Working with individuals living with various psychological and psychiatric conditions can be both rewarding and challenging. Sometimes it may seem that the extreme challenges outweigh any hint of reward! With an increasing emphasis on community-based treatment alternatives, all of us are likely to face challenging and difficult individuals in our everyday work, and sometimes this will involve difficult behavior experienced when working with people who live with mental illness.
All of the concepts taught in the Prepare Training®
program apply to individuals with mental illness. It is important that professionals serving the mentally ill in any setting approach these individuals with a sense of respect, service, and safety.
Tips for Prepare Training® Certified Instructors
Certified Instructors have a responsibility to teach any segment of the Prepare Training®
program in a relevant fashion for the specific audiences they serve. In considering working with professionals who are engaged in home visits with individuals living with mental illness, it is important to think about specific examples in which Prepare Training®
concepts and skills apply to behaviors that could be exhibited by these individuals. The concepts and skills are all very powerful, and their simplicity makes them powerful.
Some of the concepts and skills that should come to mind whenever dealing with difficult, challenging, and perhaps even aggressive behavior sometimes seen in individuals living with mental illness include:
- Take a step back—physically, emotionally, and psychologically.
- Remain calm, and make a plan.
- When communicating with an individual in crisis (or with family members or even with other staff), keep directives simple and clear.
- When directing an individual in crisis (or family members or even other staff), always communicate respectfully, even when being firm and directive.
- When someone is expressing anxiety, support them.
- When someone is being defensive, direct them, always keeping respect, service, and safety in mind.
- If someone is violent, initiate violence response procedures and know how to call for help if needed. This includes the importance of having a plan to summon law enforcement if necessary.
Many concepts taught in the Foundation Course and in Violence Response Procedures I are directly applicable to people living with mental illness. These include:
- The CPI Crisis Development ModelSM
- The CPI Verbal Escalation ContinuumSM
- Paraverbal Communication
- Empathic Listening
- Integrated Experience
- The CPI COPING ModelSM
Be sure to use specific examples from the work of your training participants, especially where these concepts and skills apply. There are numerous opportunities to address these areas as you deliver lectures, conduct exercises, and engage in discussions. This is especially (though not exclusively) the case with content application. However, even before the Certified Instructor gets to the unit on content application, the examples invoked throughout all other units should reflect the realities faced by participants in their everyday work.
Myths and Realities About Mental Illness
Mental illness involves medical diagnostic categories. These diagnostic categories involve many different types and subtypes, and an individual's specific diagnostic issues should be carefully and sensitively managed by qualified professionals.
The concepts and skills taught in the Prepare Training® program relate to behaviors, as opposed to diagnostic categories. It is important that Certified Instructors address behaviors in the context of the models we teach, because crisis behaviors unfold and present themselves in a roughly similar developmental pattern whether they are displayed by a "typical" person in her home or by a person living with mental illness in her home.
For example, defensive behavior is defensive behavior, and a directive response is most appropriate. A key characteristic of defensive behavior is some degree of irrationality as presented by a person's behavior. This could be the irrationality seen in the behavior of a "typical" parent who is inordinately frustrated with his child. It could also be seen in the behavior of a person living with mental illness who is upset with his social worker for taking him away from his favorite television show. In either case, a firm, directive approach is best, with the level of direction dependent upon the level of irrationality.
It is important to consider some of the myths about mental illness in understanding our approach to individuals who suffer from its devastating effects:
MYTH: The cause of mental illness is either poor character or poor parenting.
FACT: Mental illness is a "no-fault" disease, just like diabetes or arthritis.
MYTH: People who have mental illnesses are more dangerous than those who do not.
FACT: People who have mental illnesses are no more violent than someone suffering from any serious illness. More often, they are the victims of violence. People with severe mental illness often have problems making "judgment calls," which lead them to be taken advantage of or abused.
MYTH: A person can recover from a mental illness through positive thoughts and a supportive family.
FACT: Mental illness is a physical, not a moral condition. Recovery comes through receiving the necessary treatment and support services.
MYTH: Most people with mental illness are poor and have a lower-than-normal IQ.
FACT: Mental illness can strike anyone at any time. Most people with mental illness are of average intelligence or higher.
MYTH: Depression results from a personality weakness or character flaw. People who are depressed could just snap out of it if they tried hard enough.
FACT: Depression has nothing to do with being lazy or weak. It results from changes in brain chemistry or brain function, and medication and/or psychotherapy often help people recover.
Effective Communication Strategies
Some people living with mental illness need no support; others need only occasional support; and still others require substantial support. All fundamentals of respect, service, and safety should be utilized when interacting with persons who exhibit symptoms of mental illness.
The guidelines you need to effectively communicate with a person living with mental illness are essentially the same guidelines you would use in communicating with any person.
- Listen actively to the person.
- Speak directly to the person.
- Treat the person with dignity, respect, and courtesy.
- Offer assistance but do not insist or be offended if your offer is not accepted. Do not "over-assist" or be patronizing.
- If you are in a public area with many distractions, consider moving to a quiet or private location. Reduce background noise if possible.
- Be prepared to repeat what you say, orally or in writing. Provide information gradually and clearly. Repeat information using a different communication approach, if necessary.
- Don't pretend to understand if you do not. Ask the person to repeat what was said.
- Be patient, flexible, and supportive. Take time to understand the individual and make sure the individual understands you.
- Focus on abilities and adapt your communication skills to the person's needs.
- Allow a person time to say or do things at her own pace.
- If known, provide reasonable accommodations according to current law and policy.
Staying Safe During Home Visits
If you are called upon to work alone—or if you find yourself alone unexpectedly—you can implement strategies to enhance your safety. By planning ahead and avoiding unnecessary risks, many crisis situations can be avoided. When crisis moments do occur, the planning and practicing you've done are the keys to taking appropriate, practical steps to keeping yourself and others as safe as possible.
Home visits might present a number of unique challenges:
- You are providing a service on someone else's "turf," where you may not be familiar with the neighborhood, the home itself, or the people who are present.
- Most significantly, you are often alone and without the benefit of having a team available should a crisis situation arise.
- Prevention and planning are the keys to safe and successful home visits.
Before the Visit:
- Gather as much information as possible about the person you're visiting.
- Obtain clear, specific directions to the home. Know exactly where you're going.
- Try to plan a visit during daylight hours if you have safety concerns. If you must make a visit after dark, consider traveling by cab, or using an escort system so you won't have to walk alone in the neighborhood.
- Leave a list with your office of where you will be, and call in at designated times.
- Establish a procedure for your office to follow if you don't call in.
- Request that another staff member accompany you if you don't feel safe.
Traveling to the Site:
- Keep valuable items out of sight or don't bring them at all.
- Drive with your car doors locked.
- Park in a well-lit, visible area.
- Don't get out of the car if you feel unsafe.
- Carry as little as possible into the home.
During the Visit:
- Establish the goal of the visit. State the goal to the person in advance, and once you have achieved the goal, leave.
- Keep in mind that you are at work. All policies, guidelines, and laws applicable to your workplace are likely applicable to the home you visit.
- Make it clear that you have a schedule to keep and are expected elsewhere.
- If possible, keep a clear path to the door. Avoid positioning yourself anywhere you could be trapped.
- Unless absolutely necessary, avoid entering bedrooms or other rooms away from the main exit.
- Respect an individual's personal space. Maintain an appropriate distance. If you must touch the person in order to provide care or assistance, explain exactly what you're going to do before you do it.
- Guard your privacy. Avoid giving out personal information, such as your home address or telephone number.
- Pay attention to your internal warning signals. Leave at any time if you don't feel safe.
- Be aware of your paraverbal communication. Paraverbal communication refers to the tone, volume, and cadence (rate and rhythm) of your speech. Many identical statements can have completely opposite meanings, depending on your paraverbals. For example, the question, "What's wrong?" could be stated in a caring, supportive way or in an angry, impatient way. Be sure that your paraverbal communication is consistent with the message you want to send.
- Speak at an even rhythm and allow silence. Be sure to allow enough time for the individual to respond to one statement or question before you go on to the next. Individuals with some conditions may take a while to process the information you communicate.
- Don't argue. If an individual is confused about the facts of a situation, don't argue with her. Instead, try to understand how she's feeling. Often, fear and confusion are at the root of behavior. Offering reassurance will be more beneficial than trying to correct her misperceptions. For example, instead of saying "No one is trying to poison you," you might say, "It sounds like you're frightened." Try to ignore verbal outbursts and insults.