2: But you said I could borrow the car.
#1:
#2: Well, I lost track of the time.
#1:
#2: Well, you’re just being unreasonable. You don’t want me to have a good time.
#1:
#2: You’re always on my case.
8.f NAMI Family-to-Family


Class 8: Reflective Responses Exercise Scripts
Flash Card Script #1: Dropping out of Program
Rel Card 1: I don’t want to go to the day program anymore. They don’t do
anything there.
FM Card 1: It sounds like you’re bored with what goes on there.
Rel Card 2: They just sit all day and have dumb meetings and watch TV.
FM Card 2: It must be pretty hard to put up with. The days must feel pretty long
when there’s not enough to do.
Rel Card 3: Yeah. I don’t want to go there anymore.
FM Card 3: Well it may not be the best place for you, I can see that. But what’s
the alternative? You’re even more bored when you have to hang
around the house.
Flash Card Script #2: Why Can’t I Live at home?
Rel Card 1: Why can’t I live at home? Everyone else lives at home! Why do I
have to live in a grungy room downtown? It’s not fair.
FM Card 1: It must be hard to live away from home when everyone else lives at
home. You’re right: It’s really unfair.
Rel Card 2: Well I want to come home and I promise that I won’t be a problem.
FM Card 2: You must be feeling left out, and I understand why you want to
come home. Believe me, if we could, we’d have you here.
Rel Card 3: So why can’t I come home?
FM Card 3: It’s probably hard for you to remember some of the difficulties we
had when you were living at home. Remember how I just can’t stop
nagging and fussing at you? Remember how you decided you’d
feel less pressure if you lived independently?
8.g NAMI Family-to-Family


Flash Card Script #3: Going Back to school
Rel Card 1: I don’t know if I can go back to college this fall. I don’t think I can
hack it.
FM Card 1: It must be depressing to feel you can’t be where you want to be. I
know this means a lot to you.
Rel Card 2: Well, it doesn’t look like it’s in the cards for me.
FM Card 2: I guess sometimes you really feel discouraged.
Rel Card 3: Maybe I could take a couple of courses at the community college.
FM Card 3: Well, maybe you can. Maybe you can handle part of the load. How
do you feel about that?
Flash Card Script #4: I’m going off my meds
Rel Card 1: I’m not going to take my meds anymore.
FM Card 1: It sounds like you’re really fed up with having to be on meds.
Rel Card 2: Well, I’m feeling better and I don’t need them anymore.
FM Card 2: I imagine it would look that way. You’re doing better so you figure
you can knock meds off.
Rel Card 3: Yeah, and I won’t ever have to take them again.
FM Card 3: I bet you really wish that. But remember what you learned last time.
It’s the meds that are helping you feel better.
8.h NAMI Family-to-Family


Flash Card Script #5: The Mafia is After Me
Rel Card 1: The Mafia is coming after me. They’re outside the house.
FM Card 1: It must be frightening to think someone is going to harm you.
Rel Card 2: I can hear them talking. They’re going to kill me.
FM Card 2: It must be disturbing to think someone is coming after you.
Rel Card 3: I’m going to lock myself in my room.
FM Card 3: I know you think you have to get away. But I am concerned for you
right now. I’m concerned you might be having a relapse.
Flash Card Script #6: They’re All Looking at Me
Rel Card 1: Everyone’s looking at me. I hate it when they all talk about me that
way.
FM Card 1: It must be upsetting to feel people are always talking about you.
Rel Card 2: Particularly that woman in the corner. She wants to steal my
boyfriend.
FM Card 2: You must feel really uncomfortable thinking that people want to
take something away from you.
Rel Card 3: Well, it’s because I look terrible.
FM Card 3: Being in a public place sometimes makes you real nervous and
sensitive. I think you look fine. I don’t think anyone is talking about
you.
8.i NAMI Family-to-Family


Agenda
A. Opening
B. How a thought disorder interferes with the ability to understand communications
C. Empathy Exercise: What this is like
D. Why do we need to work on communication skills?
E. I-Statement Communications
F. Reflective-Response Communications
G. Expressed Emotion and Talking to the Person Behind the Symptoms of Mental
Illness
H. Adjourn
8.j NAMI Family-to-Family


Opening
In this class we have our second Skill Workshop, this time on the subject of
communication. As before, we will be doing a number of exercises based on several
key principles of communication. If you understand these principles, then these
techniques for communicating with your family member will make more sense.
We are not teaching communication skills because we think you have been “doing it
wrong.” We also don’t believe that communications in families of individuals with mental
illness are inherently “dysfunctional” and need to be “fixed.” What we do believe is this:
When someone you care for has a brain disorder, their capacities for communication
are often drastically altered.
Every illness we have studied in this course involves problems in areas of attention,
memory and information processing. People with brain disorders experience a high
degree of perceptual overload. In depressive episodes, individuals are hypersensitive to
the slightest degree of noise and confusion; episodes of mania bring a rush of
fragmented thoughts; in panic disorder and OCD, people are distracted by a flood of
internal fears which make it impossible to focus on anything else. Nowhere is this
problem more apparent than in brain disorders that include episodes of psychosis.
So, let’s take a minute to see how thought disorders interfere with the ability to
understand communication, using schizophrenia as a prime example.
How a thought disorder interferes with the ability to understand communication
Having schizophrenia means you are overwhelmed with information; by thoughts and
feelings from within, and by a bombardment of sounds from outside. We learned in
Class 4 that people with this disorder appear to have a faulty “shut- off’ mechanism and
are unable to filter out noise. They also have difficulties with working, or “short term”,
memory. The results of these processing deficits include:
1. Inability to concentrate, or screen-out incoming stimuli.

2. Inability to “track” complex communications.
As a result, people with schizophrenia have difficulty limiting their thoughts and
therefore they cannot focus easily on any one thing. They often appear distracted and
distant. There is an onslaught of competing memories, sensations and thoughts.
8.1 NAMI Family-to-Family


Listen to some first person accounts, taken from Dr. Fuller Torrey’s book:
“Everything seems to grip my attention although I am not particularly interested in

anything. I am speaking to you just now, but I can hear noises going on next door and
in the corridor. I find it difficult to shut these out, and it makes it more difficult for me to
concentrate on what I am saying to you.”
“Sometimes when people speak to me my head is overloaded. It’s too much to hold at
once. It goes out as quick as it goes in. It makes you forget what you must have heard,
because you can’t get hearing it long enough...”
Now let’s see if we can set up an exercise so you can experience what this actually
feels like for the person with the thought disorder; what we call an “Empathy Exercise.”
Empathy Exercise: What this is Like
Directions for setting up the exercise:
1. Tell the group you are going to ask them to re-create the experience of a
person with a thought disorder: Some will play the role of the “patient” in the
hospital; others will simulate the patient’s “mental environment.” Have them
count off 1-2, 1-2 around the group. All #1’s will be the patient; all #2’s will
enact the mental environment. (If someone does not wish to participate, ask
him/her to be an “observer” and sit next to the Teacher during the main
exercise.)
2. Teacher 1 calls a short “private” meeting with Group 2 (out in the hall).
Explain to Group 2 that you want them to stand behind the patient ‘s chairs
and be a “chorus” of
• the “voices” in his head

• incidental voices and noises in the patient’s “environment.”
Pair them up, and give them each a “voices” or “environment” Blue Card.
(Make sure to ask if the statement on the Blue Card is OK for each pair to
read.)
Tell them to wait for the cue; you will first give them some instructions. When
you say, ‘‘All right, let ‘s begin,” Group 2 should start speaking, softly to
moderately, all at the same time, repeating the message on their Blue Card
until you say “Stop!”


Directions for setting up the exercise:
1. Teacher 2 stays in the room with Group # 1; get them to sit next to one
another in a line. Explain that they will be asked to do a simple drawing
exercise. Hand out 3 x 5 index cards and pens. Teacher 2 participates
with Group # 1 in the exercise and stays with them during the debriefing.
2. Teacher 1 brings Group # 2 back into the room and asks them to line
up behind Group # 1 “patients”. Teacher 1 sits or stands facing both
groups.
Teacher 1 reads the instructions below in a strong voice, without expression
This is not a test. No one will be checking your performance, but there are a few rules:
1. Please do not ask questions.

2. Please do not look at your neighbor’s paper.
3. Please do not interrupt me, or make any comments until after I call “Stop”
“All right, let’s begin”.
1. Draw a square.
2. Draw a second square, placing its right side at the

midpoint on the bottom of the first square.
3. Draw a third square at an angle at its middle, placing

the top of it midpoint, on the right bottom point of the
second square.
4. Draw a fourth square, placing its top midpoint on the

lowest point of the third square.
5. Draw a fifth square, placing its top point on the bottom

left hand point of the fourth square.
Call STOP!


Directions for debriefing the exercise:
Ask for people’s reactions to the exercise, starting with the group sitting down who
played “the patient.”
• Ask each one what they felt: Uncertainty? Confusion? Anxiety? Did they
tune out, give up, not try at all? Did they feel disoriented? Frustrated?
• Point out that their reactions are just like those of people with mental
illness.
• Ask the group in the back row about their experience. Could they hear the
“wall of sound” they were making?
• Did everyone get a sense of how difficult the “life of the mind” must be for
someone living with this type of bombardment all the time? Particularly
when someone is approaching them with complex information?
Ask class to move their chairs back to their proper places; get everyone settled
down to resume the lecture below
We are trying to learn about our relatives by understanding their world. If we have
empathy for what they are experiencing we will more readily accept some of the
difficulties they have and we will no longer expect them to respond “as if” none of this
was happening.
If we can understand the “shattered screen” our relative is coping with, we will also
understand the following Basic Communication Guidelines.
Teacher direct class to Handout # 1
Ask for volunteers to take turns reading the guidelines on the handout; then
resume the lecture below


Why do We Need to Work on Communication Skills?
Now that we have these basic principles in mind, let’s move on to our next question:
Why is it necessary for us to consider and practice communication skills? We admit we
“overdid” the last exercise on purpose, so that you would get a vivid sense of what it
must be like for your relatives to try to pay attention to what you are saying when they
are symptomatic.
To “get through” to a relative with this kind of cognitive overload, we need to

communicate in a way that is absolutely understandable. You will find that you can also
use these communication skills in everyday conversations with people.
It’s been our experience that many of us think that “not knowing what to say” to a
person with mental illness is somehow a failure on our part. As expectations go, this is
pretty ridiculous! Did any of us take training courses in mental illness before it struck
our family! Of course not!
We also need to acknowledge that our backgrounds determine how we communicate

within our families. While mainstream American culture generally has a straight forward
and direct communication style, other cultural groups have a more indirect style of
communication. Our backgrounds may also determine who may or may not voice an
opinion within our families. Regardless of your background, we believe that the
techniques we will explore in this class can prove useful.
We all know that crisis periods of illness, and recurring symptoms of brain disorders,
can cause a breakdown in communication. We seem to lose the threads of our
established communication patterns with our loved ones. To restore these connections,
we must learn to talk to each other again in a way that is not controlled by illness. We
must feel free to communicate our needs and concerns, and we must encourage our
loved one to openly express their needs and concerns.
This means we must utilize two basic communication approaches. We must state our
own positions clearly on the one hand, and remain open and receptive to our relative’s
position on the other. These are communication skills we can learn and practice that will
make these encounters go better.
What we want to do now is to give you some of the fundamentals and spend time
tonight practicing them together. We are going to focus on two techniques which are
the foundation of communicating effectively with anybody, but particularly with a family
member who is struggling with a brain disorder.


The first technique we call the “I-Statement.” The second technique is called the
“Reflective Response.” Let’s start with the I-Statement.
Teacher direct class to Handout # 2,

The I-Statement Guide, you will not read the handout,
Teacher resume lecture below
I-Statement Communications
Let’s define an I-statement: When I make an “I-statement,” I am making a very specific,

direct communication about what I think, or what I feel, or what I want. In “I-
statements,” I am at the center of the communication. I take complete responsibility for
my feelings and opinions. I don’t waiver: I don’t equivocate. I say what I mean. And that
is all that I do. I don’t explain. I don’t go on about it.
Ask the class to suggest some “I-Statements
Write these down on the flip chart pad; make a point of putting a BIG PERIOD at the end
of each statement, return to the lecture below
Let’s take, for example, the I-Statement ‘‘I’m angry that you keep smoking in the house.”
Write this statement on the flip chart pad
I-Statements are very helpful to us when we need to communicate negative feelings or

voice our objection to something our relative is doing. In a moment, you will see why
we don’t want to start a conversation like this with “You-Statements.” But first, let’s
practice some I-Statements we might use to communicate that we are upset.


Write the following on the flip chart pad:
I feel _____________ when you _________________.
Ask the group to fill in the blanks, write their responses under the blank lines on the
pad;
Be dramatic about placing a BIG PERIOD at the end of the last blank each time;
Let the class know that the period means “stop”, don’t go on and on about it
After 4 or 5 suggestions, return to lecture below
Now, what is the likely effect when we convey our feelings this clearly and this directly?
What are we really communicating?
Ask the class what they think; allow 2-3 minutes for responses;
Then direct class back to Handout # 2 and ask for a volunteer to read the points
listed under Points to Remember at the bottom of Handout # 2
Then return to the lecture below
Now, to hear what a real I-Statement conversation actually sounds like, let’s try one.


Ask for 2 volunteers to demonstrate the scripted “I-Statement” conversation using the
script from page 8e and 8fin the front of this class
One volunteer is the family member who reads # 1;

the other is the ill relative who reads # 2
give each volunteer the top half of the script; ask them to read the role play with
each other starting with the family member reading # 1.
When they are done, ask them to repeat it one more time, then return to lecture
The script is reproduced below for your convenience:
I-Statement Exercise
#1 (FM): I get angry when you don’t bring the car back on time.
#2 (Rel): But you said I could borrow the car.
#1 (FM): I know we have that arrangement. But I get upset when you don’t get
back at the time we agreed upon.
#2 (Rel): Well, I lost track of the time...
#1 (FM): I think if you can’t handle time, then I can’t agree to let you have the
car. I need to know you can follow through on our bargain.
#2 (Rel): Well, you’re just being unreasonable. You don’t want me to have a
good time.
#1 (FM): I don’t agree. It’s up to you. If you are late again, I will cancel our
agreement. If you’re on time, then I will stay with our deal.
You can see that the Family Member never deviated from the I-Statement
framework to communicate his/her feelings or opinions: “I get angry,” “I get
upset,” “I need to know,” “I don’t agree.” There is no doubt about where the Family
Member stands.
Now, let’s do this again, but this time we’re going to have a “You-Statement”
conversation. The Family Member is going to start each communication with a “You”
instead of an “I” statement. Please note that the relative’s lines stay the same (until the
last comment). Watch what happens!


Ask the volunteers to read the “You Statement” script from page 8e and 8f at the
front of this class, starting with the Family Member reading the role of # ; read this
through once then return to lecture below
The script is reproduced below for your convenience:
#1 (FM): You make me angry when you don’t bring the car back on time.
#2 (Rel): But you said I could borrow the car.
#1 (FM): You’ve been late several times. You agreed to have the car home by 6.
#2 (Rel): Well, I lost track of the time.
#1 (FM): You shouldn’t be driving a car if you can’t remember the time. You
never know what time it is. By now you should be able to keep track
of the time.
#2 (Rel): Well, you’re just being unreasonable. You don’t want me to have a
good time.
#1 (FM): Me? It’s you that’s irresponsible. You never do anything you
promise to do...
What happened in this conversation that was different than the “I-Statement”
conversation?
Allow 2-3 minutes for the class to discuss the difference, then return to lecture
below
Well, we are sure that you get the point! The “You-Statement” conversation has
deteriorated considerably from the one before. This shows us that when we move away
from I-Statements with our relative we tend to do the following:
1. start blaming and being judgmental
2. start making assumptions about his motives
3. start generalizing a specific problem to other behaviors when the communication

begins to go badly.


4. start venting our negative feelings
Thank the volunteers for their help; give them a big round of applause!
Return to lecture below
In other words without I-Statements things bog down. We get more frustrated and our
loved one feels defeated. We have voiced our anger and frustration in a way that gets
us all messed up.
Before leaving I-Statements, we need to mention they are also great for making
requests and giving positive feedback. I-Statements are direct form of communication
that most of us may not be comfortable with, but we encourage you to give them a try.
Mental illness requires us to do things differently in order to support our loved ones.

Using “I-Statements” to make positive requests and provide positive feedback
Ask for volunteers to read the Handout
Ask class for other examples of using positive I-Statements; after 3-5 examples,
So, here’s the main point. When you get the hang of making I-Statements, don’t “undo”
them by expressing doubt, or qualifying your statements. Say what you mean, and
mean what you say, period! Remember, our relatives are often disorganized, distracted
and disturbed. It helps them when we are clear, calm and concise.
We do want to point out, that using “I-Statements” will not automatically make your life
wonderful. This skill is about clarity, making communication more clear with less need
for interpretation. What we know is that the only thing you can control is you, and if your
communication style changes, so will your loved one’s - - - eventually!
Ask the class for questions or comments about “I-Statements”;

Allow no more than 2-3 minutes for this discussion, then announce break


********** BREAK **********

Stop for a 10 minute break for people to breathe, have refreshments, etc.
Reflective Response Communications
The second communication skill we want to introduce tonight is the technique of

Reflective Responses. This approach in communication is like the “I-Statement,” but
here the subject has shifted. In “I-Statements” we communicate what we, the subject,
are feeling and wanting. In Reflective- Responses we focus upon what the other
person, our family member, is feeling and experiencing. He or she becomes the subject.
Why are Reflective-Responses Necessary?
In mental illness we are dealing with a set of completely unique behavior problems in
our adult relatives. How do we cope with someone who has rampant paranoia, whose
descriptions of reality are delusional, who blames us for everything we try to do to help
and protect them? These things make us feel uncomfortable, embarrassed, angry or
even guilty. We tend to avoid talking to our relatives about their odd behaviors and
troubled feelings because we are afraid that talking about it will only make it worse.
Actually the opposite is true. When we can reflect what our relatives are feeling back to
them, it often reduces those feelings and makes it easier to communicate with them.
Listen to what Kayla Bernheim says about this in her book “The Caring Family”:
“Rather than simply denying the person’s perceptions, you would do better to
respond reflectively and with concern. This is more easily accomplished if you
can learn to focus your attention on how your disturbed family member is
feeling rather than on your own feelings of uncertainty or guilt.”
When do we use Reflective-Responses?
Reflective Responses are useful whenever our family member is communicating

something “odd” to us, when they are being oppositional, or when we are being
challenged for some action we had to take that makes them mad.
For example, I’m going to ask my Co-Teacher to play the role of my relative and give
me a “hot potato” communication.
Co-Teacher asks angrily:

“Why did you put me away? I don’t need to be in the hospital!!!”


At this point, I have two choices on how I can respond. I can respond from “my side,”
explaining my position (“We didn’t want to put you in the hospital. We didn’t know what
else to do. You know we love you, etc.”),
Or...
I can stay with my relative’s statement, simply reflecting it back. A Reflective-Response

goes like this:
“/ can see you’re really angry. I guess I would be too if I felt that somebody I
trusted was locking me up against my will. We must seem awfully heartless to
you right now.”
In Reflective-Responses, we put ourselves in the other person’s shoes. All our

explanations and good intentions, although they are undoubtedly true, are unlikely to
satisfy a distressed person at this moment. Our relatives will continue to feel isolated, as
if no one cares about their opinion or feelings.
When we validate their experience, our relatives feel heard; they feel less “crazy.” After
all, there is still a person in there, behind the frightening symptoms of mental illness,
and it is this person we are trying to communicate with.

Reflective Responses Guide
Ask for volunteers to read only the 4 Basic Steps for making Reflective Responses
from the Handout, then return to lecture below
Another way to understand this is to use the “Airport” metaphor. Whatever runway your
relative “takes off’ on, you come in on the exact same runway. You do not land on
another runway. If s/he says, “My food is poisoned,” you say, “It must be frightening to
think someone is trying to hurt you.” If s/he says, “I’m never coming back!”, you say, “It
must seem like getting out of here is sometimes the only thing to do.”
What you are doing is staying with the feelings that have been communicated.
This means you are going to listen for the emotional content of what you are hearing,
rather than getting upset about the words. In this way, you can reflect back the
essential part of your relative’s communication.
Now, to give you some practice, we want to try some “sample dialogues” to help you get
the knack of this-what we call a Reflective Responses Exercise. Remember that the
skills you will be working on are:
1. listening for the feelings behind the words, and

2. not disconfirming (or arguing) right off the bat!


Teacher have Blue Cards out and Ready, the responses are also in the front pages of
this Class
I’m going to ask for volunteers to choose a partner so we can practice in pairs. One
person in the pair will play the ill relative and deliver the “hot potato” lines; the other will
play the family member and try to answer with reflective responses. If you are here with
your partner, or another family member we ask that you choose a different person for
this exercise. All the dialogues you will practice are written down on these blue cards
so don’t be shy!
There are 2 opportunities in the script for the Family Member to “listen for feelings” and
respond “reflectively.” Then after the relative’s third comment, the Family Member can
“disconfirm”—this is, say what s/he really thinks is the “truth” about the situation.
Wait for volunteers; someone will eventually come up front!

When the team is seated; give each participant the proper Blue Card; face down;
Instruct the person playing the ill relative that s/he will begin by turning their card over
and reading the “hot potato” statement.
Instruct the person playing the family member not to turn their card over until s/he
tried a reflective response on their own,
Return to lecture below before the team begins reading the script
Now we don’t want to put anyone on the spot. Reflective responses are hard to come
up with because we are so tempted to disconfirm and defend “right off the bat.” So, first
try to reflect what the other person is feeling; then, turn over your card if you’re stuck,
and read a reflective response. Now let’s hear the hot potato!


Teacher stay up front near the team; be warm and protective
Tell the person playing the ill relative to begin; if the family member gets “stuck”; tell
them to turn the card over and read the response.
On the second “hot potato”, if the family hesitates, you might “coach” by asking
“what do you think the ill relative is feeling? Respond to that feeling”
Thank the volunteers and give them a round of applause.
Then ask them to trade “hats”, so that the “ill relative” is now the “family member”;
Have them actually switch chairs, then repeat the exercise
Give them a huge hand and ask them to return to their seats.
Ask for another pair of volunteers to do the next exercise; give them the new Blue
Cards; follow the same procedure until all six sets of scripts have been practices
Debriefing the Exercise:
At the end of the exercise, ask the class what their reactions are to this “practicing” of
reflective responses;
Did they find this way of responding difficult or awkward? Did it make them anxious?
Did they feel stumped?
If so, they are absolutely normal! We all feel this way at first when we stay with our
relative’s emotions this way.
Encourage the class to talk about their feelings about this. Allow 2-3 minutes then


Expressed Emotion and Talking to the Person Behind the

Symptoms of Mental Illness
We’ve done a lot of talking in our two skill workshops about “owning” your feelings. To
recognize what is going on for you and your relative emotionally, is to take an enormous
step forward. In mental illness, where we have so many overwhelming feelings, we
seem to feel the need to “bottle-up”.
There is a kernel of truth in that feeling. A large body of research shows that people
with mental illness are more likely to become symptomatic again if their family members
use high levels of what is referred to as “expressed emotion”. Expressed Emotion, or
EE, is a technical term that refers to emotions such as criticalness, hostility and
emotional over-involvement.
The two communication skills we’ve practiced here are all about speaking feelings
without being critical or hostile. In I-Statements you get to speak your feelings; in
Reflective Responses, you reflect your relative’s feelings. Either way, this is a way to
address feelings without explicitly judging them.
Emotional over-involvement is the third element of EE and even this term can be
misleading. You are not emotionally over-involved just because you want your relative
to do well and because you are opening up a conversation about how to make things
better. Emotional over-involvement usually takes the form of being so invested in
everything going right, that you end up getting into the blame game about how you must
have failed if the illness does happen to get worse.
After all that we learned about the biological basis for these illnesses, we hope that you
can see that neither you, nor your ill relative is responsible for causing the illness or
determining its course. Paying attention to your own expressed emotion by paying
attention to whether you are being critical, hostile or emotionally over-involved is
something that you can do proactively that will create a healthy environment for
recovery.
Using the communication skills we discussed can lower the expressed emotion. It helps
us to break the silence we think we must maintain around difficult issues and topics. In
I-Statements, we express feelings that may make our relative uncomfortable. In
Reflective-Responses, we are allowing our relative to state feelings that may make us
uncomfortable. However, as uncomfortable as all of this may be, if we work at not being
hostile, and not being critical, we are defusing a potential time bomb of resentment and
distrust.
Instead we are addressing tough subjects the way that we normally converse with
people in everyday life. We try to have forthright exchanges; we honestly state our
position; we listen to others with concern when they express their problems and
opinions.


When approaching someone with mental illness, we tend to draw back from open
communications, fearing that our relative “can’t handle” a direct approach. If you get
nothing else out of all of this, we hope you will remember that talking about issues the
way we have demonstrated is much better than avoiding them.
We also hesitate to offer what people in distress need most; a receptive, empathetic
ear. Remember, in Reflective-Responses you are not “agreeing” with your ill relative.
You are taking the time to acknowledge the reality of his or her experience, instead of
jumping right in to disconfirm it. This means you have a chance to communicate your
empathy and understanding of the real difficulties s/he must contend with.
When we use I-Statements and Reflective Responses, we are actually returning to a

natural context for communication with our relative. We are talking to him or her as a
real person, rather than an ill person. We are doing our best to relate to the human
being behind the symptoms of mental illness.
Because our relatives are not accustomed to communicating this way, we need to get
set for a reaction on their part. They may bristle at our I-Statements at first; or stop
talking when we start to reflect feelings. But if we persist with our communication
strategy, they will appreciate being treated as people who can hear what we need, and
who deserve to be listened to with respect.
Your insistence on re-framing the way you communicate with your relative will enable
you to interact in a meaningful way. Even though for some of us these moments of
connection may be fleeting, they are a precious gift to those we love.
Finally, let’s emphasize our familiar disclaimer regarding any new skills. You will not
leave tonight with a “new-better-than-ever-magic-tonic” for communication. These skills
need to be tried and practiced, and then practiced some more.
We do maintain that communication patterns can be changed, but they are as habitual
as how we fix breakfast or drive to work. If we think about these patterns, we can alter
them. Effective communication can reduce family tension, enhance our relationships,
and enable us to understand more fully the lived experience of our loved ones who
suffer from mental illness.
Ask if there are any final questions,

Thank the volunteers again,
Good night!


CLASS 8
CLASS HANDOUTS

Class 8: Handout # 1
Basic Communication Guidelines
1. Use short, clear direct sentences. Long, involved explanations are difficult for
people with mental illness to handle. They will tune you out.
2. Keep the content of communications simple. Cover only one topic at a time; give
only one direction at a time. Be as concrete as possible.
3. Do what you can to keep the “stimulation level” as low as possible. A loud voice, an
insistent manner, making accusations and criticisms are painfully defeating for
anyone who has suffered a mental breakdown.
4. If your relative appears withdrawn and uncommunicative, back off for a while. Your
communication will have a better chance of getting the desired response when your
relative is calmer and in better contact.
5. Assume that a good deal of everything you say to your ill relative will “fall through
the cracks.” You will often have to repeat instructions and directions. Be patient;
you will be rewarded in heaven.
6. Be pleasant and firm. If you do not “waffle “or undermine what you are expressing,
your relative will not as readily misinterpret it. Communications are our “boundaries”
in dealing with others. Make sure your boundaries are sturdy and clear.


I-Statement Guide
Suggested “I-Statements”: “I get upset when you shout at me. I would appreciate it if
you spoke quietly to me.” (other suggestions from you or the class)
“I-Statements” are Helpful to Me When I Want to:
1. Express negative feelings: “When you pace in the front yard, I get uncomfortable. I
would feel better if you would stop that.”
2. Make a request: “I want to you to wash up your dishes. I feel relieved to know the
kitchen will be tidy when I get home from work.”
3. Give positive feedback: “I like your hair pulled back. I’m happy when I see you
taking care of yourself.”
Points to Remember:
1. People coping with mental illness are often intensely self-involved and distracted.
Many times they are not remotely aware of our feelings and responses. !-
Statements get their attention.
2. I-Statements announce that we have strong feelings about some of the things our
relative is doing. If our relatives are clear that we are angry or upset, they will
realize they have “hit our limit.” Broadcasting our limits calmly and firmly signals
them that they need to back down. It’s easier to reach an agreement when your
relative hears exactly how you feel. I-Statements do this job.
3. I-Statements also communicate that you are ready to take the initiative, to bring the
issues out into the open, to stand your ground.


Use I-Statements to Signal Boundaries and Limits. to do This:
1. I say what I mean. I make direct, clear statements as to what I expect.
2. I mean what I say. I am consistent and follow through on what I have said.
3. I stick with the issue I’ve raised. I don’t “waffle” on the point.
It doesn’t work to duck I-Statements by using the pronoun “You.” You-Statements

sound like “you” are pointing your finger at the other person, accusing and blaming.
Your message will not get across if your relative is automatically placed in a defensive
position.


Using “I-Statements” for Positive Requests and Feedback
Examples of Positive Requests using “I-Statements”
“I would like you to go to the day program. I feel better when I know you have
something to do.”
“I will wait for you to brush your hair so we can go to town.”
“I would be more comfortable if you wouldn’t blow smoke in my direction.”
Examples of Providing Positive Feedback using “I-Statements”
“I am so happy to see you exercising.”
“You look nice with your hair back. I feel good when I see you taking care of yourself.”


Reflective Responses Guide
Basics Steps for Making Reflective Responses
1. Acknowledge the reality of your relative’s “lived experience”—that is, their reality
(rather than your reality).
2. Direct your response to what someone having this experience must be feeling
(rather than what you are feeling).
3. Communicate that you understand what s/he believes and how s/he feels.
4. Do not attempt to correct or “disconfirm” his/her viewpoint until you have reflected
his/her perception and feelings.
What you are doing is staying with the feelings that have been communicated. This
means you are going to listen for the emotional content of what you are hearing, rather
than getting upset about the words. In this way, you can reflect back the essential part
of your relative’s communication.
“Rather than simply denying the person’s perceptions, you would do better to respond
reflectively and with concern. This is more easily accomplished if you can learn to
focus your attention on how your disturbed family member is feeling rather than on
your own feelings of uncertainty or guilt.”
Kayla Bernheim, The Caring Family


CLASS 8
ADDITIONAL RESOURCES

The Other Side: Living with Schizophrenia

by Norma MacDonald
There has been so much written about acute schizophrenic illnesses, and there is so
much material available on delusions and hallucinations, that I won’t go further into
those. What I do want to explain, if I can, is the exaggerated state of awareness in
which I lived before, during, and after my acute illness.
At first, it was as if parts of my brain “awoke” which had been dormant, and I became
interested in a wide assortment of people, events, places, and ideas which normally
would make no impression on me. Not knowing that I was ill, I made no attempt to
understand what was happening, but felt that there was some overwhelming
significance in all this produced either by God or Satan. I felt that I was duty-bound to
ponder on each of these new interests, and the more I pondered, the worse it became.
The walk of a stranger on the street could be a “sign” to me which I must interpret.
Every face in the windows of a passing streetcar would be engraved on my mind, all of
them concentrating on me and trying to pass me some sort of message.
Now, many years later, I can appreciate what had happened. Each of us is capable of
coping with a large number of stimuli, invading our being through any one of the
senses. We could hear every sound within earshot and see every object, line, and
color within the field of vision, and so on. It’s obvious that we would be incapable of
carrying on any of our daily activities if even one-hundredth of all these available
stimuli invaded us at once. So the mind must have a filter which functions without our
conscious thought, sorting stimuli and allowing only those which are relevant to the
situation in hand to disturb consciousness. And this filter must be working at maximum
efficiency at all times, particularly when we require a high degree of concentration.
What had happened to me in Toronto was a breakdown in the filter, and a hodge-
podge of unrelated stimuli were distracting me from things which should have had my
undivided attention. work in a situation like that is too difficult to be endured at all. I
withdrew farther and farther, but I became more and more aware of the city around
me... By the time I was admitted to the hospital I had reached a stage of “wakefulness”
in which the brilliance of light on a window sill or the color of blue in the sky would be
so important it could make me cry. I had very little ability to sort the relevant from the
irrelevant. The filter had broken down. Completely unrelated events became intricately
connected in my mind.


Communicating with a Psychiatrically Disabled Person
A poet has defined mental illness as the “crippling of the organ of reciprocity.” Certainly
one of its most characteristic aspects is the difficulty, even breakdown, of
communication between the stricken person and others. What follows is some practical
advice on the subject of communication.
Communicating effectively does not solve all problems or make your relative well. It
usually makes things better. It won’t make as much difference as you wish it would.
Communicating in specific ways is very important for the mentally ill who are confused,
don’t understand, or misinterpret. Indirect speech is often misinterpreted. (Example:
“Do you think you could take out the trash?” Answers: “I don’t think about the trash at
all.” Or “Of course I think I could do it,” followed by not taking out the trash).
Clearer communication is an efficient change to make, in that small changes will make
noticeable differences. Individuals with psychiatric disabilities often have difficulty
sorting out incoming messages. This requires you to communicate in special ways if
you wish to be understood.
Persons with a Psychiatric Disability at Times Can:
• have trouble with reality • be withdrawn.

• be fearful • have changing emotions
• be insecure • have changing plans
• have trouble with concentrating • have little empathy for you
• be overstimulated. • believe delusions.
• easily become agitated • Have low self- esteem and lack
• have poor judgment motivation
• be preoccupied.
We Must be Willing to:
• be simple & truthful • get attention first

• stay calm • initiate relevant conversation
• be accepting • keep to one plan
• be brief • recognize their lack of empathy
• limit input & not force discussion as a symptom of their disability
• recognize agitation & allow • ignore, don’t argue
escape • stay positive
• not expect rational discussion
Making positive requests in a direct, pleasant and honest way helps you get what you
want and need from others. Requests are different from demands.


Demands annoy people. Requests made in a positive way help you build cooperative
relationships in which each person’s contributions are respected and valued.
1. Look at the person.

2. Say exactly what you would like them to do.
3. Tell them how it would make you feel.
Use phrases like “I would like to ... I would really appreciate it if you would ... It’s very
important to me that you help me with ...”
Expressing Negative Feelings:
Highly emotional expressions, blaming, threats (especially of withdrawal of love), and

character assassination are damaging to all, but especially detrimental to people
with mental illness. Research links these communications to re- hospitalizations! The
goal is to state calmly the behavior you are unhappy about, giving an acceptable
alternative and communicating a continued acceptance of the person.
1. Look at the person. Speak firmly.

2. Say exactly what they did that upset you.
3. Tell them how it made you feel.
4. Suggest how the person might prevent this from happening in the future.
Use phrases like “I feel angry that you shouted at me, Tom. I’d like it if you spoke more
quietly next time.”
Setting Limits:
Be clear, specific, and firm about what is acceptable versus unacceptable behavior.
Remaining calm but firm increases the chances that the person will comply and not
become more upset. Sometimes you should make calm, clear demands. Example:
“Set down the knife,” or “To live at home you must take your medication.” Use this
technique very rarely and only in situations which are very important. You have only a
certain number of limits you can set. Use them wisely.
Praising (Seeing the Glass Half Full):
Use praise to encourage any progress, no matter how small. Praise can be attention,
physical affection, expression of interest, and commendation. Notice any improvement
or effort and ignore flaws in performance. Be specific about what you liked. Don’t
sugarcoat a punishing remark. (e.g.: “Thanks for doing the dishes, but you put the
plates in the wrong place,” etc.)
Source: Adapted from a talk given by Christopher Amenson, Ph.D. to NAMI San Luis Obispo


Expressing Negative Feelings
1. It is important to communicate negative feelings in an effective manner.

Generalized expressions of negative feelings (“How can you stand to lie around
all day doing nothing?”) are not only ineffective in bringing about behavioral
change, but this high expressed emotion can increase the risk of your relative’s
illness taking a turn for the worse.
This does not mean that we need to bottle up our feelings, but we need to be
thoughtful about when and how we express ourselves. Expressions of negative
feelings for specific behaviors, coupled with requests for behavioral change (“I
get mad when you stay in bed past noon. I would appreciate it if you try to get
up out of bed by 10:00 a.m.”) are much more effective than just being hostile or
critical.
2. Negative feelings—such as anger, annoyance, irritation, hurt, frustration,

anxiety, uneasiness, fear, sadness, and unhappiness—occur as part of normal
living. Negative feelings, when they are expressed directly and clearly, can be
constructive in some instances. We must learn how to express the negative
emotions we have in such a way that our family relationships are strengthened,
not weakened and hurt.
3. Expressing negative feelings directly with as little hostility as possible will help
you solve family problems by getting them out in the open in honest, clear and
constructive ways. Do not let family tensions and dissatisfactions build up and
simmer. They will come out eventually in harmful and indirect ways that will make
problem solving difficult.
4. How to Express Negative Feelings Directly:
• Always allow yourself to “cool down” before you approach your relative.
Otherwise you will act on your angry feelings rather than expressing them
more calmly.
• State specifically what it is that the other person has done or said or failed to
do or say which is producing the negative feeling in you. Be clear and
specific, not vague.
• Express yourself when the problem behavior occurs; do not wait until later.
• Say how the person’s behavior is affecting you by owning up to the real
feelings you are experiencing. Be direct and honest about how the other
person’s behavior is making you feel. Do not be indirect.


• Request that the person change his behavior or ask the person to help you
try to solve the problem by coming up with alternatives.
Example: “When you pace back and forth and spend so much time just
staring into space, I feel very sad and uncomfortable. I would feel much
better if you would try to do something constructive and helpful here in the
house. Can you think of some things that you could handle right now?”
Example: “When you pace up and down in front of the house, I feel
uncomfortable. I would feel better if you would stop that.”
Notice how the last part of this communication incorporates a positive

request.
Example: “When you refuse to take your medication, I feel helpless and
annoyed. I would be relieved a lot if you would take your medication without
being reminded. What could we do to help you remember? Would it help to
keep the bottle of pills on the dinner table in full view?”
• Look at the other person when you are expressing Negative Feelings. This
helps to make your expression more direct. Lean toward the person or come
close to him.
• Have a serious expression on your face and use a firm tone of voice but do
not be overly dramatic about your negative feeling. Crying or yelling is not
helpful. It is important to keep your facial expression and your voice in tune
with the feelings you are expressing but remember that your ill relative may
become overwhelmed if they are trying to understand your words and at the
same time trying to read your nonverbal expressed emotion.




Chapter 3A
Multnomah County Drug Court;
Multnomah County Mental Health Court
The Honorable Angel Lopez
Multnomah County Circuit Court
Portland, Oregon
Contents
Multnomah County STOP Drug Court Program Narrative . . . . . . . . . . . . . . . . . . . . . . 3A–1
S.T.O.P. Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3A–11
STOP Treatment Program Petition, Waiver and Agreement . . . . . . . . . . . . . . . . . . . . . . 3A–13
What Is Mental Health Court? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3A–15
Eligibility Criteria for Multnomah County Mental Health Court . . . . . . . . . . . . . . . . . . 3A–17
Multnomah County Mental Health Court Frequently Asked Questions . . . . . . . . . . . . . . 3A–19
The Multisite Adult Drug Court Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3A–21
Chapter 3A—Multnomah County Drug Court; Multnomah County Mental Health Court
Your Law Practice: Understanding Clients with Mental Illness 3A–ii

II. PROGRAM NARRATIVE
A. PROGRAM DESCRIPTION
i) STOP court model underpinnings.
Sanction, Treatment, Opportunity, and Progress (STOP) Court is an intensive drug court
designed to meet the needs of individuals charged with possession of a controlled substance. All
project partners, Circuit Court, District Attorney, Defense Bar, Department of Community
Justice (DCJ) and Volunteers of America (VOA), support STOP’s approach to implementing the
10 key components, as follows:
1. Integrated treatment and justice system
Integrated treatment is core to STOP’s design. The primary treatment provider, VOA, attends
each court hearing and integrates court directions into treatment plans.
2. Ensure public safety and protect due process
Sanctions and incentives, outlined below, are clearly outlined prior to being imposed.
3. Early and prompt placement
A Deputy District Attorney reviews new cases for eligibility each day. Candidates who declare
into STOP drug court appear before the Judge within one week.
4. Continuum of treatment and rehabilitation
Intake and assessment by VOA occurs within two weeks for every new STOP client utilizing the
American Society of Addiction Medicine (ASAM) criteria. Clients are referred to specialized
treatment agencies depending on their needs (e.g., detoxification, residential care, etc.).
5. Frequent alcohol/drug testing
All STOP clients are randomly alcohol/drug tested based on level of care. Clients phone the
urinalysis (UA) test line daily and must provide a UA if requested. All no-shows and no-samples
are considered positive unless excused by the court team.
Multnomah County STOP Drug Court II. Program Narrative Page 1
Your Law Practice: Understanding Clients with Mental Illness 3A–1

6. Coordinated compliance strategy
STOP Court maintains strict compliance requirements and ensures that all partner staff uphold
the values of individual responsibility and accountability for participants. Final decisions and
actions, however, by always lie with the STOP Court Judge, following input from other partners.
Both incentives and sanctions are applied when appropriate to encourage each participant’s
success in treatment.
7. Ongoing judicial/participant interaction
Clients attend court hearings between once a week to once every six weeks. Individual schedules
are determined by treatment progress, sobriety, and pro-social behavior.
8. Measure goals and gauge effectiveness
DCJ monitors all data involving enrollment, type of discharge and recidivism by examining its
own data as well as the data from Department of Corrections, LEDS, eCourt, and the Department
of Human Services’ Measures & Outcomes Tracking System (MOTS). Additionally, VOA
utilizes the ACORN Outcome Questionnaire during weekly counseling sessions and phase
advancement. ACORN evaluates for different symptoms, including sleep habits, depression and
participation in sober activities, and changes are noted by participants self-report.
9. Continuing education
Throughout its history, STOP Court has supported continuing education opportunities across
partners, participating in continuing education as part of the credentialing/licensing process
associated with their position and in regional and national drug court meetings to ensure
alignment with best practices.
10. Collaboration
In addition to primary partners listed above, STOP has relationships with multiple community
agencies, including the Multnomah County Sheriff s Office, Central City Concern, Hooper

Detox Center, CODA, DePaul. Allied, and the Veteran’s Administration.
ii. Target population and how this serves the goals for your local criminal justice system
In existence since 1991, the STOP diversion drug court accepts clients with a felony drug
possession charge with no accompanying felony. STOP Court clients are often relatively new to
the criminal justice system, but considered to be high need for intervention and treatment to
avoid re-offending. The intent of STOP Court is to break the drug abusing, criminogenic
lifestyles of these individuals while providing them with a life skill set that addresses drug abuse,
housing, employment and a solid support system. STOP Court’s overarching purpose is aligned
with the local justice system in its efforts to increase public safety, reduce jail overcrowding and
prevent further prosecutions.
iii) Process for identifying eligible participants according to established program criteria.
Eligible STOP participants are identified pre-adjudication through referrals from the Multnomah
County District Attorney’s (MCDA) office, which determines eligibility based on police reports.
The STOP Program is offered to people charged with Possession of Controlled Substance (PCS)
charges as well as other drug-related charges such as tampering with drug records (e.g., forging
prescriptions for pharmaceutical drugs). STOP participants may have more than one charge
when they enter the Program but any prior convictions on violent charges exclude offenders from
participating. The MCDA determines a client’s eligibility and informs the potential client at the
time of arraignment. The client must enter a conditional discharge plea; successful completion
results in dismissal of the felony charge.
iv) Process for assessing risk and needs for the target population.
STOP is diversion treatment court; participants have not been convicted and are not on probation
for the STOP-related felony charge. As such, they do not receive a PSC or an LS/CMI. Based on
their charges and history, however, offenders are considered to be high need for intervention and

treatment to avoid re-offending and progressing through the justice system. Further assessment is
conducted once they engage in treatment where VOA offers a variety of Cognitive Behavioral
groups that address criminal thinking and addiction that are assigned based on VOA’s
assessment and treatment plan.
v) Ensuring Low Risk/High need are not mixed with High/Medium risk offenders
High and medium risk offenders are not served by STOP
vi) Describe all evidence-based practices, services, and curricula.
STOP Court’s comprehensive treatment approach incorporates a number of Evidence Based
practices (EBPs), each selected based on its effectiveness with the population served and
alignment with the program model. The VOA program is guided by the Behavioral Health
Recovery Management (BHRM) model which emphasizes a strength-based approach for both
chronic and acute disorders. At intake, each client completes an alcohol/drug assessment and
medical examination, which inform subsequent treatment decisions.
All STOP
, treatment is divided between the Engagement Team and the Recovery Team. Primary
evidence-based practices employed by the engagement team are Motivational Interviewing
(MI)1, TransTheoretical Therapy (TTT)2, and ASAM PPC-2R3. Later phases of treatment focus
on additional evidence-based practices including: Matrix Model4, Seeking Safety5, Dialectical
Behavioral Therapy6, Integrated Dual Diagnosis Treatment7, and Cognitive-Behavioral Therapy.
In the second and third phases, the intensity of treatment are matched to the severity of criminal
1
Miller, W.R., Rollnick, S. Motivational Interviewing, New York: Guilford Press, 2002
2
Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches
you how to free yourself from bad habits. New York: W. Morrow; 1994.
3
American Society of Addiction Medicine, American Society of Addiction Medicine’s (ASAM) Second Edition -Revised of Patient Placement
Criteria (ASAM PPC-2R) Chevy Chase, MD, 2001.
4
Center for Substance Abuse Treatment. Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment for People With
Stimulant Use Disorders. DHHS Publication No. (SMA) 06-4152. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2006.
5
Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Addiction. New York: Guilford Press. 2002
6
Linehan, M.M. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. 1993
7
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. B. Integrated Treatment for Dual Disorders: A guide to effective practice. New York:
Guilford Press. 2003.

and addictive risks.
vii) Overall program capacity including clinical, case management and supervision.
DCJ created the Sanctions, Treatment, Opportunity, Progress (STOP) Drug Court in
1991, which was the first drug court in Oregon and the second in the country. Since that time, the
STOP Court has been a model used by other jurisdictions for creating, sustaining, and evaluating
Drug Courts at both a regional and national level. Today, the STOP Court and the newer START
court share many of the same partners and can build on similar strengths, such as shared access
to recent federal grants that have expanded mentoring and parenting resources for START and
STOP clients. STOP’s current capacity is 250 participants at any given time for clinical services
only; none are on supervision. Annual participant data for the past 24 months is provided below.
Table 1: Annual Participant Data for 2014

# Participants Served Annually 333
# Participants Successfully Completing 91
# Unsuccessful Participants Terminated by court -absconds and 92
revokes are not applicable to STOP court participants
Participants continuing in program following year 132
vii) Program structure, phases, requirements for transitions and program completion.
STOP utilizes a three level phase system, which is based on the Matrix Model. Progression
through these phases is determined by the STOP clinical treatment team, based on an assessment
using the ASAM PPC 2-R Level of Care. Throughout treatment, individuals are continually
assessed to ensure they are receiving the appropriate level of services and level of care is
adjusted if warranted. In order to graduate from STOP, participants must: successfully complete
treatment phase III; provide negative UA’s for a continuous three month period; attend all
required programming, including individual counseling sessions with his/her counselor, and;

attend a minimum of two Alumni meetings, which are offered two times per month.
Phase I (Engagement): designed to encourage participants to begin taking responsibility for
their circumstances and behaviors utilizing the Matrix Model which includes: group counseling,
individual sessions with a counselor, random urinalysis testing, and outside support meetings on
non-treatment days. Phase 1 includes the Discovery Group based on Stages of Change, Early
Recovery Skills Group focused on achieving initial sobriety, and Relapse Prevention Group
which focus on skills for maintaining abstinence.
Phase II (Life Skills): Participants receive individual counseling sessions, random drug
urinalyses and breathalyzer tests as required. Groups in this phase include Family Education
Group and gender-specific groups in which aspects of addiction and lifestyle may be processed
openly and effectively.
Phase III (Recovery skills and on-going recovery): During this phase, individuals continue
attending Process Group and individual sessions with their counselor. Participants focus on
acquiring recovery skills into the circumstances and situations of daily life and ongoing recovery.
ix). Program evaluation efforts (including CJC peer review).
The STOP Court was the subject of a 10 year longitudinal study (1991-2001) to examine
effectiveness using a comparison of the entire population of drug court eligible offenders with
those who entered STOP. Among other findings, the study found STOP reduced the incidence
and frequency of criminal recidivism for participants by nearly 30% compared to offenders who
did not participate. The study also showed the STOP Court cost less to operate than the cost of
“business as usual”: the cost per STOP participant was $5,168 while the cost per offender not
participating was $6,560, a difference of $1,168. The STOP Court was evaluated again as part of
a statewide study of Drug Courts completed in 2011. While the report does not specifically
outline individual drug court results, date received from the state indicates the STOP Court had a

statistically significant lower recidivism rate than the control group at 1, 2, and three years after
starting the program. Finally, a Peer Review was conducted on October 29, 2014 by the CJC,
which revealed multiple strengths as well as 5 recommendations, as outlined below.
#1: All key team members attend staffing and status hearings and lack of a Drug Court
Coordinator: All key team members currently attend staffing and status hearings; as necessary,
DCJ participate, though STOP clients are not under DCJ supervision. OJD provides a STOP
coordinator who coordinates the docket and tracks data, but does not participate in court. The
newly formed Advisory Council will continue to define this role and ensure coverage by
partners, though it is unlikely the Coordinator’s role will be enhanced unless additional funding
is secured.
#2: Court has processes in place to ensure quality and accountability of treatment:
DCJ’s Business Services Team and Research and Planning Unit (RAP) monitor START
contracts to ensure: mini-assessments; billing monitoring; program monitoring; and corrective
action plans when necessary. The RAP unit conducts site visits to ensure clients are receiving
services as specified in the contract. In addition, the RAP Quality Improvement Specialist is
being certified as a Correctional Program Checklist (CPC) evaluator, an evidence-based tool to
evaluate alignment with best practice standards. Finally, RAP releases annual Performance
Measure Reports to assess contractor alignment with performance targets and recommendations.
#3: Court has an advisory committee: STOP partners have agreed to create a bi-monthly
“Operations Committee” comprised of core team members as well as ancillary community
partners such as CODA and Allied Health. This Operations Committee will function as STOP’s
advisory group and receive program data and reports for review and recommendations.
#4: New hires complete formal training or orientation: The newly formed Operations
Committee will oversee formal trainings and orientation for all newly hired STOP court

members.
#5: Program has written rules for team responses to participant behaviors: The newly
formed Operations Committee will work to create written guidelines to ensure consistent team
responses to participant behaviors.
b. NEED TO SUSTAIN THE SPECIALTY COURT PROGRAM
i.) Need for proposed program with local quantitative data and ii) qualitative information.
Multnomah County created the STOP Court in 1991 to reduce recidivism by addressing and
treating drug dependency. Since its inception, STOP has served over 2, 100 individuals. DCJ is
responsible for the community supervision of over 14,000 adult offenders in Multnomah County,
Oregon. Many of these offenders suffer from a substance use disorder or dependency. In 2014,
PSC assessments of clients beginning their period of supervision revealed that 40% evidenced a
medium or high risk, and of these offenders, 60% also demonstrated a need for treatment or case
planning pertaining to substance misuse based on the LS/CMI.
The STOP drug court team meets with graduates monthly and conducts client surveys bi-
annually in order to obtain feedback and recommendations regarding the program. As a result of
recommendations from client interviews and surveys, STOP has implemented several changes:
1.) UA hours have been expanded to better accommodate new and employed participants, 2.)
Participants have more than one opportunity to provide a UA, 3.) Additional groups to
accommodate employed participants, 4.) Increased weekend hours
c. EVIDENCE OF COLLABORATION IN PLANNING AND IMPLEMENTATION
i.) Existing partnerships in addressing participant needs
STOP Court is a broad collaboration among governmental and non-profit agencies with the
services and experience necessary to fully implement the program model. State and Local
government partners include the Multnomah County Circuit Court, the Multnomah County

Department of Community Justice, Metropolitan Public Defender, the Multnomah County
District Attorney’s Office, and the State of Oregon’s Criminal Justice Commission. VOA, a
partner of Multnomah County drug courts for over ten years, is a 501c3 nonprofit organization
that provides addictions treatment, mental health and wellness services through its InAct
Addiction Treatment Center. Coordinated efforts ensure criminogenic and addictive behaviors
are consistently and predictably addressed through incentives, sanctions, offender accountability
and professional teamwork. A representative from each of these primary partners, with the
exception of DCJ, attends each court hearing, which are scheduled three times per week. This
multi-disciplinary team has developed a close working relationship. Input from the court team is
provided prior to the Judge’s ruling involving sanctions, incentives or status in the program.
DCJ’s involvement, which is limited due to the fact that STOP clients are not on supervision, is
to align STOP services with existing activities, provide contract and data oversight and serve on
the Operations Committee. Other meetings are attended as needed.
ii) Collaborations/partnerships; iii) MOU, and iv) letters of support
Roles and Responsibilities for each partner organization are outlined in the attached MOU,
which includes a commitment to coordinate through weekly staff meetings as well as bi-monthly
Operations Meetings involving both core partners and other involved community agencies. DCJ
holds contracts with STOP partners using a blend of Multnomah County and CJC funding
streams and monitors them using a schedule outlined below. All partnerships outlined above are
necessary for successful STOP operations. Support letters from the Local Public Safety
Coordinating Council (LPSCC) and Adult Mental Health & Substance Abuse Advisory Council
(AMSACC) are attached to this application.
d. EVIDENCE OF STAFF COMPETENCY
All STOP court staff possess the knowledge and experience necessary to excel in their work with

STOP Court participants. All treatment staff are currently either Certified Alcohol and Drug
Counselors (CADC), or Qualified Mental Health Professionals (QMHP) working towards
certification. Relevant certifications and licenses are included as attachments to this application.
CJC-Funded Positions:
Counselor III (1 FTE), Provide addictions and mental health counseling: Ronald Plumlee,
MSW, CSWA, CADC I
Support Services Specialist (0.5 FTE), Performs urinalysis testing, other administrative
duties: Curtis Thorne
Clinical positions funded by Multnomah County DCJ and Medicaid/Insurance Billing:
Corrections Counseling Program Director, Provides program management; supervises STOP
clinical supervisors: Anthony Jordan, MPAE, CADC II
STOP Clinical Supervisor, Provide supervision to counseling staff, addictions and mental
health counseling, and court liaison duties: Barbara Baker, LPC, University of Denver), CADC
I; Alexandria Bangert, LPC, CADC II
STOP Counselor III, Provide addictions and mental health counseling: Megan Marshall,
QMHP (MA Professional Mental Health Counseling, Lewis and Clark); Nicole Evans, QMHP
(MA Professional Mental Health Counseling, Lewis and Clark); Robert Sloan, LPC, CADC III
Adelante Clinical Supervisor, Provides bilingual/bicultural addictions counseling to Latino
STOP participants: Miguel Tellez, CADC II, CGAC II
Psychiatric Mental Health Nurse Practitioner, Provides psychiatric treatment and medication
management: Sarah Sharaf Banger, PMHNP

4-Step Circular Process

S.T.O.P. Stages
Stage I Stage II
Mandatory: Attend at least 1 Mandatory: Attend at least 2
Alumni Group meeting per Alumni Group meetings per
month. month.
Incentive: Attend at least 3
Alumni Group meetings per 4 Step Connect with Alumni Group
mentor at least once.
month.
Process Incentive: Attendance at 3 or
more meetings and attendance
at least 1 event with Alumni
Group mentor per month.
Graduation
Stage III
Mandatory: Write about the
STOP Court experience and Mandatory: Attend at least 3
present at an Alumni Group Alumni Group meetings per
meeting. month and at least 1 event
Incentive: Becoming and with Alumni Group mentor.
Alumni Group member. Incentive: Attendance a 3
events with Alumni Group
mentor.

S.T.O.P. STAGES
Stage I
• Attend at least 1 Alumni Group meeting per month.

• Attendance at least 3 Alumni Group meetings per month earns incentive.
Stage Il
• Attend at least 2 Alumni Group meetings per month.

• Must connect with Alumni Group Mentor at least once.
• Attendance at 3 or more Alumni Group meetings AND attending at least 1 event with
Alumni Group Mentor earns incentive.
Stage Ill
• Alumni Group attendance at least 3Xs per month

• Attend at least 1 event with Alumni Group Mentor.
• Attendance at 3 events with Alumni Group Mentor earns an incentive.
For Graduation
• Write about STOP Court experience and present at one of the Alumni Group meetings.
• Becoming an Alumni Group Member earns an incentive.

STOP Treatment Program Petition, Waiver and Agreement
Name: Case #
Last First Middle Date of Birth:
Address Phone ( ) -
( ) -
I. Petition
I ask from the Court and the State the opportunity to complete drug treatment instead of being prosecuted criminally. I understand that
there is a 14-day trial period, during which I will participate in the program to see if it is right for me. I understand that in order to
begin this program I must submit a Waiver of Indictment, if I have not already been indicted by the Grand Jury. I understand that on
my 14th day in this program, I must make a final decision to stay in the program or to decline the program. If I choose to stay in the
program, I must either plead guilty or no-contest to the charge(s). On the 14th day, my choices are either to:
1. Decline the program , keeping all of my Constitutional Rights, except for my right to a Grand Jury Indictment, and set
my case for trial (or have my lawyer negotiate a plea bargain);
OR
2. Declare into the program by entering a plea of guilty or no-contest and to continue with drug treatment.
On my 14th day, if I declare into STOP, I will be permanently in the STOP Program. I have been warned that if I fail to appear on
the 14th day, the Court may refuse to allow me to participate in the STOP Program. Once I am permanently in the
program, there are only two ways I can finish the STOP Program: GRADUATION or TERMINATION:
GRADUATION (succeeding) TERMINATION (getting kicked out of the program)

I will be allowed to withdraw my former plea I will be convicted of the charges, based upon my former plea, and I will
and my Drug charges will be dismissed go straight to sentencing. The Court could impose the maximum
forever. sentence allowed under the law.
WARNING: I understand that if I am not a citizen of the United States of America, pleading guilty or no-contest to a drug-
crime means that I will be deported if INS learns of my conviction; unless, for some reason, the United States Attorney
General decides not to deport me.
II. Waiver
In order to participate in the STOP Program, I give up the right to fight my case. This means:
l. I permanently give up the right to a preliminary hearing, to a Grand Jury Indictment, and I agree to proceed upon the
information of the District Attorney;
2. I give up any former jeopardy rights on this charge and any other offenses based upon the same criminal episode;
3. I give up my right to a speedy trial;
4. I know that my drug treatment participation and records are confidential under State and Federal law. I waive that
confidentiality with regard to Volunteers of America Oregon, InAct (or any other drug treatment provider designated by
this Court) so that the provider may report to the Court, consult with my attorney, and consult with the Deputy District
Attorney regarding my participation and progress in drug treatment. I understand that my progress in drug treatment will
be discussed in open court and that all information about my drug treatment will be shared among the STOP Program
team members, which include the Court, my lawyer, the treatment provider and the Deputy District Attorney.
1 Updated June 2015

STOP Treatment Program Petition, Waiver and Agreement
III. Agreement
I agree as follows:
1. To complete an evaluation for diagnosis so that my counselor can put together a drug and alcohol treatment plan for
me;
2. To authorize release of all treatment information by my provider to the Court and to the STOP program drug court
team (that information WILL NOT be used by the District Attorney for any prosecution, but will be used by the
Court to determine whether I may remain in the STOP Program);
3. To complete Phase I of treatment within 1 year of the date I declare into the program and to complete the treatment
program to the satisfaction of the Court.
4. That the STOP Program will require that I receive treatment for a minimum of one year;
5. That the Court may extend the treatment program for additional time to allow me to successfully complete my
treatment requirements;
6. That I will not possess or use illegal drugs or knowingly associate with any person possessing or using illegal drugs;
7. That I will not use, possess, distribute or grow marijuana;
8. That I will not take over the counter medications which contain alcohol nor will I consume alcohol;
9. That I will not consume food items that contain poppy seeds;
10. That I will not consume “spice”, “bath salts”, or any other mood altering designer drug;
11. That I will disclose my participation in a drug treatment program to any doctor attempting to prescribe me medication
containing opioids, amphetamines, or benzodiazepines;
12. That I will, as soon as possible, alert my drug treatment provider of any drugs that I am prescribed;
13. That l will not work with any law enforcement agency in a capacity where I may come into contact with any illegal
drugs (Nothing in this agreement, however, prevents me from giving historical information to law enforcement);
14. To pay a compensatory fine on a payment plan set up by Volunteers of America Oregon, InAct. The payment plan
will be enforced by the Court. The Court maintains the authority to review the amount of the compensatory fine. The
amount of the compensatory fine will be based upon my income as it relates to the Federal Poverty Line and will be
determined by a Sliding Fee Scale. The maximum amount of the compensatory fine is $3,500.00. I agree to provide
proof of my income. I understand that I will still owe the compensatory fine if I am later terminated from the STOP
program and any funds paid are not refundable. I also understand that I must pay the compensatory fine in full in
order to successfully complete the STOP program, unless the Court for good cause excuses payment of the fee.
15. That ANY failure in the treatment program (such as being absent from any treatment activity, any violation of the
terms of this agreement, or the commission of a new crime) could result in modification of the treatment program, sit
sanctions, jail sanctions, or any other sanction the Court chooses to impose. In addition, I agree that ANY failure in
the treatment program also could result in termination from the program. If I am terminated from the STOP Program,
I will be convicted of the crime(s) to which I previously entered a plea of guilty or no-contest;
16. That as a part of my treatment I may be required to complete my GED if I do not have a high school diploma or its
equivalent. In addition I agree as a part of my treatment, I may be required to seek and maintain employment;
17. That the Court may require me to appear at any time, regardless of my compliance and success in treatment;
18. To keep the treatment provider and my lawyer advised of my current address at all times during my participation in
the treatment program;
19. To submit current medical insurance information and to keep the treatment provider and the Court advised of any
changes in my medical insurance. I agree to apply for the Oregon Health Plan, or any other insurance program, if I
am eligible. I hereby authorize release of information necessary to bill third-party insurance for the treatment that I
receive;
20. To follow the conditions and directions of the Department of Community Justice as a part of my Conditional
Discharge. I agree that I will disclose involvement in any supervision or treatment program, whether past, present or
future. I understand that the treatment provider and the Court will be advised of my criminal history;
21. I agree to remain in the State of Oregon until written permission to leave is granted by the Court;
22. I agree to obey all laws;
23. I agree to not possess any weapons, firearms or dangerous animals;
24. I understand that my supervision in the STOP Program is ultimately under the authority of the Court; and
25. 1 will hold myself accountable and treat myself and others with respect.
Petitioner Date Petitioner’s Attorney Date
Deputy District Attorney Date

2 Updated June 2015

Multnomah County
Mental Health and Addiction Services
What is Mental Health Court?

Mental Health Court (MHC) is an innovative program that provides mentally ill offenders with
an opportunity to stabilize, engage in treatment and avail themselves other social services.
Participation in the program is a voluntary option to a traditional prosecution of criminal cases.
MHC may not exceed the greater of the maximum period of probation for the crime or violation
of maximum sentence for the crime or violation. Participants, as a result of their stability, tend
to re-offend less and stay out of jail. By sharing their accomplishments with the court and the
other MHC participants, every participant receives encouragement and increased support in
the community from the entire court team.
The MHC team:

Judge, Public Defender, District Attorney, Court Monitor, Probation Officer, treatment
providers.
The court monitor’s role:

Each participant is assigned a court monitor that will meet with the participant to put together a
plan of action, which could include: mental health treatment, substance abuse treatment,
obtaining benefits and housing. The monitor works with the participant in a supportive manner
with the intention of establishing new contacts and community supports, identifying resources
and services that promote mental health/sobriety and stability in the community, or solidifying
connections already made in the community. The monitor will have regular contact with
community supports in order to report back to the court.
Working with community partners:

The court monitor is responsible for regularly connecting with the participant’s community
supports to assure the participant is taking part in assigned treatment, maintaining in housing
or completing their community service. Depending on what is required by the Judge, or what
phase the participant is in, the court monitor may make weekly or biweekly contact with the
community supports involved with the participant. This contact may be in person or over the
phone. Release of Information forms will be signed so information sharing can be easily
facilitated. We encourage our community partners to initiate communication with us when a
concern or question arises about your client or the system in general.
1|Page
Updated7/1/14

Expectations of participants in MHC:

• Follow the treatment plan/ plan of action set up with the participant by the court team
• Follow the instructions of the judge
• Follow all laws
• Treat others with respect
• Complete honesty and truthfulness
Participants in MHC are supervised by a formal probation officer or by the Judge (bench
probation).
When and where Mental Health Court is held:

Every Thursday at 2:00 p.m. in Room 428~ Judge Youlee You’s courtroom
Multnomah County Circuit Court
1021 S.W. 4th Street (between Salmon and Main Streets)
Portland, OR 97204
Contacting the MHC team:

Referrals and Information: Jean Dentinger, MPA, Manager: jean.m.dentinger@multco.us
Office Phone: (503) 988-5464
Office Fax: (503) 988-3926
Manager: Jean Dentinger MPA; (503) 988-5464, X 88259

Court Monitor. Caron Kepic B.A., QMHA; (503) 988-8277
Court Monitor. Marilyn Fox MA; (503) 988-8198
Court Monitor. Tim Barnhart; (503) 988-8358
Court Monitor. Kevin Bodin; (503) 988-8127
2|Page
Updated7/1/14

Eligibility Criteria for Multnomah County Mental Health Court
Defendants are evaluated for eligibility for Mental Health Court based on five factors:
First: Does the defendant have a recent diagnosis for schizophrenia, schizoaffective
disorder, bi-polar affective disorder, or major depression? These four diagnoses
constitute the majority of cases accepted into Mental Health Court (other diagnoses
are evaluated on a case by case basis.)
Second: Does the defendant have a history of repeated interactions with the
criminal justice system and are the interactions traceable or related to the
defendant’s mental illness? The stronger the connection is between a defendant’s
mental illness and their history of repeated criminal conduct, the more likely they are
to be a suitable candidate for Mental Health Court. The defendant’s criminal history
and dangerousness will be taken into account.
Third: Does the defendant currently have an addiction to drugs or alcohol? Drug or
alcohol dependence must be secondary to the defendant’s underlying mental illness in
order for the defendant to be a suitable candidate for Mental Health Court.
Fourth: Will the additional support offered by the Mental Health Court team help
the defendant complete the directives of their probation or reduce the risk of their
reoffending? The Mental Health Court team connects defendants with housing and
social services, coordinates volunteer and social activities, and assists defendants with
establishing medical care for physical and mental health ailments.
Fifth: Is the defendant “able” and “willing” to participate in Mental Health Court?
• Able: A defendant with limitations that will make it difficult for them
to appear in court frequently or follow other court directives may not be
suitable for Mental Health Court.
• Willing: Participation in Mental Health Court is voluntary.
Defendants with a significant history of reluctance to treatment or
supervision on probation may not be suitable for the program.
The factors listed above will all be considered in determining a defendant’s eligibility
for Mental Health Court. No single factor controls. All admissions are at the
discretion of mental health court Judge, with great weight given to the input of the
Mental Health Court team.
Approved by Chief Criminal Judge Frantz May 14, 2014


Multnomah County Mental Health Court

Frequently Asked Questions
What is Mental Health Court?

Mental Health Court (MHC) is an innovative program that provides mentally ill offenders with
an opportunity to stabilize, engage in treatment and avail themselves of other social services.
Participants, as a result of their stability, tend to re-offend less and stay out of jail.
When did the Mental Health Court start?

The first Mental Health Court was created in Florida in the 1980's. Since then, 150 Mental
Health Courts have opened in 32 states. Multnomah County's MHC opened its doors in June
2008. It is funded with State of Oregon Mental Health and Addiction Services dollars as a jail
diversion program.
What offenses are eligible for Mental Health Court resolution?

Defendants must not have a history of serious offenses. Most other offenses are eligible. We
will consider some excluded crimes on a case-by-case basis.
What are the diagnoses that a defendant can have in order to be eligible for Mental
Health Court participation?
In general, any of the following Axis I diagnoses are required in order for a defendant to be
eligible for MHC participation: schizophrenia, schizoaffective disorder, bipolar disorder, and
major depression. Defendants may have other diagnoses in addition to these listed, but one
of these needs to be the primary diagnosis. Other Axis I diagnoses may be considered on a
case by case basis. If a defendant has a predominant Axis II disorder, cognitive impairment,
or predominant substance abuse diagnosis, this may preclude him or her from entering the
MHC program.
Are there other criteria needed before a defendant is eligible for Mental Health Court
participation?
Most of the participants in MHC are able to receive mental health treatment because they are
on or are eligible for the Oregon Health Plan or the Multnomah Treatment Fund. If a potential
participant is not on either of these plans, he or she must have other insurance that fully
covers mental health treatment.
How does a case get to Mental Health Court?

Judges may transfer their eligible bench probationers to MHC for close supervision and
services as appropriate. In pending cases, a defendant's attorney can schedule a settlement
conference with Judge Youlee Yim You, the MHC Judge, to discuss entry. Probation officers
may also recommend MHC for their eligible probationers.
What happens when someone enters Mental Health Court?

The defendant meets with a MHC Monitor to create a plan of action, which could include
mental health treatment, substance abuse treatment, housing, public assistance benefits, etc.
Court hearings scheduled regularly to support the defendants in their progress, and to provide
further assistance as needed. Participation in MHC is a minimum of 12 months.
Page 1 of 2

How big is the Mental Health Court caseload?

There is three MHC staff that collectively provides services to a total of 80 clients. The small
caseloads allow the staff to provide greater support to the defendants.
When and where is Mental Health Court held?

MHC is held every Friday at 9:30 a.m. in Judge You's Courtroom, #428, in the Multnomah
County Courthouse.
What is a typical Mental Health Court sentence or sanction?

Defendants are monitored closely with the intention of establishing new contacts, resources
and services, or solidifying connections already made regarding housing, treatment, benefits,
etc. Participation in MHC may not exceed the greater of the probation period or the maximum
sentence for the crime or violation. Judge You is the Probation Judge for all defendants
involved in MHC. Additional sanctions may include increased appointments with a probation
officer, increased appearances before Judge You, spending supervised time in court,
community service, serving time in jail, or revocation of probation.
What kind of successes have participants in Mental Health Court seen?

We have assisted participants in acquiring housing after being homeless for long periods of
time. Others have reported that family members are proud of them, some for the first time in
their lives, for their accomplishments in MHC. Some participants have successfully reunited
with family members after addressing significant family issues during the course of their court-
mandated treatment. Participants often share their accomplishments with the Judge and the
court team when they appear in court. They often acknowledge they have hope their lives will
improve, in part because they have the support of the Court. Most participants do not re-
offend and stay out of jail while participating in MHC.
Contacts for Mental Health Court:

Manager of Diversion Courts (including MHC): Jean Dentinger, MPA (503) 988-8259
Deputy District Attorney: Melissa Marrero (503) 988-5502
Public Defender: Joe Hagedorn (503) 225-9100
Judge You's Judicial Assistant: Marie Brandis (503) 988-3404
Updated: 08/24/2015
(Phone Numbers)
Page 2 of 2

What Have We Learned from the Multisite Adult

Drug Court Evaluation? Implications for Practice and Policy
The Multisite Adult

Drug Court Evaluation
By Shelli B. Rossman, M.A., and Janine M. Zweig, Ph.D.
May 2012
I n 2011, the National Institute of Justice (NIJ) and a team of research-

ers from The Urban Institute’s Justice Policy Center, RTI International,
and the Center for Court Innovation completed a five-year longitudinal
process, impact and cost evaluation of adult Drug Courts. The Multisite
Adult Drug Court Evaluation (MADCE) compared the services and out-
comes in twenty-three adult Drug Courts from seven regions in the U.S.
against those of six comparison sites in four regions. The comparison
sites administered diverse programs for drug-involved offenders, includ-
ing Treatment Alternatives for Safer Communities (TASC), Breaking the
Cycle (BTC), and standard court-referred, probation-monitored treatment.
Offender-level data were obtained from 1,157 Drug Court participants
and 627 comparison offenders who were carefully matched to the Drug
Court participants on a range of variables that influenced outcomes. The
study was designed to answer three basic questions:
Do Drug Courts Work? For Whom Do Drug Courts

Drug Court participants and matched Work Best?
comparison group members were compared Analyses examined the extent to which the Drug
on key outcomes, including self-reported drug Courts affected subgroups of offenders charac-
use, oral fluids drug test results, self-reported terized by demographic variables, primary drug
criminal behaviors, official criminal recidivism of abuse, criminal history, violence history, and
records, and psychosocial outcomes. associated mental health problems.

Figure 1. Oral Swab Drug Test Results at 18 Months
50%
45%
40% 46%
35%
30% Drug Court
25% Comparison Group
29%
20%
15%
10%
5%
0%
% Positive for any Drug (p <.01)
How Do Drug Courts Work? significantly less. Figure 1 compares the rates of
positive oral swab drug tests at eighteen months.
The study identified which policies and practices
in the Drug Courts might predict better outcomes. Drug Court participants reported committing signifi-
In addition, the study examined participants’ cantly fewer criminal acts than the comparison group
perceptions of the programs to determine whether after participating in the program. Figure 2 compares
those perceptions influenced outcomes. the percentages of participants who reported
engaging in any criminal activity at eighteen months.
MADCE Findings
Drug Court participants reported sig-
The key findings from the MADCE supported many nificantly less family conflict than the
of the expectations upon which best practices in comparison offenders at eighteen
the Drug Court field are currently based; however, months. Drug Court participants were
they also revealed some unexpected results that also more likely than the comparison
may challenge some of those practices. offenders to be enrolled in school at six
months.
Drug Court participants were significant-
ly less likely than the matched compari- Drug Court participants reaped psychosocial
son offenders to relapse to drug use, benefits in areas of their lives other than drug use
and those who did relapse used drugs and criminal behavior. Drug Court participants
significantly less. reported significantly less family conflict than
the comparison offenders at eighteen months.
Drug Court participants were also more likely
Effectiveness of Drug Courts than the comparison offenders to be enrolled
Drug Court participants were significantly less likely in school at six months and needed less assistance
than the matched comparison offenders to relapse with employment, educational services, or financial
to drug use, and those who did relapse used drugs issues at eighteen months.
2 Need to Know

THE MULTISITE ADULT

DRUG COURT EVALUATION
Figure 2. Criminal Activity in the 6 Months Before the 18-Month Survey
45%
40%
43%
35%
30%
25% 31% Drug Court
Comparison Group
20%
15%
10%
5%
0%
% Reporting Criminal Activity (p <.05)
Target Population over the comparison programs. The absence of statistical

significance may have been influenced by the nature
Drug Court reduced drug use equivalently for most subgroups
of the target populations. Many of the Drug Courts in
of participants, regardless of their primary drug of choice, past
the MADCE reduced low-level criminal offenses that
criminal history, or associated mental health problems. Little
are typically not associated with high incarceration or
empirical justification exists for denying admission to
victimization costs. This suggests Drug Courts will need
Drug Court based on an offender’s clinical presentation or
to target more serious offenders to reap significant cost
criminal history.
benefits for their communities.
Participants with violence histories reduced substance use just
as much in Drug Court as those without violence histories Best Policies
and reduced criminal activity even more. Thus, prohibitions The most effective Drug Courts had the following policies
contained in state and federal statutes against admitting or characteristics:
violent offenders into Drug Courts may not be justified on
the grounds of effectiveness or cost. • Greater leverage over their participants. The participants
were made aware of the alternative sentences they
Participants with violence histories reduced faced if they failed the program and were in regular
substance use just as much in Drug Court contact with program personnel and the judge.
as those without violence histories and • Greater predictability of sanctions. The programs had a
reduced criminal activity even more. written schedule of sanctions for infractions that they
shared with participants and staff. However, the teams
The largest cost benefits were achieved by reducing serious retained discretion to overrule the sanctions if there
offending on the part of a relatively small subset of the Drug were good reasons to do so.
Court participants. On average, the Drug Courts returned
net economic benefits to their local communities of • Consistent point of entry. The more effective Drug Courts
approximately $2 for every $1 invested; however, this maintained one point of entry into the program, either
did not represent a statistically significant improvement at preadjudication or postadjudication, but not both.
Need to Know 3

• Positive judicial attributes. The more effective Recommendations to

Drug Courts had judges whose interactions with
the participants were respectful, fair, attentive, Drug Courts
enthusiastic, consistent, predictable, caring, and
knowledgeable. The Role of the Judge
The results of the MADCE support the centrality
The most effective Drug Courts had of the judge in influencing Drug Court outcomes.
greater leverage over participants, Judges exert considerable influence and authority
greater predictability of sanctions, over participants, and when used strategically, this
consistent point of entry, and positive influence can elicit substantial positive change.
judicial attributes.
Judges exert considerable influence
and authority over participants, and
Best Practices
when used strategically, this influence
The most effective Drug Courts provided the can elicit substantial positive change.
following services:
• More frequent judicial status hearings (at least • Train judges on best practices regarding judicial
twice per month) behavior. Judges do not necessarily have
the innate traits that elicit the most positive
• Higher and more consistent levels of praise from
outcomes from participants, and thus may
the judge
benefit from training in best practices for
• More frequent urine drug testing (at least twice judicial behavior. New Drug Court judges
per week) should participate in team and judicial-specific
training to acquire the knowledge and skills of
• More frequent clinical case management
an effective Drug Court judge.
sessions (at least once per week)
• Hold frequent judicial status hearings. Twice
• A minimum of thirty-five days of formal
per month is the minimum frequency for
drug-abuse treatment services
status hearings that the MADCE found
effective. Most of the effective Drug Courts
Participants’ Perceptions of the Judge in the MADCE held status hearings four times
The primary mechanism by which the Drug Courts per month.
reduced substance use and crime was through the partic-
ipants’ perceptions of and attitudes toward the judge. Most of the effective Drug Courts in the MADCE
Significantly better outcomes were achieved by held status hearings four times per month.
participants who rated the judge as being knowl-
edgeable about their cases and who reported that • Choose Drug Court judges carefully. Not all judges
the judge knew them by name, encouraged them may be suited to the Drug Court model in
to succeed, emphasized the importance of drug and terms of their personality and attitudes toward
alcohol treatment, was not intimidating or unap- offenders and the judicial relationship. Drug
proachable, gave them a chance to tell their side of Courts may best be served if administrators
the story, and treated them fairly and with respect. assign judges to the Drug Court docket who are
committed to the problem-solving court model
and are interested in serving in this role.
4 Need to Know

THE MULTISITE ADULT

• Give them time—judges may need time to develop effective • Avoid suitability determinations. Drug Court teams are
approaches to the Drug Court bench. Rotating judges on not very successful at predicting who will succeed in
and off the Drug Court bench will likely decrease not their program. Therefore, they should avoid allowing
only the judges’ abilities to successfully implement entry only to offenders they believe will be better
their roles, but also the overall success of the Drug suited to the services.
Court program.
• Monitor participant satisfaction. Drug Courts should Sanctions Policies and Practices
continuously monitor participants’ attitudes about The most effective Drug Courts in the MADCE had a
the judge. If a judge elicits widespread negative coordinated sanctioning strategy, yet exercised flexibility
responses from the participants, corrective action may in its implementation in a way that mattered considerably
be indicated. to the participants. Perhaps the participants perceived this
flexibility as being more fair because it took individual
Rotating judges on and off the Drug Court circumstances into account. This suggests Drug Courts
bench will likely decrease not only the should distribute a written schedule of sanctions to its
judges’ abilities to successfully implement staff and participants, yet maintain flexibility when
their roles, but also the overall success of applying it. In this way, participants will be forewarned
the Drug Court program about the potential sanctions for noncompliance and will
expect more severe sanctions with repeated infractions.
Equally important, however, the Drug Court team should
Drug Court Eligibility allow for individual circumstances that might warrant a
less severe reaction from the court.
An important finding emerging from the MADCE is that
Drug Courts appear equally effective in reducing crime
and drug use among a wide range of offenders; however, There is no empirical basis
their cost-effectiveness may be reduced by focusing on for many of these eligibility restrictions
low-risk participants. Therefore, Drug Courts should currently being imposed in Drug Courts.
consider broadening their eligibility requirements to
reach higher-risk offenders.
Leverage
Drug Courts should consider broadening Participants fared better in the Drug Courts when they
their eligibility requirements to reach understood what specific alternative sentences would be
higher-risk offenders. if they failed the program and if they maintained regular
contact with Drug Court staff and the judge. This provides
a further rationale for Drug Courts to target higher-risk
• Consider removing eligibility restrictions based on the
populations who face a realistic prospect of jail or prison
offender’s drug of choice, criminal history, or co-occurring
time if they are terminated. In addition, all team members
mental health disorders. There is no empirical basis for
in the Drug Court should make a concerted effort to peri-
many of these eligibility restrictions currently being
odically remind participants about the potential conse-
imposed in Drug Courts.
quences of termination. Finally, participants should
• Consider including violent offenders with substance use sign entry contracts clearly acknowledging the potential
diagnoses. The MADCE findings revealed that many consequences of failure and the presumptive alternative
violent offenders in Drug Court programs reduced sentence if they do not graduate from the program.
drug use as much as other participants and reduced
their criminal behaviors even more.
Need to Know 5

treatments of short duration may not allow partici-

Drug Courts should distribute a written pants sufficient time to tackle their substance use
schedule of sanctions to its staff and problems and alter their attitudes and behaviors
participants, yet maintain flexibility accordingly. Treatment must be of sufficient length
when applying it. and dosage to achieve sustained success.
Drug Courts work, so ensure provisions

Case Management are made to fund their continued
Many Drug Courts rely predominantly on existence.
group-based counseling services for treatment.
However, the MADCE results underscored the
importance of individual case-management sessions Recommendations to
as well. Given the myriad challenges faced by
addicted offenders, once-weekly individual contacts
Policy Makers
might not be sufficient. Whether or not the primary With good cause, policy makers have consistently
case manager is a court staff member or treatment funded Drug Court programs across the country
provider, participants are likely to have better for two decades, and the number of programs has
outcomes if they meet with the case manager more grown exponentially during that time. But what do
than once per week, at least during the first phase the MADCE findings mean for policy makers in the
of treatment. future?
Participants are likely to have better Drug Courts work, so ensure provisions are made
to fund their continued existence. The research
outcomes if they meet with the
evidence clearly establishes the effectiveness
case manager more than once
and potential cost-effectiveness of Drug Courts.
per week, at least during the first phase
Government agencies should continue to spend
of treatment
resources funding Drug Court programs. They
should sponsor training and technical assistance
Drug Testing to encourage the implementation of evidence-
based practices and to ensure Drug Courts target
Continuous monitoring of alcohol and other drug the most appropriate offender populations for their
abstinence is critical to the success of Drug Courts. programs.
Drug tests should be performed frequently, certainly
more than once per week during the initial phase Encourage Drug Courts to include more serious
of the program. Drug tests not only assist program offenders in their programs. Drug Courts
staff to monitor program compliance, but also achieve higher reductions in recidivism and
communicate to participants that they are being greater cost savings when they treat high-risk,
closely watched, perhaps increasing perceptions of prison-bound populations. As a condition of
court leverage. public sponsorship, federal funders and local
policy makers should require Drug Courts to
Treatment expand their eligibility criteria to include more
serious offenders.
Providing substance abuse treatment is integral
to the Drug Court model. Drug Courts that offer (Continued on page 8)
6 Need to Know

THE MULTISITE ADULT

About NADCP
It takes innovation, teamwork and strong judicial Such success has empowered NADCP to champion
leadership to achieve success when address- new generations of the Drug Court model. These
ing drug-using offenders in a community. That’s include Veterans Treatment Courts, Reentry Courts,
why since 1994 the National Association of Drug and Mental Health Courts, among others. Veterans
Court Professionals (NADCP) has worked tirelessly Treatment Courts, for example, link critical services
at the national, state and local level to create and and provide the structure needed for veterans who
enhance Drug Courts, which use a combination of are involved in the justice system due to substance
accountability and treatment to compel and support abuse or mental illness to resume life after combat.
drug-using offenders to change their lives. Reentry Courts assist individuals leaving our nation’s
jails and prisons to succeed on probation or parole
Now an international movement, Drug Courts are
and avoid a recurrence of drug abuse and crime. And
the shining example of what works in the justice
Mental Health Courts monitor those with mental
system. Today, there are over 2,500 Drug Courts
illness who find their way into the justice system,
operating in the U.S., and another thirteen coun-
many times only because of their illness.
tries have implemented the model. Drug Courts
are widely applied to adult criminal cases, juvenile Today, the award-winning NADCP is the premier
delinquency and truancy cases, and family court national membership, training, and advocacy
cases involving parents at risk of losing custody of organization for the Drug Court model, representing
their children due to substance abuse. over 27,000 multi-disciplinary justice professionals
and community leaders. NADCP hosts the largest
Drug Court improves communities by successfully
annual training conference on drugs and crime in
getting offenders clean and sober and stopping
the nation and provides 130 training and techni-
drug-related crime, reuniting broken families, inter-
cal assistance events each year through its profes-
vening with juveniles before they embark on a
sional service branches, the National Drug Court
debilitating life of addiction and crime, and reducing
Institute, the National Center for DWI Courts
impaired driving.
and Justice for Vets: The National Veterans
In the 20 years since the first Drug Court was Treatment Court Clearinghouse. NADCP publishes
founded in Miami/Dade County, Florida, more numerous scholastic and practitioner publications
research has been published on the effects of Drug critical to the growth and fidelity of the Drug Court
Courts than on virtually all other criminal justice model and works tirelessly in the media, on Capitol
programs combined. The scientific community has Hill, and in state legislatures to improve the response
put Drug Courts under a microscope and concluded of the American justice system to substance-
that Drug Courts significantly reduce drug abuse and abusing and mentally ill offenders through policy,
crime and do so at far less expense than any other legislation, and appropriations.
justice strategy.
Need to Know 7

(Continued from page 6)
reductions in crime and drug use, but only when

Drug Courts achieve higher reductions the programs adhere to the lessons of research and
in recidivism and greater cost savings maintain fidelity to the model.
when they treat high-risk, prison-bound
populations. The field has matured sufficiently and
has amassed enough evidence-based
Develop best practice standards to guide Drug Court information to achieve substantial
operations. Now is the time to develop and codify reductions in crime and drug use, but
standards of practice for Drug Courts. The field only when the programs adhere to
has matured sufficiently and has amassed enough the lessons of research and maintain
evidence-based information to achieve substantial fidelity to the model.
www.NDCI.org www.DWICourts.org www.JusticeForVets.org
8 Need to Know



Chapter 3B
Involuntary Civil Commitment Hearings
The Honorable Kenneth Stewart
Clackamas County Circuit Court
Oregon City, Oregon
Contents
Presentation Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3B–1
Judge’s Checklist—Civil Commitment Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3B–3
Report of Examiner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3B–5
Chapter 3B—Involuntary Civil Commitment Hearings
Your Law Practice: Understanding Clients with Mental Illness 3B–ii

I. Timing:
A. Hearing must take place within five judicial days of the issuance of a citation by the court
to the PAMI (Person Alleged to be Mentally Ill)
1. If the PAMI has been detained by a notice of mental illness, the five judicial days
timing starts then.
2. The hearing may be postponed for an additional five days upon a judicial finding of
good cause.
II. Participants:
A. Judge
1. This is a hearing on the record.
B. PAMI
C. PAMI’s attorney.
D. Attorney representing state’s interest.
E. Examiner(s)
1. One is required
a. A second if requested in writing by the PAMI or PAMI’s attorney.
2. Qualification:
a. A psychiatrist or person certified by the state as a mental health examiner.
3. Purpose:
a. To conduct an examination of the PAMI’s mental condition and prepare a sworn
written report to the court.
b. See attached Report of Examiner.
III. Conduct of the hearing:
A. See attached Judge’s Checklist for Civil Commitment Hearing.
IV. Revocation hearing for failed conditional release or failed Trial Visit during period of
commitment. ORS 426.273 and 426.275
A. Same participants.
B. Same notice and timing provisions as in commitment hearing.
C. Same rights to counsel.
D. If the court finds PAMI not adhering to conditions court may continue the placement on
the same or modified conditions or return the PAMI to the Oregon Health Authority for
involuntary care or treatment on an inpatient basis for the remainder of the treatment
period.
V. Certification of continued mental illness.
A. OHA may certify that PAMI is still mentally ill. ORS 426.301
1. Notice of certification is given to the director or designee of facility where PAMI is
confined who in turn serves it on the PAMI.
2. PAMI has right to counsel and has fourteen days to protest further commitment.
3. If not protested, the commitment will continue up to 180 additional days
B. Protest of further commitment. ORS 426.303
1. Generates a hearing in the Circuit Court in the county in which the facility is located.
C. Court hearing. ORS 426.307.
1. State must prove by clear and convincing evidence that the PAMI is still a mentally ill
person.
Your Law Practice: Understanding Clients with Mental Illness 3B–1


JUDGE’S CHECKLIST
CIVIL COMMITMENT HEARING
I. Deliver citation to appear and proof of service to investigator. Place signed

proof of service into court file. Hand report forms to examiners.
II. Call the case: “This is the time set for hearing in the matter of (name of
PAMI) case no. M 123456 .”
III. Advise PAMI of rights (ORS 426.100).
a. The reason for being brought before the court,
b. The nature of the proceedings,
c. The possible results of the proceeding,
d. The right to subpoena witnesses, and
e. The right to be represented by and/or be appointed counsel.
IV. Opening Matters
a. Defense counsel may make statements for the record or advise the
court of potential issues that may arise.
b. State may offer exhibits
i. Investigator’s report
ii. Notice of Treatment
V. State’s Witnesses
a. Direct examination by State.
b. Cross-examination by defense counsel.
c. Questioning by examiners.
d. Re-direct by the State.
VI. Examination of PAMI (Person Alleged to have Mental Illness)
a. Questions by defense counsel.
b. Questions by examiners.
c. Questions by state.
VII. PAMI’s Witnesses
a. Direct examination by defense counsel.
b. Cross-examination by State.
c. Questions by examiners.
d. Re-direct by defense counsel.
VIII. Rebuttal Evidence by State.
IX. Go off record to allow examiners to complete reports.
a. Review of reports by counsel and judge.

X. Receive examiner’s report on record.

a. Swear in examiners.
b. Questions of examiners by court and counsel.
XI. Closing Statements
Xll. Judicial Findings
a. Must meet clear and convincing burden of proof by State.
b. Is there a mental disorder?
c. Has State proven one of the following criteria?
i. Basic needs?
ii. Danger to self?
iii. Danger to others?
iv. Chronic mental illness (ORS 426.005(1)(e)(C)).
v. Is there a nexus between the disorder and applicable criterion?
d. If State meets burden of proof for mental illness, then determine by
a preponderance of evidence if PAMI is willing and able to engage in
voluntary treatment (ORS 426.130(1)(6)(A)).
i. Is it available?
ii. Will PAMI probably participate?
iii. Is voluntary treatment in PAMl’s best interests?
e. If you find PAMI is mentally ill and that voluntary treatment is not
appropriate, then is conditional release available and acceptable?
(ORS 426.125)
XIII. Disposition
a. Discharge:
i. If PAMI is not found mentally ill (ORS 426.130 (1)(a)).
ii. If PAMI is found mentally ill but appropriate for voluntary
treatment (ORS 426.130 (1)(b)).
b. Conditional Release (ORS 426.125)
i. Must find PAMI mentally ill and not a good candidate for
voluntary treatment.
ii. Establish friend or family member as monitor.
iii. Establish conditions of release.
c. Civil Commitment (ORS 426.130(1)(b)(C)).
i. Establish length of commitment up to 180 days.
d. Determine if special firearm order is needed (ORS 426.130(1)(b)(D)).
XIV. Fill out and sign appropriate order and have investigator make copy for
hospital and place it in file.

IN THE CIRCUIT COURT OF THE STATE OF OREGON

FOR CLACKAMAS COUNTY
In the Matter of ) Case No. [case#]

)
[mip] ) REPORT OF EXAMINER
Alleged to be a mentally ill person. )
STATE OF OREGON )
) ss
County of Clackamas )
I, the undersigned, being first duly sworn, depose and say:
 I am duly and regularly licensed by the State Board of Medical Examiners for the State of
Oregon to practice medicine and surgery, and have had approved residency training in
Psychiatry; or
 I am certified and recommended by the Mental Health Division of the State of Oregon to
examine persons alleged to be mentally ill;
I was appointed by the Judge of the above Court to examine the above-named allegedly
mentally ill person as to the person's mental condition and that by virtue of said appointment I
have examined [mip] and report:
(1) Presenting problem:
(2) Description of allegedly mentally ill person's appearance and behavior during the
examination:
(3) Brief History Including: (a) mental health history, (b) substance abuse and use history, and
(c) social history including family and interpersonal history:

(8) Assessment of past pattern of behavior involving unlawful violence or threats of unlawful
violence.
(9) Diagnostic impression and rationale for making the diagnostic impression.
CONCLUSIONS:
Based upon the findings herein above set forth, I: (___) Do; (___) Do Not; find that the person has a
mental disorder; and
(a) (___) is; (___) is not; dangerous to self; or

(a) (___) is; (___) is not; dangerous to others; or
(a) (___) is; (___) is not; able to provide for basic personal needs;
(a) (___) is; (___) is not; now receiving such care as is necessary for
health
or safety
(a) (___) is; (___) is not; chronically mentally ill as defined in
ORS 426.495; and
(a) (___) is; (___) is not; exhibiting symptoms or behavior substantially
similar to those that preceded and led to one or
more state hospitalizations during the past three
years; and will unless treated, continue, to a
reasonable medical probability physically or
mentally deteriorate so that the person will become
a person described in section (a) above.

RECOMMENDATIONS:
If mentally ill, specify type of treatment facility best calculated to help the person recover from
his/her mental illness.
It is my opinion that this person would cooperate with and benefit from a program of voluntary
treatment. (___) Yes; (___) No;
It is my opinion that this person has demonstrated a past pattern of behavior or participation in
incidents involving unlawful violence or threats of unlawful violence or a single incident of
extreme, violent, unlawful conduct. (___) Yes; (___) No;
THE FOREGOING REPORT IS TRUE, as I verily believe.
Certified Mental Health Examiner
Examiner (print name)
Signed and Dated this _____ day of __________________________,20___.
Judge
I have examined the foregoing report.
Attorney for State's Interests
Attorney for allegedly mentally ill person.
Original: Court
Copies: County Mental Health Program Director or Designee Receiving Facility.


Chapter 3C
Investigator’s Role
Mark Niederkorn
Mental Health Specialist
Clackamas County
Oregon City, Oregon
Contents
Investigator’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3C–1
Types of Petitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3C–1
Types of Custody . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3C–1
14-Day Diversions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3C–2
Chapter 3C—Investigator’s Role
Your Law Practice: Understanding Clients with Mental Illness 3C–ii

Investigator’s Role
In general, the investigator gathers and orders facts leading up to the filing of a petition for
civil commitment, and then determines based on these facts whether or not there is probable
cause for a court hearing. This involves interviewing the principals in the case (Person Alleged
to be Mentally Ill, community providers, family, hospital providers, law enforcement) and
then deciding whether the preponderance indicates a need for judicial review or not. This
decision often turns on the PAMl’s willingness to engage in treatment voluntarily. There may
be probable cause regarding the provable presence of a mental disorder and one or more of
the other criteria (danger to self, danger to others, inability to meet basic needs) but if the
PAMI is willing to engage in treatment, a 14 day diversion might be more appropriate than a
court hearing. This all happens within the first three days of a 5 day hold, with day 4 typically
used for case processing at the courthouse, and a hearing scheduled for day 5.
Types of Petitions
 Two Party (ORS 426.070)
- 15 days to complete investigation and make recommendation to court
- PAMI remains in the community with civil rights intact and is cited to appear in
court if the investigator finds probable cause
 Two Physician or Hospital Hold (ORS 426.232)
- Lasts 5 judicial days
- PAMI is hospitalized involuntarily
- Investigator decides a disposition by the end of Day 3 (hearing, discharge the

hold, or 14 Day Diversion
- OAR 309-033 -0240 goes into some detail regarding which court should hear the
case (county of residence, county where custody is placed, or county where the
hospital is located)
Types of Custody
 Police Officer Custody (ORS 426.228)
 Designee Custody (ORS 426.233)
 Transport Custody (ORS 426.231)
 Magistrate Custody (ORS 426.070, OAR 309-033-0240)
Your Law Practice: Understanding Clients with Mental Illness 3C–1

14 Day Diversions (ORS 426.237)
 Typically, the PAMI meets probable cause for a hearing, but is willing to receive
treatment
 Generates a court ordered attorney to provide counsel to the PAMI (usually by

telephone) because the PAMI is still being held involuntarily



Chapter 4A
Representing Clients Affected by
Mental Health Challenges
Kyra Hazilla
Oregon Attorney Assistance Program
Portland, Oregon
Contents
Representing Clients Affected by Mental Health Challenges . . . . . . . . . . . . . . . . . . . . . 4A–1
1) Stress Is Affecting All of Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A–1
2) Stress Can Negatively Affect Behavior in Many Ways . . . . . . . . . . . . . . . . . 4A–1
3) What to Do When Things Are Challenging . . . . . . . . . . . . . . . . . . . . . . . 4A–2
4) How to Take Care of Yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A–3
5) Crisis Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A–3
Self-Care Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A–7
Links to Additional Discussion Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4A–9
Chapter 4A—Representing Clients Affected by Mental Health Challenges
Your Law Practice: Understanding Clients with Mental Illness 4A–ii

Representing Clients Affected by Mental Health Challenges

Involvement in legal proceedings is stressful
1) Stress is affecting all of us.

a) Stressed out lawyers.
b) Stressed out clients: People hire a lawyer or have one appointed as a result of stressful
circumstances. Many of the issues for which people seek legal representation are anxiety-
provoking. Being a client in such legal proceedings can strain and negatively impact a
person’s functioning ability, which will affect our efforts to represent them.
2) Stress can negatively affect behavior in many ways:

a) Stress can exacerbate existing mental health challenges.
i) Mental Health diagnoses are more common than heart disease, lung disease and
cancer combined. In the U.S., 57.4% of adults will meet the criteria for diagnosis with
a mental disorder at some point in their lives.
ii) People can struggle with symptoms but not meet criteria for diagnosis.
Mental Health Diagnosis Annual % of U.S. adults
Anxiety disorders 19.1%

Major depressive disorder 6.8%
Substance use disorder 8.0%
Bipolar disorders 2.8%
Eating disorders 2.1%
Schizophrenia .45%
Any mental disorder 19.6%
iii) Only 41% of people who had a mental health diagnosis in the past year received
professional health care or other services.
iv) Many reasons people do not seek treatment:
(1) Stigma
(2) Lack of insight of information that effective help is available.
(3) Lack of access to services.
b) Stress can cause mental health or physical health issues. (Stress-diathesis model: this
theory purports that an individual’s biological vulnerabilities, or predispositions, to
particular psychological disorders can be triggered by stressful life events.)
c) Stress can “flip our lids” and cause our prefrontal cortex to go “off-line” and limit our
response flexibility.
i) Prefrontal Cortex functions: body regulation, attuned communication, emotional
balance, response flexibility, empathy, insight, fear-extinction, intuition and morality.
d) Mirror neurons/amygdala and emotional contagion. Newborns and physical mirroring,
emotional mirroring and empathy.
e) Trauma history.

3) What to do when things are challenging.

a) How to work with a stressed person.
i) Setting limits
(1) Limits in your role.
(2) Limits on unacceptable behavior.
ii) Meeting people where they are, using empathy and active listening
iii) Defusing/Non-Violent Communication
(1) Anything you know about this person that could be soothing (food, music, therapy
animals for dysregulated people).
(2) Social connectedness.
(3) What is the need that the person is expressing?
b) Know yourself
i) What is most likely to trigger you?
ii) Direct Trauma
(1) Traumatic situation in front of you.
(2) Situation that triggers previous trauma.
iii) Vicarious trauma (Also: Secondary Traumatic Stress, Compassion Stress,
Compassion Fatigue, “the cost of caring,” Secondary Victimization, Co-
Victimization, Vicarious Trauma, Emotional Contagion, Burnout, and for therapists it
is called Countertransference.)
(1) Law itself can be traumatizing.
(2) Working with traumatized people can be traumatizing.
(3) How do you know if trauma is affecting you? (Hint: it is.)
(a) Changes to identity, world view, relationships, spirituality, sensory system,
etc.:
1. Preoccupation with work
2. Questioning identity
3. Distancing from others
4. Hopelessness
5. Anxiety
6. Depression
7. Disillusionment
8. Addictions
9. Loss of empathy
10. Difficulty maintaining boundaries
11. Cloudy cognitive processing
12. Poor decision-making skills
13. Difficulty taking care of self
14. Lack of interest in others
15. Intrusive recall of client’s trauma imagery
16. Nightmares
17. Insomnia
18. Exhaustion
19. General malaise
c) Keep yourself safe
(1) Meetings at the courthouse (anywhere with security and metal detectors).
(2) Safety planning.

(3) Trust your intuition and recognize where trauma is triggering you
d) Get social support.
e) Consult: with colleagues, experts, the Oregon Attorney Assistance Program.
i) Low impact debriefing
4) How to take care of yourself.

a) Recognize that it is a wonderful and amazing part of being human that allows us to be
affected by those around us.
i) The ability to be vicariously traumatized means our brains are working.
ii) Vicarious resilience!
b) Self-care
i) Healthy work habits (eating lunch, getting outside, exercising, grabbing coffee with a
friend, and checking in with yourself regularly).
ii) Use Self-Care Inventory as an aspirational checklist.
c) Trauma, even if it’s not objectively life or death situation, your body believes it is.
d) Recognize that in times of personal stress, we have much less ability to respond to
professionally challenging situations with equanimity.
e) Call the OAAP for help, (503)226-1057. We have Attorney Counselors available 24
hours a day, 7 days a week, 365 days a year.
Crisis Situations
D Mental Health First Aid: Many of us have been trained in providing first aid. First aid is
the help given to an injured person before/until medical treatment can be obtained. In
2001, Australians Betty Kitchener and Anthony Jorm developed the concept of Mental
Health First Aid. Mental Health First Aid is the help offered to a person developing a
mental health condition or experiencing a mental health crisis until appropriate
professional treatment and support are received or until the crisis resolves.
L Many people with mental health conditions do not seek help or delay in seeking help.
LL In the United States, only 41 % of the people who had a mental disorder in the past
year received professional health care or other services.
LLL Half the people who seek help for depression delay seeking help for 8 years or more.
LY Individuals with mental health challenges frequently do not seek professional
assistance/treatment for a variety of reasons.
The stigma still associated with mental conditions.
People with mental health conditions may not have the insight that they need help
or may be unaware that effective help is available.
Lack of access to professional mental health services.
E The aims of Mental Health First Aid
L Preserve life when a person may be in danger to self or others.
LL Provide help to prevent the condition from becoming more serious.
LLL Promote and enhance recovery.
LY Provide comfort and support

F 7KH0HQWDO+HDOWK)LUVW$LG$FWLRQ3ODQ
i) Action A: Assess for the risk of suicide or harm
ii) Action L: Listen nonjudgmentally
iii) Action G: Give reassurance and information
iv) Action E: Encourage appropriate professional help
v) Action E: Encourage self-help and other support strategies
d) Assessing for the risk of suicide or self-harm
i) Warning signs:
(1) Thinking or talking about things like:
(a) Wanting to die
(b) Feeling hopeless or having no reason to live
(c) Feeling trapped or in unbearable pain
(d) Feeling like a burden to others and/or that others would be better off without
them
(2) Behaviors suggestive of suicidal intent:
(a) Talking or writing about death, dying or suicide
(b) Looking for ways to kill himself/herself (seeking access to pills, weapons or
other means)
(c) Increased use of alcohol or drugs
(d) Being anxious, agitated or reckless
(e) Sleeping too little or too much
(f) Withdrawing from usual activities
(g) Isolation from others
(h) Showing rage or talking about seeking revenge
(i) Displaying dramatic changes in mood
(3) The following warning signs demand immediate attention:
(a) Threats to hurt or kill oneself or talking about wanting to hurt or kill oneself
(b) Talking about writing about suicide or death, especially when these actions
are out of character for the person
(c) Obtaining or looking for ways to kill oneself
(d) Giving away prized possessions and other personal belongings or putting
affairs in order
e) Recommended response: You need to ask the person the following questions:
(1) Are you having thoughts of suicide? / Are you thinking about killing yourself?
(a) If the person answers yes, you need to ask these three questions:
(b) Have you decided how you would kill yourself?
(i) Have you decided when you would do it?
(ii) Have you taken any steps to secure the things you would need to carry out
your plan?
(2) Has the person been using alcohol or other drugs? A/D use can make a person
more susceptible to acting on impulse.
(3) Has the person made a suicide attempt in the past? A previous attempt is a risk
factor that a person is more likely to try again or complete suicide.
f) If possible do not leave them alone if they have a plan and a means to carry out the
plan
g) Urge the person to seek help.

h) Help the person eliminate access to firearms or other means, including unsupervised
access to medications.
i) Call the person’s doctor/therapist
j) Emergency room or 911
k) Utilize support system if possible
(1) Get information at the outset of contact about support network as part of an intake
form?
l) Call the Oregon Attorney Assistance Progam for resources: (503)226-1057
m) National Hotline: 1-800-273-TALK (8255)
(1) Toll-free number
(2) Available 24 hours a day, every day


Self-Care Inventory
How frequently do I do the following?
0 1 2 3
Never Rarely Sometimes Often
Physical Self-Care
_____ Eat regularly (e.g., breakfast, lunch, & dinner)
_____ Eat healthy foods
_____ Exercise regularly (3 times per week)
_____ Get enough sleep
_____ Preventative medical care
_____ Medical care when needed
_____ Take time off work when sick
_____ Get massages
_____ Dance, swim, walk, run, play sports, sing, or do other physical activity you enjoy
_____ Take time to be sexual
_____ Take vacations
Psychological Self-Care
_____ Decrease stress in your life
_____ Make time away from demands
_____ Write in a journal
_____ Read literature that is unrelated to work
_____ Do something at which you are not an expert or in charge
_____ Let others know different aspects of you
_____ Be curious
_____ Say no to extra responsibilities
Emotional Self Care

_____ Connect with others whose company you enjoy
_____ Stay in contact with the people that matter in your life
_____ Love yourself
_____ Laugh
_____ Cry
_____ Play with animals
_____ Play with children
_____ Identify comforting activities, objects, people, relationships, places and seek them
Spiritual Self-Care
_____ Spend time in nature
_____ Find spiritual connection or community
_____ Cherish optimism and hope
_____ Be open to not knowing
_____ Sing

_____ Pray
_____ Spend time with children
_____ Be open to inspiration
_____ Have gratitude
_____ Meditate
_____ Listen to music
_____ Engage in artistic activity
_____ Yoga
_____ Have experiences of awe
_____ Be mindful of what is happening in your body and around you
_____ Make meanings from the difficult periods
_____ Seek truth
Workplace or Professional Self-Care

_____ Take time to eat lunch
_____ Take time to connect with co-workers
_____ Make quiet time to complete tasks
_____ Identify projects or tasks that are exciting/rewarding
_____ Set limits with clients and colleagues
_____ Balance your workload so that you are not "overwhelmed"
_____ Arrange your workspace so that it is comfortable and comforting
_____ Get regular supervision and consultation
_____ Negotiate for your needs (benefits, pay raise)
_____ Have a peer support group
Adapted from “Compassion Fatigue Prevention and Resiliency,”J. Eric Gentry, PhD, LHC, and from “Risking
Connection: A Training Curriculum for Working with Survivors of Childhood Sexual Abuse,” Saakvitne, K.W., Gamble, S.,
Pearlman, L.A., Lev, B.T. (2000). Baltimore, MD: Sidran Press.

LINKS TO ADDITIONAL DISCUSSION MATERIAL

Hand Model of the Brain: https://books.google.com/books?id=gXf2aZitl9wC&pg=PA15
How You Can Use the NVC Process: http://www.nonviolentcommunication.com/pdf_files/4part_
nvc_process.pdf
Some Basic Feelings and Needs We All Have: http://www.nonviolentcommunication.com/pdf_files/
feelings_needs.pdf




Chapter 4B
The Ethics of Representing
Clients with Mental Illness
Helen Hierschbiel
Oregon State Bar
Tigard, Oregon
Contents
I. The Lawyer’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–1
II. Core Obligations of Competence, Diligence and Communication . . . . . . . . . . . . . . . 4B–3
A. RPC 1.1: Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–3
B. RPC 1.3: Diligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–3
C. RPC 1.4: Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–3
III. Managing Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–4
A. Conflicts Between Current Clients—Directly Adverse . . . . . . . . . . . . . . . . . 4B–4
B. Conflicts Between Current Clients—Material Limitation . . . . . . . . . . . . . . . . 4B–5
C. Conflicts Between Current and Former Clients . . . . . . . . . . . . . . . . . . . . . . 4B–6
IV. Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–6
V. Mandatory Reporting Obligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–8
VI. Communicating with Unrepresented Persons . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–9
VII. Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–9
Selected Oregon Rules of Professional Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4B–11
Chapter 4B—The Ethics of Representing Clients with Mental Illness
Your Law Practice: Understanding Clients with Mental Illness 4B–ii

I. The Lawyer’s Role

A. Lawyer-client relationship is one of agency, with client as principal and lawyer as
agent. Client autonomy and control of decision-making constitute core principles
of the relationship.
B. As representative of clients, lawyer may perform several functions:1
1. As advisor, provides client with informed understanding of client’s rights and
obligations and explains practical implications,
2. As advocate, zealously asserts client’s position under the rules of the
adversary system,
3. As negotiator, seeks a result advantageous to the client but consistent with
the requirements of honest dealings with others, and
4. As evaluator, examines a client’s legal affairs and reports about them to the
client or to others.
C. RPC 1.2(a) acknowledges the autonomy of the client, and tells us that a lawyer:
1. must “abide by the client’s decisions concerning the objectives of
representation,”
2. must consult with the client about how those objectives are to be pursued,
and
3. may take action that is “impliedly authorized to carry out the
representation,” but
4. some decisions are the sole province of the client, including whether to settle
a matter.
D. The traditional or “normal” lawyer-client relationship is based on the assumption
that the client, when properly advised and assisted, is capable of making
decisions about important matters.
E. RPC 1.14 recognizes that it may not be possible to maintain a normal lawyer-
client relationship when the client is under a legal disability such as minority or
incompetence.
1. The rule distinguishes between situations in which maintaining the normal
lawyer-client relationship is difficult and when it is impossible:
a. When the client’s ability to make adequately considered decisions is
diminished, the lawyer must nevertheless maintain as normal a client-
lawyer relationship as far as reasonably possible.
b. When a client’s incapacity is so severe that the client cannot act in the
client’s own interests and is at risk of substantial physical, financial or
other harm, a lawyer may take reasonably necessary protective action to
1
ABA Model Rules of Professional Conduct, Preamble [2].

protect the client, including seeking the appointment of a guardian or

conservator.
F. First, determine whether client has sufficient capacity to enter into the lawyer-
client relationship. Oregon law presumes an adult person to be competent.
Cloud v. US National Bank, 280 Or 83, 90 (1977).
1. To assess capacity, you must have a fundamental understanding of capacity
and competence. There are many different definitions and constructs for
determining capacity and they can be confusing. ABA Model Rule 1.14,
Comment [6], recommends that lawyers look to the following six factors to
assess a client’s capacity:
a. the client’s ability to articulate the reasoning leading to a decision;
b. the variability of the client’s state of mind;
c. the consistency of a decision with known long-term commitments or
values of the client;
d. the substantive fairness of the decision;
e. the irreversibility of the decision, and;
f. the ability of the client to understand the consequences, risks and finality
of a decision.
G. In taking any protective action, the lawyer should be guided by such factors as:
a. the wishes and values of the client,
b. the client’s best interests,
c. the goals of intruding into the client’s decision-making autonomy to the
least extent feasible,
d. maximizing the client’s capacities, and
e. respect for the client’s family and social connections.2
2. RPC 1.14 does not say, but clearly implies, that a client’s diminished capacity
does not permit substitution of the lawyer’s personal judgment for that of
the client.
a. At least one commentator suggests that when the client is incapable of
communicating, the lawyer can be said to no longer represent the client
“as a client,” but instead represents “the best interests of the client” and
must necessarily ascertain what those interests are.3
b. Communication with the client may be the best way to determine the
client’s desires, but with a client who cannot communicate, the lawyer
2
ABA Model Rule 1.14, Comment [5].
3
§19.3, HAZARD, G., HODES, W. AND JARVIS, P., THE LAW OF LAWYERING (4th ed. 2015).

will have to process all the clues and determine how best to proceed to
pursue the client interests.4
c. Stated another way, the lawyer must pursue the lawyer’s reasonable
view of the client’s objectives or interests as the client would define them
if able to make adequately considered decisions on the matter.5
H. Assessment of capacity does not end after creation of the lawyer-client
relationship. Instead, it should be evaluated continually throughout the
relationship.
II. Core Obligations of Competence, Diligence and Communication
A. RPC 1.1: Competence
1. A lawyer must possess the legal knowledge, skill, thoroughness and
preparation reasonably necessary for the representation.
2. Competence can be acquired during the course of the representation
through study or association with more experienced counsel.
3. Competence requires consideration of the client’s individual circumstances
and how they affect the client’s decisions.
4. Practice Tip: When representing clients with mental illness, competence may
require lawyers to develop an understanding of the fundamentals of capacity
and how the mental illness may interfere with the clients’ considered
judgment.
B. RPC 1.3 Diligence
1. A lawyer may not neglect a legal matter entrusted to the lawyer.
2. A lawyer must always act with commitment and dedication to the client’s
cause and with zeal in advocacy on the client’s behalf.6
3. Oregon courts measure neglect on a continuum and will find it only where
there has been a failure to act over time.
4. Neglect is not the same as negligence.
5. Cf. ABA Model Rule 1.3, which mandates “reasonable diligence and
promptness in representing a client.”
C. RPC 1.4 Communication
1. A lawyer must:
a. keep a client reasonably informed about the status of the matter,
b. promptly comply with reasonable requests for information,
4
Id.
5
RESTATEMENT (THIRD) THE LAW GOVERNING LAWYERS, §24(2) (2000).
6

c. explain a matter to the extent reasonably necessary to permit the client

to make informed decisions about the representation.
2. The client should be provided with enough information to participate
intelligently in decisions concerning the objectives of the representation.
3. The adequacy of communication depends in part on the kind of advice or
assistance that is involved.
a. when time allows for consideration of a settlement offer, the lawyer
should review all important provisions with the client before proceeding
to an agreement.
b. in litigation, the lawyer should explain the general strategy and chance of
success, and should consult with the client regarding tactics, but need not
describe trial or negotiation strategy in detail.
c. The lawyer should fulfill reasonable client expectations for information
consistent with the duty to act in the clients interests.7
4. Effective communication with a client with mental illness takes into
consideration the client’s developmental age, cognitive ability, emotional
and mental development, and communication skills.
5. A lawyer may delay communicating or withhold information when the client
would likely react imprudently to an immediate communication, but a lawyer
may not withhold information to serve the lawyer’s own or a third person’s
interests or convenience.8
6. Communication with a client with mental illness may require additional time,
effort, and flexibility.
7. Practice Tip: Manage clients’ expectations regarding communications by
explaining at the outset of the representation, the timelines for the case and
when you normally return phone calls and respond to email correspondence.
III. Managing Conflicts of Interest
A. Conflicts Between Current Clients—Directly Adverse
1. RPC 1.7(a) prohibits a lawyer from representing a client if the representation
will be “directly adverse” to another client of the lawyer or the lawyer’s firm.
a. A representation is directly adverse if the lawyer will be advocating for
one client in a matter against a person the lawyer represents in another
matter, even if the other matter is wholly unrelated.
7
8

2. RPC 1.7(b) allows a directly adverse representation if:

a. the lawyer reasonably believes she can provide competent and diligent
representation to each client,
b. the representation will not obligate the lawyer to contend for something
for one client that the lawyer must oppose for the other, and
c. the clients give their informed consent, confirmed in writing.
 “Informed consent” is agreement to a proposed course of conduct
after the lawyer has communicated adequate information and
explanation about the material risks of and reasonably available
alternatives to the proposed course of conduct.
 “Confirmed in writing” means a writing given by the consenting client
or a writing promptly transmitted by the lawyer confirming an oral
consent.
3. No amount of consent will alleviate a lawyer of the duty to provide
competent, diligent and independent representation to each client. Any time
a lawyer considers whether to seek client consent to a simultaneous
representation, the lawyer must first determine honestly whether the lawyer
can satisfy obligations to both clients under the circumstances.
4. Consent of clients who are incapacitated may be a legal, if not practical,
impossibility. However, continuing a representation if the court denies a
motion to withdraw will not violate the rules.9
B. Conflicts Between Current Clients—Material Limitation
1. A lawyer also may not represent a client if there is “a significant risk that the
lawyer’s representation of the client will be materially limited by the lawyer’s
responsibilities to another client, a former client, a third person, or by the
lawyer’s own interests,” unless the client gives informed consent, confirmed
in writing. RPC 1.7(a)(2).
2. This rule applies where the interests of the other client, former client or third
person are not “directly adverse,” but where there is a risk that the lawyer’s
ability to consider, recommend or carry out a course of action for the client
will be limited by the lawyer’s other responsibilities or interests.10
3. The rule is premised on the notion that a lawyer should exercise independent
professional judgment on behalf of a client. It protects against the risk that
the “pull of other loyalties will impair the quality of the lawyer’s
representation” and ensures that the range of options a lawyer develops and
9
In re Lathen, 294 Or 157 (1982).
10

presents on behalf of one client are not limited by lawyer’s responsibilities to

another client.11
4. A lawyer’s representation may also be limited by the lawyer’s own personal
interests. For example, if the client asserts the lawyer has committed
malpractice or engaged in ethical misconduct, there is a risk that the lawyer’s
interests in defending against such claims might limit the lawyer’s
independent and professional judgment in representing the client.12
5. Representation notwithstanding the material limitation is permissible if the
elements of RPC 1.7(b) are met. See discussion above.
C. Conflicts Between Current And Former Clients
1. A lawyer who has previously represented a client in a matter may not
thereafter represent another client in the same or a substantially related
matter if the interests of the current and former client are adverse, unless
both clients give their informed consent, confirmed in writing. RPC 1.9(a).
2. A lawyer whose prior law firm has represented a client in a matter may not
represent a client with adverse interests in the same or a substantially
related matter if, while at the prior firm, the lawyer acquired information
protected by RPC 1.6 that is material to the matter, unless the clients give
their informed consent, confirmed in writing. RPC 1.9(b).
3. Matters are “substantially related” for purposes of RPC 1.9 if either:
a. the lawyer’s representation of the current client will injure or
damage the former client in connection the same transaction
or legal dispute in which the lawyer previously represented
the former client (i.e., the lawyer may not attack or undercut
the work done for the former client), or
b. there is a substantial risk that confidential factual information
as would normally have been obtained in the prior
representation would materially advance the current client’s
position in the new matter.
IV. Confidentiality
A. Oregon RPC 1.6 prohibits lawyers from revealing “information relating to the
representation of a client,” which includes:
1. Information protected by the attorney-client privilege
a. Attorney-client privilege is a creature of statute (ORS 40.225). Its principal
function is to protect communications between attorney and client from
11
§12.1, HAZARD, G., HODES, W. AND JARVIS, P., THE LAW OF LAWYERING (4th ed. 2015).
12
See OSB Formal Ethics Op No 2009-182 (Client filing bar complaint against his attorney shortly before
trial does not give rise to a per se conflict of interest); In re Knappenberger, 337 Or 15 (2004)(Potential
malpractice claim does not automatically give rise to a self-interest conflict).

discovery or disclosure in litigation. The four basic requirements for a

communication to be privileged are:
 A client or someone looking to become a client
 A lawyer (or a representative of a lawyer) or someone the prospective
client reasonably believes is a lawyer
 A communication in aid of seeking or getting legal advice and
 A reasonable and continuing expectation of confidentiality.
b. The privilege applies only to the substance of communications, not to the
underlying facts communicated. Generally, the dates and general subject
matter of communications between attorney and client are not
privileged. The identity of a client is also generally not protected by the
attorney-client privilege.
c. Communications with representatives of a client may or may not be
protected by the privilege; in any event, the individual representative has
no personal privilege.
d. Practice Tip: Lawyers should take care not to allow a client representative
to discuss personal legal issues, particularly ones involving the person’s
relationship with the entity client. Conversations where that is a
possibility should be prefaced with a clarification of who the lawyer
represents and that the lawyer will not keep information confidential
from the entity client.
e. Practice Tip: Consider carefully whether a third person really needs to be
included in your conversation with the client. A third person can help
ease a client’s stress and assist a client with understanding and retaining
information you are conveying; however, the presence of a third person
during a conversation with a client can also act to waive privilege.
2. Other information that the client has requested be kept confidential or which
would be embarrassing or detrimental to the client if revealed.
a. Information learned from a third party or communications that are
outside the privilege or have lost their privilege
b. The lawyer’s observations and opinions about a client
c. Practice Tip: Don’t assume that information is not protected under RPC
1.6 just because it is available in the public record.
B. Notwithstanding the nearly absolute prohibition on disclosure, RPC 1.6 allows
disclosure in the following circumstances:
1. The client has given informed consent,
2. The disclosure is expressly permitted in the rule, or

3. The disclosure is impliedly authorized in order to carry out the

representation.
a. Note that under RPC 1.14(c), a lawyer is impliedly authorized to reveal
protected information to the extent reasonably necessary to take
protective action to protect the client’s interests.
C. The specific exceptions to the duty under RPC 1.6(b) include:
1. When the client has expressed the intention to commit a crime,
2. To prevent reasonably certain death or substantial bodily harm,
3. To secure advice about the lawyer’s own compliance with the RPCs,
4. To establish a claim or defense on behalf of the lawyer in certain, situations
5. To comply with other law or court order, or
D. Courts have uniformly held that permitted disclosures under this rule must be
narrowly tailored to meet the purpose of the exception. Accordingly, permission
to reveal the client’s intent to commit a crime, for instance, doesn’t permit the
lawyer to disclose other information about the crime that is not reasonably
calculated to prevent the commission of the crime.
E. RPC 1.6 focuses on disclosure of confidential client information. Other rules also
limit the use of information relating to the representation of a client.
1. Confidential client information cannot be used to the disadvantage of the
client unless the client gives informed consent, confirmed in writing. RPC
1.8(b).
2. RPC 1.9(c) prohibits a lawyer who has represented a client in a matter (or
who acquired confidential information while the lawyer’s firm represented
the client) from thereafter either:
a. using the information to the disadvantage of the former client except as
expressly permitted or required by the rules, unless the information has
become “generally known,” or
b. revealing the information except as the rules would permit or require.
V. Mandatory Reporting Obligation
A. ORS 419B.010 requires lawyers who have reasonable cause to believe that any
child with whom they come in contact has suffered abuse or any person they
come in contact has abused a child, to immediately report or cause a report to
be made to DHS or law enforcement.
B. ORS 124.060 requires lawyers who have reasonable cause to believe that any
person 65 years of age or older with whom they come in contact has suffered
abuse or any person with whom they come in contact has abused a person 65

years of age or older, to immediately report or cause a report to be made to DHS

or law enforcement.
C. Lawyers are exempt from the above reporting obligations if one of the following
applies:
1. The information was learned from an official report,
2. The information is subject to the attorney-client privilege, or
3. The information was communicated to the lawyer during the course of
representation and would be detrimental to the client if disclosed.
D. Practice Tip: Your duty of confidentiality will almost always trump your
mandatory reporting duty. Call the OSB General Counsel when in doubt.
VI. Communicating with Unrepresented Persons
A. Oregon RPC 4.3 provides that
1. Lawyers dealing with pro se parties should not state or imply that they are in
disinterested.
2. When the lawyer knows or reasonably should know that the pro se party
misunderstands the lawyer’s role in the matter, the lawyer must make
efforts to correct that misunderstanding.
3. Lawyers should not give legal advice to unrepresented persons, other than
the advice to secure counsel.
4. The rule applies regardless of whether the lawyer is representing a client or
the lawyer’s own interests.
B. Practice Tip: When dealing with an adverse party who is pro se and may have
mental health challenges, take care to follow up any conversation with a written
communication that clarifies your role and the substance of your conversation.
VII. Withdrawal
A. A lawyer must withdraw from representation if:
1. Continued representation will result in the lawyer violating either the rules of
professional conduct or some other law;
2. The lawyer’s physical or mental condition materially impairs the lawyer’s
ability to represent the client; or
3. The lawyer is discharged.
B. A lawyer may withdraw from representation if:
1. Withdrawal can be accomplished material adverse effect on the client
2. The client is using the lawyer’s services to engage or persist in criminal of
fraudulent conduct

3. The client insists on taking action the lawyer considers repugnant or with
which the lawyer has a fundamental disagreement;
4. The client fails to fulfill an obligation to the lawyer and the lawyer has given
the client reasonable warning of withdrawal;
5. The representation will result in an unreasonable financial burden on the
lawyer or has been rendered unreasonably difficult by the client; or
6. Other good cause for withdrawal exists.
C. When withdrawing, a lawyer must take steps to the extent reasonably
practicable to protect the client’s interests, such as:
1. Giving reasonable notice;
2. Allowing time for employment of other counsel;
3. Surrendering papers and property to which the client is entitled, and
4. Refunding unearned fees.


Selected Oregon Rules of Professional Conduct
RULE 1.1 COMPETENCE RULE 1.3 DILIGENCE

A lawyer shall provide competent A lawyer shall not neglect a legal matter
representation to a client. Competent entrusted to the lawyer.
representation requires the legal
knowledge, skill, thoroughness and RULE 1.4 COMMUNICATION
preparation reasonably necessary for the (a) A lawyer shall keep a client
representation. reasonably informed about the status of a
matter and promptly comply with
RULE 1.2 SCOPE OF REPRESENTATION AND reasonable requests for information
ALLOCATION OF AUTHORITY BETWEEN
CLIENT AND LAWYER (b) A lawyer shall explain a matter to the
extent reasonably necessary to permit the
(a) Subject to paragraphs (b) and (c), a client to make informed decisions regarding
lawyer shall abide by a client's decisions the representation.
concerning the objectives of representation
and, as required by Rule 1.4, shall consult RULE 1.6 CONFIDENTIALITY OF
with the client as to the means by which INFORMATION
they are to be pursued. A lawyer may take
such action on behalf of the client as is (a) A lawyer shall not reveal information
impliedly authorized to carry out the relating to the representation of a client
representation. A lawyer shall abide by a unless the client gives informed consent,
client's decision whether to settle a matter. the disclosure is impliedly authorized in
In a criminal case, the lawyer shall abide by order to carry out the representation or the
the client's decision, after consultation with disclosure is permitted by paragraph (b).
the lawyer, as to a plea to be entered, (b) A lawyer may reveal information
whether to waive jury trial and whether the relating to the representation of a client to
client will testify. the extent the lawyer reasonably believes
(b) A lawyer may limit the scope of the necessary:
representation if the limitation is (1) to disclose the intention of the
reasonable under the circumstances and lawyer's client to commit a crime and
the client gives informed consent. the information necessary to prevent
(c) A lawyer shall not counsel a client to the crime;
engage, or assist a client, in conduct that (2) to prevent reasonably certain
the lawyer knows is illegal or fraudulent, death or substantial bodily harm;
but a lawyer may discuss the legal
(3) to secure legal advice about the
consequences of any proposed course of
lawyer's compliance with these Rules;
conduct with a client and may counsel or
assist a client to make a good faith effort to (4) to establish a claim or defense on
determine the validity, scope, meaning or behalf of the lawyer in a controversy
application of the law. between the lawyer and the client, to

establish a defense to a criminal charge conditional admission and in any

or civil claim against the lawyer based proceeding relating thereto.
upon conduct in which the client was
involved, or to respond to allegations in RULE 1.7 CONFLICT OF INTEREST:
any proceeding concerning the lawyer's CURRENT CLIENTS
representation of the client; (a) Except as provided in paragraph (b), a
(5) to comply with other law, court lawyer shall not represent a client if the
order, or as permitted by these Rules; or representation involves a current conflict of
interest. A current conflict of interest exists
(6) to provide the following
if:
information in discussions preliminary
to the sale of a law practice under Rule (1) the representation of one client
1.17 with respect to each client will be directly adverse to another
potentially subject to the transfer: the client;
client's identity; the identities of any (2) there is a significant risk that the
adverse parties; the nature and extent representation of one or more clients
of the legal services involved; and fee will be materially limited by the lawyer's
and payment information. A potential responsibilities to another client, a
purchasing lawyer shall have the same former client or a third person or by a
responsibilities as the selling lawyer to personal interest of the lawyer; or
preserve information relating to the
representation of such clients whether (3) the lawyer is related to another
or not the sale of the practice closes or lawyer, as parent, child, sibling, spouse
the client ultimately consents to or domestic partner, in a matter adverse
representation by the purchasing to a person whom the lawyer knows is
lawyer. represented by the other lawyer in the
same matter.
(7) to comply with the terms of a
diversion agreement, probation, (b) Notwithstanding the existence of a
conditional reinstatement or current conflict of interest under paragraph
conditional admission pursuant to BR (a), a lawyer may represent a client if:
2.10, BR 6.2, BR 8.7or Rule for (1) the lawyer reasonably believes
Admission Rule 6.15. A lawyer serving as that the lawyer will be able to provide
a monitor of another lawyer on competent and diligent representation
diversion, probation, conditional to each affected client;
reinstatement or conditional admission
(2) the representation is not
shall have the same responsibilities as
prohibited by law;
the monitored lawyer to persevere
information relating to the (3) the representation does not
representation of the monitored obligate the lawyer to contend for
lawyer’s clients, except to the extent something on behalf of one client that
reasonably necessary to carry out the the lawyer has a duty to oppose on
monitoring lawyer’s responsibilities behalf of another client; and
under the terms of the diversion,
probation, conditional reinstatement or

(4) each affected client gives (d) For purposes of this rule, matters are
informed consent, confirmed in writing. “substantially related” if (1) the lawyer’s
representation of the current client will
RULE 1.9 DUTIES TO FORMER CLIENTS injure or damage the former client in
(a) A lawyer who has formerly connection with the same transaction or
represented a client in a matter shall not legal dispute in which the lawyer previously
thereafter represent another person in the represented the former client; or (2) there
same or a substantially related matter in is a substantial risk that confidential factual
which that person's interests are materially information as would normally have been
adverse to the interests of the former client obtained in the prior representation of the
unless each affected client gives informed former client would materially advance the
consent, confirmed in writing. current client’s position in the subsequent
matter.
(b) A lawyer shall not knowingly
represent a person in the same or a ………………………………………………………………..
substantially related matter in which a firm
RULE 1.14 CLIENT WITH DIMINISHED
with which the lawyer formerly was
CAPACITY
associated had previously represented a
(a) When a client's capacity to make
client:
adequately considered decisions in
(1) whose interests are materially connection with a representation is
adverse to that person; and diminished, whether because of minority,
(2) about whom the lawyer had mental impairment or for some other
acquired information protected by Rules reason, the lawyer shall, as far as
1.6 and 1.9(c) that is material to the reasonably possible, maintain a normal
matter, unless each affected client gives client-lawyer relationship with the client.
informed consent, confirmed in writing.
(b) When the lawyer reasonably
(c) A lawyer who has formerly believes that the client has diminished
represented a client in a matter or whose capacity, is at risk of substantial physical,
present or former firm has formerly financial or other harm unless action is
represented a client in a matter shall not taken and cannot adequately act in the
thereafter: client's own interest, the lawyer may take
(1) use information relating to the reasonably necessary protective action,
representation to the disadvantage of including consulting with individuals or
the former client except as these Rules entities that have the ability to take action
would permit or require with respect to to protect the client and, in appropriate
a client, or when the information has cases, seeking the appointment of a
become generally known; or guardian ad litem, conservator or guardian.
(c) Information relating to the
(2) reveal information relating to the
representation of a client with diminished
representation except as these Rules
capacity is protected by Rule 1.6. When
would permit or require with respect to
taking protective action pursuant to
a client.
paragraph (b), the lawyer is impliedly
authorized under Rule 1.6(a) to reveal

information about the client, but only to the (1) withdrawal can be accomplished
extent reasonably necessary to protect the without material adverse effect on the
client's interests. interests of the client;
(2) the client persists in a course of action
…………………………………………………………………..
involving the lawyer's services that the
RULE 4.3 DEALING WITH UNREPRESENTED lawyer reasonably believes is criminal or
PERSONS fraudulent;
In dealing on behalf of a client or the (3) the client has used the lawyer's services
lawyer’s own interests with a person who is to perpetrate a crime or fraud;
not represented by counsel, a lawyer shall (4) the client insists upon taking action that
not state or imply that the lawyer is the lawyer considers repugnant or with
disinterested. When the lawyer knows or which the lawyer has a fundamental
reasonably should know that the disagreement;
unrepresented person misunderstands the (5) the client fails substantially to fulfill an
lawyer’s role in the matter, the lawyer shall obligation to the lawyer regarding the
make reasonable efforts to correct the lawyer's services and has been given
misunderstanding. The lawyer shall not give reasonable warning that the lawyer will
legal advice to an unrepresented person, withdraw unless the obligation is fulfilled;
other than the advice to secure counsel, if (6) the representation will result in an
the lawyer knows or reasonably should unreasonable financial burden on the
know that the interests of such a person are lawyer or has been rendered unreasonably
or have a reasonable possibility of being in difficult by the client; or
conflict with the interests of the client or (7) other good cause for withdrawal exists.
the lawyer’s own interests. (c) A lawyer must comply with applicable
law requiring notice to or permission of a
RULE 1.16 DECLINING OR TERMINATING tribunal when terminating a representation.
REPRESENTATION When ordered to do so by a tribunal, a
(a) Except as stated in paragraph (c), a lawyer shall continue representation
lawyer shall not represent a client or, where notwithstanding good cause for terminating
representation has commenced, shall the representation.
withdraw from the representation of a (d) Upon termination of representation, a
client if: lawyer shall take steps to the extent
(1) the representation will result in violation reasonably practicable to protect a client's
of the Rules of Professional Conduct or interests, such as giving reasonable notice
other law; to the client, allowing time for employment
(2) the lawyer's physical or mental of other counsel, surrendering papers and
condition materially impairs the lawyer's property to which the client is entitled and
ability to represent the client; or refunding any advance payment of fee or
(3) the lawyer is discharged. expense that has not been earned or
(b) Except as stated in paragraph (c), a incurred. The lawyer may retain papers,
lawyer may withdraw from representing a personal property and money of the client
client if: to the extent permitted by other law.



Chapter 5
Attorney Resources
Michele Veenker
Executive Director
National Alliance on Mental Illness Clackamas County (NAMI-CC)
Clackamas, Oregon
Maeve Connor
Peer Support and Development Director
National Alliance on Mental Illness Clackamas County (NAMI-CC)
Clackamas, Oregon
Contents
Resources for Clients and Attorneys—Presentation Slides . . . . . . . . . . . . . . . . . . . . . . . . 5–1
NAMI Southwest Washington Tips to Interacting with Mental Health Consumers in Crisis . . . . . 5–7
Verbal Deescalation Techniques (Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–9
Verbal Deescalation of the Agitated Patient (Child) . . . . . . . . . . . . . . . . . . . . . . . . . . . .5–13
Clackamas County Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5–15
Washington County Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–17
Yamhill County Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5–19
Chapter 5—Attorney Resources

Resources for Clients and Attorneys
Michele Veenker
Executive Director
NAMI Clackamas
Maeve Connor
Peer Support and Development Director
NAMI Clackamas
What prevents people from getting

the help they need?
 Housing
 Lack of affordable housing
 Not enough transitional housing
 No housing for people on private
insurance
 Health care
 No access to health care
 Wait times for mental health treatment
 Lack of culturally-competent services
 Not enough rural services
 Insufficient number of beds in psychiatric hospital
 Mental health parity ~ it does not exist

What prevents people from getting

the help they need?
 Quality of care
 Not enough capacity for medication assisted treatment
 Lack of trauma-informed practices
 Bad experiences in treatment
 Not enough culturally competent providers
 Personal
 Not enough knowledge about mental illness
 Agnosia
 Stigma and denial
 Medication side effect
What if you’re worried someone

might kill themselves?
 Ask directly: “Are you thinking about killing yourself?”
 Ask, “Do you have a plan?”
 You can call the National Suicide Prevention Lifeline to
ask for advice.
 If you need to call 911, request crisis intervention
trained officers. Don’t assume they will send one just
because you explain it’s a mental health crisis.

Resources for clients

 National Suicide Prevention Lifeline 1-800-273-8255
 Teen Line 1-877-553-TEEN Or text: teen2teen at 839863
 Walk-in crisis clinics
 Multnomah County: Cascadia’s Urgent Walk-In Clinic
4212 SE Division, Suite 100, Portland, OR 97206
 Clackamas County: Centerstone
11211 SE 82nd Ave, Suite O, Happy Valley, OR 97086
 NAMI Affiliates: Find your local NAMI affiliate at
namior.org
 ARC Oregon Special Needs Pooled Trust 503-581-2726
Resources for additional training

 ASIST (Applied Suicide Intervention Skills Training)
 Adult Mental Health First Aid
 Youth Mental Health First Aid
 QPR (Question, Persuade, Refer)
All of these trainings are offered for free. Sign

up at gettrainedtohelp.com

Mental health for attorneys

“Just Like Someone Without Mental Illness Only More So”
Mark Vonnegut, M.D.
 Lawyers are 3.6 times more likely to be depressed than
non-lawyers.
 Lawyers rank fourth in proportion of suicide by
profession.
 Lawyers in public-service jobs who made the least
money, like public defenders or Legal Aid attorneys,
were most likely to report being happy.
 Lawyers in public-service jobs also drank less alcohol
than their higher-income peers. Despite the large gap
in affluence, the two groups reported about equal
overall satisfaction with their lives.
Resources for attorneys

 Oregon Attorney Assistance Program: 503-226-1057
oaap.org
 National Helpline for Lawyers: 866-LAW-LAPS
(866-529-5277)
 National Helpline for Judges Helping Judges:
800-219-6474
 International Lawyers in Alcoholics Anonymous
(ILAA): ilaa.org

Questions?
To find our more:
NAMI www.nami.org
NAMI Oregon www.namior.org
NAMI Clackamas www.namicc.org




Verbal De-Escalation Techniques ~ Adult

For Defusing or Talking Down an Explosive Situation
When a potentially violent situation threatens to erupt on the spot and no weapon is present, verbal de-escalation is
appropriate.
There are two important concepts to keep in mind:
Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of
arousal so that discussion becomes possible.
De-escalation techniques are abnormal. We are driven to fight, flight or freeze when scared. However, in de-escalation,
we can do none of these. We must appear centered and calm even when we are frightened. Therefore these techniques
must be practiced before they are needed so that they can become "second nature.”
THERE ARE 3 PARTS TO BE MASTERED IN VERBAL DE-ESCALATION
A. The Worker in Control of Him/Her Self
Appear calm, centered and self-assured even though you don’t feel it. Relax facial muscles and look confident. Your
anxiety can make the client feel anxious and unsafe and that can escalate aggression.
Use a modulated, low monotonous tone of voice (our normal tendency is to have a high pitched, tight voice when
scared).
If you have time, remove necktie, scarf, hanging jewelry, religious or political symbols before you see the client (not in
front of him/her).
Do not be defensive-even if the comments or insults are directed at you, they are not about you. Do not defend yourself
or anyone else from insults, curses or misconceptions about their roles.
Be aware of any resources available for back up. Know that you have the choice to leave, tell the client to leave or call
the police should de-escalation not be effective.
Be very respectful even when firmly setting limits or calling for help. The agitated individual is very sensitive to feeling
shamed and disrespected. We want him/her to know that it is not necessary to show us that they must be respected.
We automatically treat them with dignity and respect.
B. The Physical Stance
Never turn your back for any reason.
Always be at the same eye level. Encourage the client to be seated, but if he/she needs to stand, you stand up also.
Allow extra physical space between you – about four times your usual distance. Anger and agitation fill the extra space
between you and your client.
Do not stand full front to client. Stand at an angle so you can sidestep away if needed.
Do not maintain constant eye contact. Allow the client to break his/her gaze and look away.
Do not point or shake your finger.

DO NOT smile. This could look like mockery or anxiety.
Do not touch – even if some touching is generally culturally appropriate and usual in your setting. Cognitive dysfunction
in agitated people allow for easy misinterpretation of physical contact as hostile or threatening.
Keep hands out of your pockets, up and available to protect yourself. It also demonstrates non-verbal ally, that you do
not have a concealed weapon.
Do not argue or try to convince, give choices i.e. empower.
Don’t be defensive or judgmental.
Don’t be parental, join the resistance: You have a right to feel angry.
C. The De-Escalation Discussion
Remember that there is no content except trying to calmly bring the level of arousal down to baseline.
Do not get loud or try to yell over a screaming person. Wait until he/she takes a breath; then talk. Speak calmly at an
average volume.
Respond selectively; answer all informational questions no matter how rudely asked, (e.g. "Why do I have to fill out
these g-d forms?” This is a real information-seeking question). DO NOT answer abusive questions (e.g. "Why are all
social workers ___ ?) This question should get no response what so ever.
Explain limits and rules in an authoritative, firm, but always respectful tone. Give choices where possible in which both
alternatives are safe ones (e.g. Would you like to continue our meeting calmly or would you prefer to stop now and
come back tomorrow when things can be more relaxed?)
Empathize with feelings but not with the behavior (e.g. "I understand that you have every right to feel angry, but it is not
okay for you to threaten me or my staff.)
Do not solicit how a person is feeling or interpret feelings in an analytic way.
Do not argue or try to convince.
Wherever possible, tap into the client’s cognitive mode: DO NOT ask "Tell me how you feel. But: Help me to understand
what your are saying to me” People are not attacking you while they are teaching you what they want you to know.
Suggest alternative behaviors where appropriate e.g. "Would you like to take a break and have a cup of coffee (tepid
and in a paper cup) or some water?
Give the consequences of inappropriate behavior without threats or anger.
Represent external controls as institutional rather than personal.
Trust your instincts. If you assess or feel that de-escalation is not working, STOP! You will know within 2 or 3 minutes if
it’s beginning to work. Tell the person to leave, escort him/her to the door, call for help or leave yourself and call the
police.
There is nothing magic about talking someone down. You are transferring your sense of calms and genuine interest in
what the client wants to tell you, and of respectful, clear limit setting in the hope that the client actually wishes to

respond positively to your respectful attention. Do not be a hero and do not try de-escalation when a person has a gun.
In that case, simply comply.
This document was developed by: Eva Skolnik-Acker, LICSW, evaskolnikacker@comcast.net.


Verbal De-escalation of the Agitated Patient (Child) -

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298202/
This article is for teaching psychiatrists how to calm an agitated patient in a hospital who needs
immediate intervention, but these same steps can work with children! The article is dense, so
I’ve boiled down the basic techniques. Note: ÆAgitation exists on a continuum, e.g., from
anxiety to high anxiety, to agitation, to aggression. The agitated child may be unable to engage
in any conversation, and may be on the edge of new or repeated violence, requiring vastly
different management than a child who may be willing and able to engage.
Main objectives:
x Safety first: ensure the safety of your child, you, and others;
x Help your child manage his/her emotions and distress, and maintain or regain
control of his/her behavior;
x Avoid the use of restraint when at all possible (closing up in a room, blocking
escape);
x Avoid coercive interventions that escalate agitation (punitive actions or threats
of punishment)
1. Respect personal space - Maintain at least 2 arm's lengths of distance

between you and a very agitated child. Ideally, the child and parent should be able
to exit the room without feeling that the other is blocking his way.
2. Do not be provocative - The parent must demonstrate by body language that

he/she will not harm the child, that they want to listen and want everyone to be safe.
Hands should be visible and not clenched. Avoid concealed hands. Knees should be
slightly bent. Avoid directly facing the agitated child and stand at an angle to the child
so as not to appear confrontational. A calm demeanor and facial expression are
important. Excessive, direct eye contact, especially staring, can be interpreted as an
aggressive act. Closed body language, such as arm folding or turning away, can
communicate lack of interest. It is most important that the parent’s body language be
congruent with what they is saying. If not, the child will sense that the parent is
insincere or even “faking it” and may become more agitated and angry.
3. Establish verbal contact – only one person interacts with the child at a time!
Multiple people verbally interacting can confuse the child and result in further
escalation. It’s OK if another family member stands by quietly/calmly in case things
become unsafe.
4. Be polite and respectful, and provide orientation – Explain you are only
concerned about safety, and reassure them they are not in trouble and nothing will
happen. Explain that you just want to ensure their stress is reduced, and that nothing
needs to be discussed or dealt with now.
5. Be concise and keep it simple - agitated children are often impaired in their
ability to process verbal information. Use short sentences and simple vocabulary--
more complex verbalizations can increase confusion and can lead to escalation.
Give your child time to process what has been said, and to respond when they are
able. You may need to gently/calmly repeat yourself using the same straightforward
language, stick to the basics: “I hear you and clearly understand that you’re

upset. Right now, it’s just about calming down and being safe, nothing else is going
to happen.”
6. Identify wants and feelings. Your child may just want to vent uncontrollable
feelings. This may include ugly and offensive language. Remember your body
language and remain calm and nonconfrontational and allow them time to release
the emotional pressure. It’s not about you and your feelings.
7. Read between the lines. Listen closely to what your child is really saying and
assume it’s true for them. Your child will say things and make references that you
can use to reduce stress: “It’s too loud… it’s too cold… I hate these clothes… I hate
your rules… I hate this food…” Repeat back to them what they said or paraphrase
so they know you heard. Immediately fix as many of their problems as possible (not
all are possible). Immediate response can rapidly deescalate a child.
8. Agree, or agree to disagree. Agreement options:

x Agree with the truth. The reason for their agitation may be perfectly
legitimate.
x Agreeing in principle. Their intentions may be perfectly legitimate.
x Agree with the odds. Their concerns about prior bad experience may be
perfectly legitimate.
x
9. Set boundaries and clear limits, and do so respectfully. Again using simple
concise sentences, let your child know what behaviors are acceptable—this is not
about their “attitude” or “opinion” or character, just their behavior. Remember, de-
escalation is about safety, calmness, and wellbeing.
10. Coach your child how to stay in control. They are ready to fight or take flight
and need help getting out of this mindset. Example: “I really want you to sit down;
when you pace, I feel frightened, and I can't pay full attention to what you are saying.
I bet you could help me understand if you were to calmly tell me your concerns.”
11. Offer choices and options. For the child who feels there’s nothing left but to
fight or take flight, offering a choice can be a powerful and empowering tool. Ask
what they want to help them, or offer something as a kindness: food, a blanket,
music of their choice…

Service Clackamas County Phone

CRISIS CENTER:
SUICIDE PREVENTION CENTER: National Suicide Hotline (local Lines for Life) 1-800-273-8255
1-877-553-TEEN
Or text: teen2teen at
TEEN LINE: 839863
503-655-8600 and
503-654-2288 / 1-
888-654-2288 (24-
RAPE/SEXUAL ASSUALT: A Safe Place & Clackamas Women’s Services hour hotline)
DOMESTIC VIOLENCE HOTLINE: A Safe Place & Clackamas Women’s Services See above
SEXUAL ABUSE HOTLINE: SARC (503) 640-5311
CHILD ABUSE HOTLINE: Clackamas County Child Abuse Hotline (971) 673-7112
POLICE: 911
PARAMEDIC EMERGENCY MEDICAL SERVICES UNIT: 911
MENTAL HEALTH CRISIS/RESPONSE: Centerstone and Lines for Life (503) 655-8585
HOSPITAL EMERGENCY SERVICES: 911
EMERGENCY SHELTERS: 211 Referral Services 211 or 211info.org
YOUTH SHELTER: 211 Referral Services 211 or 211info.org
MENTAL HEALTH OUTREACH CLINIC: Centerstone (503) 655-8585
CHILDREN/YOUTH PSYCHIATRIC CLINIC:
PRIVATE PRACTITIONERS:
MEDICAL CLINIC/GENERAL PRACTITIONER:
STD INFORMATION AND TESTING STIES: Clackamas County Health Centers (503) 655-8471
CHILDREN'S SERVICES OFFICES:
STUDENT SERVICES:
CHILD CARE REFERRALS:
PARENT TRAINING:
FAMILY SUPPORT SERVICES: 211 Information & Referral 211 or 211info.org
National Alliance for Mental Illness
MENTAL HEALTH FAMILY SUPPORT SERVICES: Clackamas (NAMI Clackamas) (503) 344-5050
MENTAL HEALTH SELF HELP: NAMI Clackamas (503) 344-5050
SUBSTANCE ABUSE COUNSELING: Oregon Lines for Life Drug/Alcohol Helpline (800) 923-4357
ALCOHOLICS ANONYMOUS: www.aa.org
MENTAL HEALTH SERVICES ~ Non Crisis Clackamas County Mental Health (503) 742-5335
LEGAL ASSISTANCE/VICTIM-WITNESS ASSISTANCE:
COMMUNITY CORRECTIONS OFFICERS:
OTHER: GLBTQ Support Trevor Project GLBTQ Support 1-866-488-7386
OTHER: Housing Coordinated Housing Access (503) 655-8575
OTHER: Homeless Services ~ Clothing, meals, showers A Father’s Heart (503) 722-9780
OTHER: Dual Diagnosis Anonymous (503) 222-6484
ASIST T4T Helpers in Your Community SN2006 04/16/13 c LivingWorks Education


Helpers in Your Community: Is the helper able, available and acceptable?

CRISIS (DISTRESS) CENTER: (24/7)Washington County Crisis Line 503-291-9111, Multnomah County Crisis Line: 503.988.4888
TEEN LINE: 1-877-553-TEEN Or text: teen2teen at 839863
RAPE/SEXUAL ASSAULT CENTER: SARC 503-640-5311, Portland Women's Crisis Line 503-235-5333
DOMESTIC VIOLENCE HOTLINE: 1-800-469-8600
SEXUAL ABUSE HOTLINE: Washington Co 503-681-6917, Multnomah Co 503.731.3100
CHILD ABUSE HOTLINE: Washington Co 503-681-6917, Multnomah Co 503.731.3100
POLICE: 911 Mental Health Response Team (MHRT): Not 24/7 but can request when you call 911
MENTAL HEALTH CRISIS / RESPONSE: Washington Co Crisis Line 503-291-9111, Multnomah Co Crisis Line: 503.988.4888
EMERGENCY SHELTERS: Info and Referral 503-222-5555
YOUTH SHELTER: Info and Referral 503-222-5555
MENTAL HEALTH OUTREACH CLINIC:
MEDICAL CLINIC / GENERAL PRACTITIONER:
STD INFORMATION AND TESTING SITES: Wash Co Health Clinics 503-846-8851, Mult Co Health Clinics 503.988.5558
CHILDREN’S SERVICES OFFICES: call 211 (or on the web: 211info.org)
STUDENT SERVICES:
CHILD CARE REFERRALS: 971-223-6100
PARENT TRAINING: www.co.washington.or.us/HHS/CCF or call 211 (or on the web: 211info.org)
FAMILY SUPPORT SERVICES: call 211 (or on the web: 211info.org)
SELF HELP GROUPS:
SUBSTANCE ABUSE COUNSELING: Oregon Lines for Life Drug/Alcohol Helpline (800) 923-4357
ALCOHOLICS ANONYMOUS: 503-223-8569
MENTAL HEALTH SERVICES: Wash Co Mental Health Access Line 503-291-1155, Multnomah Co Crisis Line: 503.988.4888
RELIGIOUS/SPIRITUAL SUPPORT:
LEGAL ASSISTANCE/VICTIM-WITNESS ASSISTANCE: Legal Aid 503-648-7163 or Victim's Services 503-846-8671
COMMUNITY CORRECTIONS OFFICERS: Adult 503-846-3400 Juvenile Department 503-846-8861
Other: National Alliance for Mental Illness 503-356-6835 Other: Military Helpline 888-457-4838 (Lines for Life)
Other: Trevor Project LGBTQ Support 1-866-488-7386 Other: Oregon Military Assistance 800.511.6944
Other: Gambling HelpLine 877-695-4648 (24/7 Hotline) Other: Resource Info! Call 211, or on the web: 211info.org
ASIST T4T Helpers in Your Community SN2006 04/16/13 © LivingWorks Education


Helpers in Your Community: Is the helper able, available and acceptable?

CRISIS (DISTRESS) CENTER: Yamhill County Mental Health Crisis Line 1-800-560-5535
TEEN LINE: 1-877-553-TEEN Text Option: Text teen2teen at 839863
RAPE/SEXUAL ASSAULT CENTER: 503-640-5311 (Portland)
DOMESTIC VIOLENCE HOTLINE: Henderson House 503-472-1503
SEXUAL ABUSE HOTLINE: 503-681-6917 (Portland)
CHILD ABUSE HOTLINE: 1-800-854-3508
POLICE: 911
MENTAL HEALTH CRISIS / RESPONSE: Yamhill County Mental Health Crisis Line 1-800-560-5535
EMERGENCY SHELTERS:
YOUTH SHELTER: Youth Outreach 503-538-8023
MENTAL HEALTH OUTREACH CLINIC:
MEDICAL CLINIC / GENERAL PRACTITIONER:
STD INFORMATION AND TESTING SITES: Newberg Public Health Clinic 503-554-7842
CHILDREN’S SERVICES OFFICES: Love Inc. 503-537-3999
STUDENT SERVICES:
CHILD CARE REFERRALS: Childcare Resource and Referral 1-800-289-5533
PARENT TRAINING: 211 for Parenting Support Line
FAMILY SUPPORT SERVICES: 211
SELF HELP GROUPS:
SUBSTANCE ABUSE COUNSELING: Oregon Lines for Life Youthline 1-877-553-TEEN
ALCOHOLICS ANONYMOUS: Yamhill County Annex for more info 503-434-7527
MENTAL HEALTH SERVICES: Yamhill County Mental Health 503-434-7462
RELIGIOUS/SPIRITUAL SUPPORT:
LEGAL ASSISTANCE/VICTIM-WITNESS ASSISTANCE: Legal Aid 503-648-7163 or Victim's Services 503-846-3020
COMMUNITY CORRECTIONS OFFICERS: Adult 503-434-7513 Juvenile Department 503-434-7512
Other: National Alliance for Mental Illness 1-800-343-6264 Other:
Other: Trevor Project GLBTQ Support 1-866-488-7386 Other:
Other: Other:
ASIST T4T Helpers in Your Community SN2006 04/16/13 © LivingWorks Education


CMI15 Handbook

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Your Law Practice:

Understanding Clients with

5.75 General CLE credits and

OREGON STATE BAR

Your Law Practice: Understanding Clients with Mental Illness ii

1. We All Know Someone . . . So What Exactly Is Mental Illness? . . . . . . . . . . . . . . . . 1–i

2. Teaching Materials from NAMI Family to Family Class 8: Communication Skills

3B. Involuntary Civil Commitment Hearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3B–i

3C. Investigator’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3C–i

4A. Representing Clients Affected by Mental Health Challenges . . . . . . . . . . . . . . . . 4A–i

4B. The Ethics of Representing Clients with Mental Illness . . . . . . . . . . . . . . . . . . . .4B–i

5. Attorney Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–i

Your Law Practice: Understanding Clients with Mental Illness iii

8:45 We All Know Someone . . . So What Exactly Is Mental Illness?

10:00 In Their Own Voices: Mental Illness from the Inside

1:00 Mental Health and the Law

2:45 Legal Ethics When Representing Individuals with Mental Illness

3:45 Attorney Resources

Your Law Practice: Understanding Clients with Mental Illness vi

Adam Davis, Family to Family Health Information Center, Portland.

Your Law Practice: Understanding Clients with Mental Illness viii

Your Law Practice: Understanding Clients with Mental Illness 1–ii

National Alliance on Mental Illness

Depression and Bipolar Support Alliance

National Institute of Mental Health

American Psychiatric Association

Your Law Practice: Understanding Clients with Mental Illness 1–1

American Psychological Association

Western Psychological & Counseling Services

Your Law Practice: Understanding Clients with Mental Illness 1–2

Joe Hromco, Ph.D.

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–3

Why does this matter to an

Joe Hromco, Ph.D. Western Psychological &

What is “mental illness”?

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–4

Mental illnesses tend to be…

 Different terms: Conditions, illnesses,

Joe Hromco, Ph.D. Western Psychological &

Mental Health Conditions

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–5

Joe Hromco, Ph.D. Western Psychological &

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–6

Joe Hromco, Ph.D. Western Psychological &

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–7

Joe Hromco, Ph.D. Western Psychological &

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–8

Joe Hromco, Ph.D. Western Psychological &

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–9

Joe Hromco, Ph.D. Western Psychological &

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–10

ADHD prevalence estimates as a function of year of study publication.

Guilherme V Polanczyk et al. Int. J. Epidemiol. 2014;43:434-

Joe Hromco, Ph.D. Western Psychological &

Your Law Practice: Understanding Clients with Mental Illness 1–11

Borderline Personality Disorder

1. We All Know Someone . . . So What Exactly Is Mental Illness? . . . . . . . . . . . . . . . . 1–i

(fold)

(fold)