OVC Provider Forum Transcript

Serving Crime Victims with Mental Illness
Carole Warshaw, MD, Jennie Barr, PhD  -  2010/12/16
What might be done to ensure local mental health centers understand their role in the recovery of persons who are victims of crime?
1.  Steve
 Who might be able to provide training to our local mental health professionals on the issues surrounding violence, trauma and mental health?
2.  Carole Warshaw
 Relationship building is key. Identifying people to talk with either at the local mental health center or within your city, county or state mental health system to discuss these issues is probably the best way to start. Discussing mutual concerns and goals, identifying people who already have an interest to work on these issues, including mental health centers in other community wide efforts (coordinated community responses, family violence coordinating councils, etc.) are also helpful. In our experience, most mental health providers are aware that the majority of people they see have experienced a range of traumatic experiences over the course of their lives. If not, there is plenty of research you could draw on to back this up. In addition, one of SAMHSAs key initiatives is Trauma and Justice, so there is certainly a clear mandate from the federal level to address these issues. There is also a document produced by SAMHSA and the Council of State Governments on Violence Against Women with Mental Illness. http:consensusproject.org/jc_publicationsviolence-against-women-with-mental-illness-issue-brief
3.  Jennie Barr
 : It would be important for the mental health community to receive training specifically on the impact of victimization and how it varies based on the type of crime (sexual assault, domestic violence, DWI, homicide, etc) and surrounding circumstances (when, where, by whom, prior crimes, coping skills) and to also know and receive training on resources specific to victims of crime such as Crime Victims Compensation, availability of sexual assault exams (for crimes reported or not), crime victim rights, local crime victim assistance agencies (such as domestic violence, sexual assault centers, MADD). Good resources include OVCs website for training, resource materials and statewide crime victim coalitions. It is also critical for the crime victim assistance community to be educated by the mental health community so cross training is strongly recommended.
Please discuss any innovative approaches to serving the mental health needs of sexual abuse and assault survivors.
1.  Jennie Barr
 Since many behaviors and symptoms that may either be attributed to or may trigger mental illness following a traumatic event such as sexual abuse or an assault, the approaches to serving victims needs to be multi-faceted and trauma-informed. One effective approach is a community collaboration model referred to as a CCR or Coordinated Community Response, which is a victim-centered model that consists of multiple partner agencies that provides many services to provide for a wide range of victim needs. May include law enforcement, prosecutors, local mental health, sexual assault centers, healthcare and others specific to victims needs. Trauma-informed service providers are those that receive training to recognize that events that are life-threatening or traumatic may impact a person on their core level, basic trust and functioning so the following are important to know in working with survivors of trauma with mental illness:oNeed to feel safeoMay need extra time to be comfortable and calmoPerception or expectation that I may not be believedoDifficulty with authoritative approachesoFear of being labeled as crazy or fear of being threatened with losing children Focus on: oreassuring the survivor that what happened was NOT their faultothat you believe themorespond to requests for information, ignore distractions (tangential or targeted information) ofocus on increasing a survivors prior coping and existing resources
How should sexual assault hotline staff & volunteers best deal with frequent, repeat callers who need services far beyond the scope of the hotline? E.g., the caller who wants to stay on the line for 1+ hours per call...or calls several times per day...or is not using any other appropriate supports?
1.  Stephanie
 Since this is a repeat caller and you have already spoken with this person at length then you know what their problem is. You can research who they should be talking to and give them the name and number of the person that they should talk to that can help them with their problem. Give everyone that answers the phone the same script so that the caller can utilize the proper services. Ask them if they have a social worker that can help them with this problem. If not give them the referral information and include social services in the referrals. This referral call should not last more than 5 minutes at the most. Scripting repeat callers helps them to become infrequent callers.
how do you feel about the use of emdr (for all ages) as effective treatment for domestic violence?
1.  C. Warshaw JRC
 Part 2. In EMDR treatment, exposure is under the control of the patient. This is designed to engender a sense of mastery in the face of the traumatic experience. Some studies have suggested unusually rapid therapeutic responses using three to four sessions of therapy to treat isolated trauma. Although a growing body of research supports the efficacy of EMDR (15), others have questioned these findings, citing studies that suggest that the eye movements do not contribute to the therapeutic effects. More recently, Rothbaum, Astin, and Marsteller compared Prolonged Exposure (PE) treatment to EMDR for sexual assault survivors with PTSD. Both treatments led to clinically and statistically significant improvements immediately following treatment; 95 of PE participants and 75 of EMDR participants no longer met the criteria for PTSD at the conclusion of treatment (138). The difference between the two treatment groups was not statistically significant. These gains were maintained at a 6-month follow-up, although PE participants reported better end-state functioning than EMDR participants. The authors of the study suggest that EMDR and PE are both exposure techniques that simply diverge in administration and instructions for work between session. Although CBT models appear to be effective in treating PTSD among selected survivors of adult-onset trauma, the use of prolonged exposure techniques has raised a number of concerns that are potentially relevant to survivors of IPV, including reports of negative effects (161,162) and lack of tolerability among a subset of survivors, particularly those who have experienced childhood abuse. In addition, studies indicate that exposure therapy appears to be more appropriate for women who are physically safe, who do not have dissociative symptoms, and who are not primarily depressed. In one study, participants exhibited a poorer response if they felt defeated during a traumatic experience, alienated following the event, and had developed a sense that their lives would never be the same. For survivors of chronic childhood abuse who have not developed the internal capacity to modulate affect and arousal, symptoms may be exacerbated by exposure. The distress associated with confronting traumatic memories may make these modalities unacceptable to many survivors, particularly if they are still living in fear or, as Levitt and Cloitre note, if they have difficulty managing feelings of anger or anxiety or establishing a therapeutic relationship. In addition, research indicates that people with childhood exposure to interpersonal violence who experience symptoms of PTSD plus other conditions (such as bipolar disorder, suicidality, substance abuse, dissociation, or depression) often do not respond to conventional treatment for these conditions but are generally screened out of trials for PTSD treatment (162). As mentioned previously, randomized controlled studies assessing treatment for women who have been abused by an intimate partner, experienced the lasting effects of childhood abuse, andor who have co-morbid conditions, are still limited.
2.  C. Warshaw JRC
 Many survivors have experienced multiple forms of abuse and are dealing with both past and current trauma that may affect their ability to deal with the ongoing abuse in their lives. In addition, many of the aspects of interpersonal trauma that survivors of DV report are better addressed by complex trauma models (e.g., betrayal of trust; feelings about oneself, other people, and the world; feelings of shame, guilt, grief, loss, fear, hurt, anger, sadness, emptiness, despair, confusion, etc.). Treatment for survivors of DV includes DV-specific care, care of acute symptoms, and longer-term trauma recovery. Regardless of type of trauma, the first priority of treatment is establishing safety, no matter where the threat originates. In the context of ongoing DV, this means attending to safety from an abusive partner. If a survivor is also experiencing trauma- or mental health-related symptoms, those also need to be addressed, both in terms of how they affect a survivors ability to be safe from an abusive partner and how they affect a survivors ability to be safe from potentially dangerous coping strategies.Treatment must also attend to a range of psychological sequelae related to IPV, as well as to ongoing stressors due to stalking, harassment, or prolonged legal battles. Working with community IPV advocacy programs to provide concrete and emotional support is vital. From a phase-based perspective, clinical work with survivors who remain in danger should focus on issues of safety, stability, and support, saving trauma recovery for when it is safe to do so. Research is needed to determine which modalities are most appropriate to individual survivors and which are most helpful to survivors who are experiencing ongoing abuse and violence. Treatment also involves establishing a collaborative working alliance. If a woman is a survivor of childhood abuse and has had no safe, nurturing attachment relationships in her life, then establishing trust can be much more challenging for her and becomes a central aspect of early work.Eye Movement Desensitization Reprocessing Eye movement desensitization reprocessing involves the deconditioning of anxiety through reactivation and re-exposure to traumatic memories and the transformation of pervasive abuse-related beliefs about ones self and ones world into more adaptive cognitions.
3.  Jennie Barr
 EMDR (Eye Movement Desensitization and Reprocessing) is a form of treatment for use in relieving traumatic memories. Although I am not a trained EMDR therapist, I have seen its effectiveness with those who have experienced prolonged and acute trauma. The level of a survivors readiness need to be considered in using any modality that focuses directly on the traumatic event. The national EMDR association has a wealth that may be helpful. http://www.emdr.com/q&a.htm
I am an Employability Skills Advocate working with domestic violence survivors who are trying to find work to become less dependent on abusers/shelter residency. Many of my clients suffer from some form of mental illness due to childhood/adult DV issues. Finding work and keeping a job can be a real challenge. Is disclosure necessary to future employer? How can I best assist these clients as they try to step out into more independent living?
1.  Jennie Barr
 Any mental health issue does not have to be disclosed under HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations, which protect health information. The National Alliance on Mental Illness (NAMI www.nami.org) is a great resource as is your statewide Advocacy organization for the mentally ill (in Texas, Advocacy, Inc.), statewide disability assistance agency (in Texas, Department of Disability and Rehabilitative Services in the Health and Human Services state agency), the state mental health authority along with the statewide coalitions against crime such as the statewide domestic violence and sexual assault coalitions.
2.  C. Warshaw JRC
 In our recent research around the use of Supported Employment (SE) strategies with survivors who may be experiencing trauma-related mental health needs or mental illness, the issue of disclosure has come up in a couple of ways. Some SE programs work with employers to develop jobs or positions, and in these situations, the employers know that the person is experiencing a mental illness, but may not know specifics. In other programs, specialists work with people to find and apply for jobs. In either situation, whether and how much to disclose is decided and directed by the person seeking a job. Disclosure should take place in the context of ongoing support from employment specialist andor other supports. Research has shown that disclosure (of domestic violence) to someone at work is associated with current employment and that work place support from co-workers and supervisors positively impacted survivors, in general and around employment, with less social isolation, improved health, and fewer negative employment outcomes. (Swanberg, et al; Staggs et al) However, this depends greatly on the persons work situation, who is available for support, issues of confidentiality and safety (i.e. do co-workers know the perpetrator?), and other potential issues of retaliationnegative consequences. Support from an employment specialist could be in discussing what disclosure could look like, such as assessing safety, advantages and disadvantages, assessing who could be told, role-playing, and discussing needed supports and how to ask for them. Engaging a survivor in what she knows about herself, her work and work history as well as possible triggersactivating moments, warnings signs, coping skills in a work context would be an effective way to begin. It seems clear that developing, enhancing, and deepening long-term ongoing supports (in general and specifically around employment) are critical. Connecting survivors who are experiencing mental illness or trauma-related mental health needs to peer support providers or groups and working with survivors to develop supports in the workplace may be effective ways for DV programs to provide ongoing job support. Ongoing supports to help manage and navigate experiences and interactions at work some of which may be developing skills like relaxation, grounding, breathing or using WRAP planning. Some of these supports may be in requesting specific accommodations a quiet space that someone can go to, flexibility to take a walk or flexibility around startend times, regular supervisionjob coach, extra time to finish a project, etc. These may require some level of disclosure to employer but also may be protected by ADA?. A Supported Employment example that may be useful:An SE program in Texas combined rapid entry supported employment with social network enhancement and focused on helping people participating to develop natural supports and social networks both in and out of the workplace. In this program, friends, family, neighbors and coworkers came to provide ongoing support in place of employment or mental health professionals (Toprac et al., 2002). For one participant, peers and co-workers helped her set worklife boundaries that helped her prevent burning out or taking on too much. (Burke et al, chapters with examples - unpublished)Jennifer Swanberg, Caroline Macke, and TK Logan. Working Women Making It Work: Intimate Partner Violence, Employment, and Workplace Support J Interpers Violence March 2007 22: 292-311Staggs, S. L., Long, S. M., Mason, G. E., Krishnan, S. R., & Riger, S. (2007). Intimate partner violence, social support, and employment in the post-welfare reform era. Journal of Interpersonal Violence, 22, 345-367.
Police and service providers are often confused about how to handle people who are LGBT. Few DV shelters will accept transgender or gay male victims, and if mental illness is a factor it's especially challenging. Most police officers have little or no training in handling LGBT cases with sensitivity. Can you point to any communities where training has made a significant difference in the way these victims are treated?
1.  C. Warshaw JRC
 Many LGBTQ organizations and communities are working to develop strategies to intervene and prevent violence and support survivors (and perpetrators towards accountability) without using the police or the criminal legal system for some of the reasons above, in addition to the violence and harassment that many queer, trans, and gender non-conforming people (part. people of color) experience from police. Examples of this include the NW Network in Seattle (http:www.nwnetwork.org) CARA http:www.cara-seattle.org, Audre Lorde Project (NY) http:alp.orgcommunitysos. NCAVP may be doing some of this work around police and access to services. http:www.avp.orgncavp.htm. There is some really great information in the LGBTQ DomesticIPV in the US in 2009 report by NCAVP around police response. They may be a good contact in this area & may know of additional resources. http://www.avp.org/documents/2009DV-IPVREPORTFINAL2.pdf
What sorts of special services are available for victims whose mental illnesses prevent them from being interviewed? Are there other techniques that can be used, and that are accepted by courts, to obtain details about the crime? Specifically, what about an autistic child who cannot verbalize his experience or answer questions directly?
1.  Carole Warshaw
 we would also refer you to the SAMHSA NREPP (National Registry of Evidence-based Programs and Practices http://www.nrepp.samhsa.gov/SearchResultsNew.aspx/?sb&qtrauma
2.  Jennie Barr
 According to Responding to Violent Crimes Against Persons With Disabilities: A Manual for Law Enforcement, Prosecutors, Judges and Court Personnel published by the Disability Services ASAP (A Safety Awareness Program) at Safeplace, Austin, TX, the following suggestions are offered for working with crime victims with cognitive disabilities (e.g. mental illness) Do not assume the individual knows who you are, your role, what the problem may be Explain what law has been broken and how they are impacted and involved Remind over and over it is not your fault Offer empowerment in as many ways as possible you are your own expert I need your help and hope you can help me Speak clearly, simply, straightforward and ask for specific details if someone cannot speak or speak clearly, ask for indicators (head nod, finger movement) One question at a time, take time to listen and prepare for what is comingMore suggestions in this great resource.
Getting the cases through the system can be an issue. What resources are easily available that holds respect with law enforcement and district attorneys? We need training for service providers, law enforcement, & prosecutors (SART task force participants) but I have not been successful at convincing them of the NEED.
1.  Jennie Barr
 A successful prosecution with an available, cooperating witness and community support advocates is a best example for encouraging training and collaboration among community partners working together. When a case starts with a crime investigation that is supported by the local healthcareSANE nurses (if injuries or assault involved) and crime advocacy partners (e.g. sexual assault or DV advocates, CACchild advocateforensic interviewer) and a victim is involvedparticipating as part of a prosecution, the positive outcome may be the result of all entities working together in support of that victim. Knowing each other, their roles and having positive contactexperiences strengthens the victim-centered response. If a SART exists, consider asking the DA to host training or meetings. Also, invite someone locally with expertise in ADA compliance, HIPAA and mental health issues to present at a meeting.
What is currently the best effective community based treatment for victims of crime with mental illness?
1.  Jennie Barr
 This is not specifically a treatment modality but rather an approach to treatment service delivery. A CCR a Coordinated Community Response is an organized, financially supported and sustainable collaboration of agencies (law enforcement, criminal justice, nonprofits, mental health authority, mental health providers, healthcare) that:bridges the community-based and systemcriminal justice based providersoprovides victim access through any door, balances victim safety with community safety, addresses not only response to crime victims, including those with mental illness, but also looks at root causes of violence in order to promote prevention of crime
2.  Carole Warshaw
 More recently, they report on a 21 week mixed-group intervention model for addressing PTSD among people with severe mental illness that was piloted at a community mental health center with promising results.137 The Trauma Recovery Group is a CBT intervention comprised of breath retraining, psychoeducation about PTSD, cognitive restructuring, learning to cope with symptoms, and making a recovery plan. In their pre-post design, participants who completed the program (59 retention rate) had significant improvement in PTSD symptoms, depression and trauma-related cognitions compared to people who dropped out. Their rationale for using Cognitive Restructuring rather than Prolonged Exposure was based, in part, on the body of positive experience using CBT to treat other symptoms among people who have MI, which is not the case for PE. In addition, people who have a mental illness appear to have greater sensitivity to stress, which PE treatment can increase. Again, the authors note that this type of treatment is best embedded within a more comprehensive array of treatment and supports (e.g., meds, case management, and other supports). For example, a survivor may have many other concerns and needs (co-morbid symptoms, substance use, issues of managing daily living, medication-related concerns and the need for skill development). For survivors of domestic violence, safety concerns and abusers use of mental health issues as tactics of control also become priorities. What this and other research point to is the need to recognize both the strengthsutility of evidence-based PTSD treatment models, particularly symptom reduction and prevention of PTSD, as well as their limitations, including flooding and exposure for someone experiencing affect dysregulation and or other disruptive mental health symptoms. Other complex trauma treatment modelsapproaches that could be adapted for working with survivors of domestic violence include Trauma Adaptive Recovery Group Education and Therapy (TARGET), The Sanctuary Model, & Risking Connection, among others. TARGET is also designed to address complex trauma among people with serious mental illness, is a strengths-based model, teaching a set of practical skills to enable participants to gain control of PTSD symptoms. The Sanctuary Model, a residential trauma treatment model for creating healing environments is designed to address the long-term sequelae of chronic abuse. It was initially developed for use on inpatient psychiatric units but has been applied in DV shelters and residential treatment programs for children and adolescents. It is a four-stage model (SAGE) addressing safety, developing affect regulation skills, processing grief and supporting emancipation (freedom from the effects of trauma, developing new capacities and meaningful connections and reinvesting in life). The Risking Connection curriculum is an individual complex trauma treatment approach developed for use in the public mental health systems in Maine and New York that addresses both provider and survivor issues, particularly transference, counter-transference and vicarious trauma.. It too emphasizes the importance of a collaborative therapeutic relationship that provides information, fosters of respect, connection and hope and supports the development of new self-capacities. Several of these models have been tested through the SAMHSA Women, Violence and Co-Occurring Disorders Study (TREM, Seeking Safety) and have demonstrated efficacy as part of a broader array of trauma-informed mental health and substance abuse services. None of these models specifically address domestic violence. More research is needed to determine if and how they can best be used in conjunction with domestic violence-specific interventions when safety and coercion are still a concern. Harris and Fallot 1996, Mueser, 2007
3.  Carole Warshaw
 I would reframe this question. Being a victim of crime isnt a mental health condition so there isnt any particular form of treatment for being a victim of crime. Likewise, having a mental illness can mean a lot of different things and treatment would depend on what a particular individual is experiencing and wanting treatment for. One way to think about this would be to consider the concept of psychiatric disability. PSYCHIATRIC DISABILITY: A normal part of the human experience that occurs when mental illness significantly interferes with the performance of major life activities, such as learning, thinking, communicating, and sleeping, among others. Trauma and mental illness (MI) can cause psychiatric disability but do not always do so. Psychiatric disability occurs when the effects of trauma andor MI significantly interfere with the performance of major life activities. Psychiatric disability may come and go, remit, or be more persistent. Safety and support can reduce psychiatric disability. That said, there are treatment models for PTSD andor trauma that have been modified for people with various MI diagnoses. 
What is the best or reasonable option when assisting victims with MH issues that remain with their abuser?
1.  Carole Warshaw
 There are a number of specific things to consider in addition to the range of advocacy resources you would provide to any survivor of DV who chooses to stay with their partner. Ways you can provide destigmatizing trauma information to survivors include:Discuss the link between lifetime trauma, domestic violence and mental health. Discuss some of the common emotional or mental health effects of domestic violence, ways these responses can interfere with accessing safety, processing information or remembering details for legal cases and what one can do about them.Discuss the things abusers do to drive or make their partners feel crazy. Discuss the ways abusers use mental health issues to control their partners. Let survivors know that these are common responses to abuse. In addition, not involving abusers in treatment, incorporating safety planning into mental health crisis planning (e.g. psychiatric advanced directives, WRAP (TM)), working to ensure that the abuser isn't controlling her medication or her funds (isn't the payee for her benefits), and addressing her feelings, concerns and safety as part of your ongoing work whether it be in an advocacy or clinical setting1.
2.  Carole Warshaw
 Part I. Just like anyone who chooses to stay with an abusive partner, creating a safe place for her explore her priorities and concerns, ensuring that the ways abusers use mental health and substance use issues to control their partners are addressed and incorporating this into safety plan are a few things to take into consideration. This is of particular concern because domestic violence presents specific risks for individuals with serious mental illness. Exposure to ongoing abuse can exacerbate symptoms and precipitate mental health crises, making it more difficult to access resources and increasing abusers control over their lives. Stigma associated with mental illness and clinicians lack of knowledge about DV, reinforce abusers abilities to manipulate mental health issues to control their partners, undermine them in custody battles and discredit them with friends, family and the courts. Abusers may commit or threaten to commit their partners to psychiatric institutions. They may force women to take overdoses, which are then presented as suicide attempts, or they may withhold medications. They may assert that accusations of abuse are simply delusions, they may lie outright about their partners behaviors or may rationalize their own, claiming their partner needed to be restrained. Such manipulation not only increases an abusers control over hisher partner, but also has a chilling effect on a womans ability to retain custody of her children, which is often one motivation behind her partners behavior. While this phenomenon cuts across cultures, immigrant women who are isolated and do not speak English are particularly vulnerable to this type of abuse.
What techniques would you suggest in working with this population during Crisis Intervention counseling, and what would you suggest avoiding?
1.  Jennie Barr
  I would suggest the following: Setting: allow space for the person to feel comfortable, do not crowd them, allow access to an exit at all times, get permission to approach them Approach: speak in a slow, calm voice, ask for information or clarification dont assume you know, if you think they may be having delusions or hallucinations, acknowledge them and ask for information but explain that you do not hearsee what they do you can acknowledge their fear or distress without participating Focus on small, concrete steps that ensure manageability and success Focus on strengths, resiliency Avoid extrapolating details or emotions that would open them further or avoid complex cognitive requirements
As we deal with innocent victims daily , there are calls we receive where the victim wants to tell their whole story, we listen but are still unable to assist them - either they don't qualify with us or their situation is not a crime. What is the best avenue to take with Mentally Ill individuals who need that extra-special guidance and care where the services they may require are not services that we provide. It's difficult to get that across to them.
1.  Jennie Barr
 Noreen, that is always a challenge since often they may need to tell their story over and over and your time is limited.A10: At the point where you realize your services may not be what can assist them, it is ok to gently interrupt and ask specific, concrete questions: How can I be helpful to you right now? Acknowledge their ability to recognize their need for assistance and assure them you will help them get that assistance; affirm their positive coping by calling (this is especially important if they have had contact with other officials in past that were not supportive) and if time allows, discuss what the person can do once they hang up with you self care or familysupport personsIdentify the actual resource (if it is not you) and give them a concrete way to follow-through (e.g. a name and a number). Have your local mental health center or state mental health authority number and other mental health resources close by e.g. a resource directoryOffer to follow-up with them (if your policy allows) and they approve. Then do what youve said you would
do you have guidance and/or strategies on how to approach domestic violence issues with individuals whose psychiatric difficulties interfere with his/her ability to view interactions as abusive?
I am employed with an emergency shelter for domestic violence victims. We frequently encounter victims who have been diagnosed with mental illnesses. At times, we are unable to accommodate those who suffer with severe mental illness. Are we in violation of ADA laws if we cannot accommodate them?
1.  Steve
 I would appreciate having the resources you speak of guidelines for DV shelters on these issues and can send them to you along with our Access to Advocacy curriculum that provides specific guidance on serving women with psychiatric disabilities. This would be much appreciated!
2.  Carole Warshaw
 Potentially, yes as well as the Fair Housing Act. If someone is acutley ill, just like someone who has pneumonia or a broken leg - an emergency room or medical setting is where they will get the most appropriate help. But, not serving a woman who has a diagnosis of a mental illness is in violation. We have specifically developed guidelines for DV shelters on these issues and can send them to you along with our Access to Advocacy curriculum that provides specific guidance on serving women with psychiatric disabilities.
I provide services to people with developmental disabilities and mental health issues in a program that offers both sexual abuse prevention and survivor therapy. Do you have any recomendations for working with this population?
Some of the obstacles in treating victims of crime with a mental illness--fully--are resources. Do you see changes on the horizon for victims with Health Care Reform?
Is there a curriculum you use in training staff regarding working with victims with disabilities.
1.  Carole Warshaw
 Yes.. OVC has a curriculum on disabilities, OVW has a Ending Violence Against Women with Disabilities grant program and many states have developed curricula on these issues. Our Center (The National Center on Domestic Violence, Trauma & Menatl Health) has curricula for DV advocacy programs and mental health providers on working with survivors of DV and other lifetime trauma who have psychiatric disabilities as well as curricula for working with children exposed to DV and their mothers. A Safe Place in Austin also has wonderful curricula on disabilities in general and on women dealing with MH and substance abuse issues
What is the best practice for those in the helping profession to engage those with MH issues in a healthy productive manner?
how do you help clients with MH issues identify and seek treatment without being able to diagnose and without sounding judgmental. Many times what happens when you recognize there is a mental illness with a client, the client discontinues services with you. How do you avoid that?
1.  J. Levy-Peck
 The best way to make good referrals for mental health treatment is to practice exactly what to say beforehand (with a colleague, for example). Normalize the need for counseling by saying something like When someone has been through the kinds of experiences you have had, he or she usually experiences a great deal of stress. You have told me that you are having trouble sleeping and are feeling very sad and anxious. You may want to consider talking to a mental health counselor to help you with some of these concerns. Many survivors have found mental health counseling to be really helpful in feeling better. It's also important to establish good relationships with trauma-sensitive therapists, and help the therapists to understand why advocacy is a great accompaniment to therapy.Jennifer Y. Levy-Peck, Ph.D., Licensed Psychologist; Program Management Specialist for the Washington Coalition of Sexual Assault Programs - jennifer@wcsap.org
How can you instill trust in this population when they are so frequently victimized?
When a mental health patient presents with complaints of sexual assault, but they are acutely psycotic or hallucinating, is the priority to complete the sexual assault exam and interview, or address their mental health needs? If they are symptomatic at the time, are they able to give informed consent for examination?
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