Understanding Mental Illness

A Review of the Disorders

 Defining Mental Illness

Clinical definition :
• Clinically significant behavioral problems
• Associated with distress (painful symptoms)
• Causes disability (impairment in functioning)
• A biological illness that responds to treatment
• Not to be confused with weakness of character
 Facts about Mental Illness
 Has nothing to do with Mentally ill are not all
intelligence dangerous
Can happen to anyone Should not be confused
Chronic but not contagious with terms psychopath or
Difficult to diagnose and sociopath
to treat
Treated but not cured
 General Signs of Mental Illness
• Observable • Behavior Changes
• Confusion • Flat Affect
• Disoriented • Withdrawn
• Darting looks • Sad or anxious mood
• Talking to self • Panic
• Poverty of Speech • Psycho somatic complaints
• Pressured speech
• Poor hygiene
• Inappropriate attire
 Schizophrenia
Symptoms
• Brain disease
• Includes psychosis
• Impacts 1 out of every 100 people. Does
not differentiate across SES
• Onset is late teens, early adulthood.
• Positive Symptoms include :
– hallucinations
– delusional thinking
• Negative symptoms include
– apathy
– withdrawal.
 Schizophrenia
Symptoms in Jail
 May appear non compliant
 Agitated by voices and delusions -may look and act dangerous
 Command hallucinations may actually be dangerous
 More likely to respond to clear directions, and reassurance in a kind tone of voice
 Poor hygiene - Not aware of their surroundings enough to know that they are
not clean
 Mood Disorders
Major Depression
Symptoms
• Affects 5 percent of the general population
• Sad mood that lasts 2 weeks
• Loss of interest or pleasure in daily activities
• Changes in sleep, appetite, decreased energy
• Thought problems affect concentration, memory, decisions, feelings of
guilt, worthlessness
• Risk of suicide is high
• Important to differentiate mental health from
physical problems
• Responds well to treatment
 Mood Disorders
Major Depression
Symptoms in Jail
Loss of interest in food and self care
May not care about legal situation
Suicide risk is real and must be monitored
Risk of suicide may increase after medication
 Mood Disorders
Mania/ Bipolar Disorder
Symptoms
 Euphoric Mood (elevated, high or happy)
 Irritable Mood (touchy)
 Three Stages of Mania Hypomania, Acute Mania, Psychosis

 Bipolar Disorder - mood swings from depression

to mania
 Can be Rapid Cycling
 Mood Disorders
Mania/ Bipolar Disorder
Symptoms in jail
Jail may be the consequence of the disorder
Jail
Mood can swing from entertaining to hostile
Mood
Talkativeness can be irritating
Talkativeness
If depressed, often cry, feel hopeless, become suicidal
If
Can be restless, pacing, demanding and destructive
Can
Often non-compliant
Often
Can be professional and well-educated
Can
 Anxiety Disorders
Panic Disorders
Symptoms
 Prevalence is 1 to 2 percent of the population; Women twice as high as men.
 Panic attacks occur without warning
 Symptoms include intense fear, heart palpitations,chest pain,
shortness of breath, dizziness
 Person is concerned that the attacks will strike again

Symptoms in Jail
 Jail environment and structure of holding can
induce symptoms
 Referral is indicated
 Anxiety Disorders
Obsessive-Compulsive Disorder
Symptoms
 Obsessions are recurrent thoughts, images, impulses that cause anxiety.
They are illogical,at times repulsive and/or center on violence or harm.

Compulsions
Compulsions are behaviors that are repetitive - attempts at reducing the
anxiety created by the obsessions.

Symptoms in Jail
Rarely
Rarely seen in jail and do not pose high risk
 Post Traumatic Stress Disorder
Symptoms
Exposure to an extremely stressful event.
Exposure
Painful memories, nightmares,, suspicion, anxiety, depression, feelings of
Painful
guilt and sleep difficulties
Symptoms worsen with exposure to similar events
Symptoms
Substance abuse is a common method to cope
Substance
Symptoms in Jail
Jail environment can trigger symptoms
Jail
Jail inmates and personnel can trigger symptoms
Jail
Lack of privacy and loss of control are issues
Lack
 Personality Disorders
 Inflexible, maladaptive, ways of  Antisocial
coping and relating
Narcissistic
Difficulty in holding steady work
and relationships Borderline
Difficult to change Avoidant
Can co -exist with other mental Paranoid
illnesses
Behavior problems
Dependent
precipitate jail Schizotypal
Schizoid
 Personality Disorders
 Predominant disorders in jail are Antisocial
and Borderline
Jail environment heightens symptoms
Effective management requires consistent
limit-setting
Suicidal risk is real and must be monitored
Jail personnel must professionally manage
housing unit, inmates and themselves
 Substance Abuse
Symptoms
 85% of jail population have substance abuse problems
High
High correlation of substance abuse and other mental illnesses
Symptoms in Jail
• Monitor risk of OD or withdrawal
• Monitor abuse of prescription drugs
• Can mimic other Mental illnesses
• Long term abuse can cause dementia
 Co-occurring Disorders

 Presence of both a mental illness and substance abuse disorder

High prevalence rates
60% of persons with a mood disorder also have a substance abuse
disorder
50% of persons with schizophrenia also have a substance abuse
disorder
In Jail - More prone to violence, impulsivity, paranoia and anxiety
Common Factors of Mental Illness and
Substance Abuse
Brain disorders
Lack of Insight
Chronic
Impacts Family
Shame and guilt
Needs Treatment
Dementia and other Cognitive Disorders
Symptoms
• Memory problems
• Confabulations
• Impaired thinking
• Impaired Judgement

Symptoms in Jail
• Poor memory and may not follow directions
• Treat individual as you would any with a disability
 Mental Retardation
Symptoms
 Poor adaptive functioning from birth
Related to intelligence, not thoughts, feelings and behaviors

Symptoms in Jail
 Not to be confused with mental illness
Requires patience
Effective Communication
 Keys to Communication
Empathy

Warmth

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



Low
Don’t stimulation
take actions level
or reactions personally

 Short,
Don’t
Simple
Be clear
consistent
force direct
content sentences
communication
Basic Communication Guidelines
Simple content
Short, clear direct sentences

Low stimulation level

Don’t force communication
Be consistent
Don’t take actions or reactions personally

Basic Communication Guidelines

 Praise
Practice
Person
Know
Be
 cooperative
may
your
patient reflective
not “get”
non listening
verbalbehavior
all the information
communication
 Basic Communication Guidelines
Person may not “get” all the information

Be patient

Praise cooperative behavior

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

Body Posture
Facial Expression
Eye Contact
Gestures
Crisis Management
 Crisis Management
Crisis defined

What is crisis intervention

Recognizing a person in
crisis – behavioral
and verbal cues
 Violence
The incidence of violence Substance use greatly
is no greater in persons increases violence
with mental illness than it Greatest risk, males in late
is in the general population teens to early 20’s
Incidence increases 60% if Past behavior best
the illness is untreated. predictor
 Warning Signs
Tremors
Hyperactivity
Rigid Posture
Clenched jaws and fists
Pulsing arteries
Verbal abuse/profanity
 Effective Crisis Intervention
 Reduce Stress

Force
Force as the last resort

Consider
Consider the symptoms of mental illness

Identify
Identify precipitating factors

Goal
Goal is to de-escalate
 5 Stages of Successful Interventions
 Immediacy- Intervene as Assess the situation- let the
soon as possible. Goal is to person talk, watch for
reduce anxiety. nonverbal cues, be a guide
Assume Control - via and avoid judgements and
providing the structure the putdowns
person needs, not be Situation Management
overwhelming them Post crisis intervention
 5 Stages of Successful Interventions
Immediacy- Intervene as Assess the situation- let the
soon as possible. Goal is to person talk, watch for
reduce anxiety. nonverbal cues, be a guide
Assume Control - via and avoid judgements and
providing the structure the putdowns
person needs, not be Situation Management
overwhelming them Post crisis intervention
Suicide and Suicide Prevention
 Facts about Suicide
Jail suicide is 9 times higher than general pop.
Jail
8 of 10 have given prior warnings
8
Ambivalent about death
Ambivalent
Ambivalence is not the same as manipulation
Ambivalence
Most jail suicides are not impulsive
Most
Risk does not increase with discussion
Risk
 Facts about Suicide
Prior attempts increases risk by 33%
Mental illness increases the risks -
61% have major depression
48% have personality disorder
40% Alcohol use
10% Anxiety
6% Schizophrenia

Understanding SI behavior increases prevention!

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

Ambivalence
Ideation
Lethality
Attempt
Gesture
 Evaluation Tool
The Sad Persons Scale

 Previous Attempts
 Sex
Ethanol
Age Rational Thinking Loss
Social Support Losses
Depression Organized Plan
No Spouse
Sickness
Why Do People Die by Suicide?
Impulsive
Depressed
Escape from suffering
Communication
Loss of a loved one
 Understanding Suicidal Thinking
 Suicide is a solution to a problem, what is the problem ?
Most suicides are acts to end intolerable feelings
Coping Patterns Fail
“Tunnel Vision” interferes with seeing alternatives
Person feels “unheard”
Ambivalence
Recognizing Suicidal Risk In Jail

◆Psychological Factors

◆Social Risk Factors

◆Behavioral Warning Signs

Special Features of Jail Suicide Risk
 Legal Status Factors

Time of the year

Long Term Factors

 Intervening
Create a safe Evaluate potential
environment Refer for treatment
Only one person Do not lie
communicate
Talk about plan
Emphasize positives
 Prevention
Admission Screening
Utilize a formal screening worksheet
Develop tiered assessments - intake,
supervisor, mental health professional referral
Observe for risk factors, even after intake
Assure treatment
Collaboration and The Team
Approach
 Shared Goals
Diversion of inmates from jail to appropriate
community care
Assure adequate mental health care while
incarcerated
Assure Continuity of Care for those inmates at the
time of their release.
 Steps to Meeting Shared Goals
 Screening and Provision of emergency
identification mental health services
EvaluationClassification Assure care
Diversion Supervision
Crisis Prevention Suicide Prevention
Pre release planning
 Team Approach Options
 Employ Mental Health Staff
Formal Contractual Agreements with Providers
Informal Agreements (MOA)
 Characteristics of a good Working
System
 Shared Vision, mission and values
Involvement of all stakeholders
Established written documentation
Formal and informal verbal communications
Ongoing Commitment
 Formal Agreements
 Purpose
Range of Services
Time Frame
Remuneration, if applicable
Expectations of the jail re documentation,
referrals, medication administration, etc
Confidentiality
Mechanism for review, evaluation and
modification
 Comprehensive Service Array
Diversion
Timely and effective treatment
Placement in programming
Linkage with support groups
Housing assistance
Educational Assistance
Entitlements
Other supports
 Systematic Planning
Cooperation
Coordination
Collaboration
Integration
Key Issues Identification of problems,
barriers and solutions
 Technical Assistance Resources
• National Institute for Corrections (Jail Center) 1-
800-995-6429
• The GAINS Center for People with Co-Occurring
Disorders in the Justice System 1-800-311-GAIN
 To contact me:

Ray Sabbatine - tykerjs@att.net

Cell 859-806-0935
Office 502-868-5595
Fax 502-868-5364