practical skills for working effectively with clients with mental health issues
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Practical Skills for Working Effectively with Clients with Mental Health Issues. Merf Ehman Columbia Legal Services Based on materials from the New England Training Consortium. Agenda. Overview of RPCs Implementation of RPCs Identifying Diminished Capacity - PowerPoint PPT PresentationTRANSCRIPT
PRACTICAL SKILLS FOR WORKING EFFECTIVELY WITH CLIENTS WITH MENTAL HEALTH ISSUES
MERF EHMANCOLUMBIA LEGAL SERVICES
BASED ON MATERIALS FROM THE
NEW ENGLAND TRAINING CONSORTIUM
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AGENDA
Overview of RPCs
Implementation of RPCs
• Identifying Diminished Capacity• Maintaining a normal client-lawyer relationship
• Interviewing skills
• Mental Health Issues
• Determining Diminished Ability
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RULES OF PROFESSIONAL CONDUCT
1.14 Client with a Diminished Capacity
1.6 Confidentiality of Information
1.4 Communication
1.2 Scope of Representation
CLIENTS WITH DIMINISHED CAPACITY RPC 1.14(A)Maintain a normal client-lawyer relationship
• As far as reasonably possible• Capacity is presumed
Diminished ability to make adequately considered decisions
• Related to representation• Reasons
POSSIBLE SIGNS OF IMPAIRMENT
COGNITIVE SIGNS
Short-term memory loss
Comprehension Problems
Communication Problems
Lack of mental flexibility
Calculation Problems
Emotional inappropriateness
BEHAVIORAL SIGNS
Delusions
Hallucinations
Grooming/Hygiene
Difficulty with activities of daily living
STIGMA
harmful effects of stigma include:
• lack of understanding by family, friends, colleagues • Discrimination at work or school• Difficulty finding housing• Bullying, physical violence or harassment• The belief that you will never be able to succeed at certain
challenges or that you can't improve your situation
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CLIENT COMMUNICATION RPC 1.4
Keep client reasonably informed
Explain a matter
enough to permit the client to make informed decisions about representation
CLINIC SETTING – Comment 3
• Adequacy of communication depends in part on the kind of advice or assistance involved.
• The guiding principle • fulfill reasonable client expectations for information consistent
with • (1) the duty to act in the client's best interests, and • (2) the client's overall requirements and objectives as to the
character of representation.
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THE COMMUNICATION PROCESS – PRINCIPLES AND TECHNIQUES
Context
Structure
Basic Interviewing Skills
Additional Considerations
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STRUCTURE
Roadmap
• Outline the process – what will happen• Your role• Client’s role• Time constraints
Objectives
• Yours• Clients• Expectations
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LISTEN
Demonstrates the interviewer is paying attention and cares
Encouragement to talk
Relevant note taking
Intentional silence
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LISTENING – ACTIVE PART
Reflect
• Purpose• Reassures client that she was heard• Reassures the interviewer that she is interpreting what
was said accurately• Brief• Not used in a way that interrupts client
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ACTIVE LISTENING CONT’D
Reflecting Content
• Summarizing, paraphrasing, or restating the client’s message
• Example: In loud angry voice with tears: “My landlord told me that no children’s toys can be left in the stairwell. I think that’s unfair because other tenant’s leave their bikes and sports stuff there. The landlord only complains about me and my kids. We are the only Black family in the building. He is constantly leaving notes on my door. It is awful.”
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ACTIVE LISTENING CONT’D
Reflecting feelings
• Acknowledges client as a whole person• Conjecture • More difficult than content
Example
• Same as last slide• How would you reflect the feelings?
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EXAMPLE
“That restaurant would not let me eat with my friends unless I left my service dog outside. That guy was mean and we had to go somewhere else just because of me.”
Client is very quiet and keeps crying, so they are having trouble answering questions
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ENGAGE CLIENTInteraction through questions (limit)
Guide client to useful information (indirectly)
Events are of equal importance to client but not to interviewer
Guide away from unhelpful information
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ENGAGE
Closed v. Open questions
• Open ended questions• Uncertain what specific information is needed
• Want client to elaborate
• Want client to talk freely
• Ex. What happened?
• Closed ended questions • Answered with a yes or no
• Ex. How old are your children?
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ENGAGE EMPATHY“To my mind, empathy is in itself a healing agent . . . because it releases, it confirms, it brings even the most frightened person into the human race. If a person is understood, he or she belongs.” (Carl Rogers)
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EXPRESSGiving information
• About the agency• About the process• About your role• About the law
Clear, simple statements
• Pacing the flow of information• Slow down as needed• Give information at different times• Information may be new, complex, or seem strange
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EXPRESSING
How do you know if client understands?
What happens if you say “do you understand?”
Give the client permission to interrupt
Ask client to explain to you
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EXPRESS CONT’D
Involves all of the prior skills
Connects all of the information gathered to help client see the situation more clearly or differently
Puts the situation in a legal context
This increases the client’s understanding and prepares him or her to deal with it more effectively
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EXPRESSING – THE END OF THE INTERVIEW
Summarize legally relevant facts
Ask if you left anything out
Apply the law to the facts
Present options
Often try to do this too soon in the interview
• This frustrates clients
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LIMIT SETTING
The “art of interrupting”
• Back to the roadmap
• Example: and then he and then he and then he – “I know from what you have told me that your relationship with your employer has been difficult. However, to finish the intake I need to know about:… can you tell me about that?”
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INTERVIEWER COMMUNICATION ISSUEBothered by client behavior
Respond v. React
• Keeping in touch with your emotions• impulsivity
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CONT’D
Focus on the problem and your feelings about it
Decide if it effects the interview (if not continue interview), if it does then:
Describe your problem to the client
Evaluate the response
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DE-ESCULATION TECHNIQUES Verbal cues
• Tone of voice• Volume of voice• Rate of speech
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AVOID
Making promises you cannot keep
Asking why questions
• Logic based• Persons in crisis not operating from that part of brain• Could make person defensive
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DO
Empathize
Accept client’s feelings, thoughts and behavior even if outside of “norm”
Compassionate but firm
Announce your actions and movements
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SPECIFIC MENTAL HEALTH ISSUES
Delusional/Paranoid
Severe Trauma (PTSC, DV)
Borderline
Suicidal
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DELUSIONAL/PARANOID
Do not engage the delusion
Focus on concrete issues
Be explicit about what you can and cannot do
Used closed questions
Recognize limitations
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HISTORY OF TRAUMA
Client’s need for safety
Client is in control – gets to make decisions
Danger of retraumatization
Share information about the process to make things as informed and predictable as possible
Proceed incrementally if possible
• Allows client to respond to each step• Time for client to make decisions
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BORDERLINE PERSONALITY DISORDER
Be explicit about goals and expectations
Set clear limits i.e. calls, visits to office, emails
Coordinate directly with others
Expect shifts in how client perceives you
Manage feelings of anger/frustration
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SUICIDAL
Resources available - 211
OK to express concern
Acknowledge feelings
Referral
Ask client if they have someone to talk to about how they are feeling
No PSY advice!
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MILD AND MODERATE IMPAIRMENTS
Communication Issues - RPC 1.4
Keeping client informed
Reasonably consult with client about means to achieve objectives
Comply with reasonable requests for info
Explain matter so client can make informed decision regarding representation
SCOPE OF REPRESENTATION RPC 1.2(C)
Can limit the assistance given to a client
Must be reasonable
Example from commentary:
• Client and Lawyer agree that the legal assistance will be limited to securing general information about a typically uncomplicated legal problem that the client will handle pro se
CONSULTATIONS – COMMENTARY (6)
May seek guidance from diagnostician
Possible uses:
• Clarification of the areas of diminished capacity /retained strengths.
• Affirmation of the client's capacity• Justification of the attorney's capacity concerns • Expert advice on strategies to compensate for identified
deficits• Indication of the need for protective action• Recommendation for follow-up testing/assessment
(anticipated restoration of capacity)
PROTECTIVE ACTION
Reasonable belief
• Client has diminished capacity • Client cannot adequately act in own interest
• Risk of harm• Substantial• Physical• Financial • Other
Protective actions
• Consult with family members• Voluntary surrogate decision making tools• Consultation with other service providers• Appointment of GAL, conservator or guardian• Consulting with agencies that can protect client
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CONSIDERATIONS FOR PROTECTIVE ACTION – COMMENTARY (5)
Wishes and values of client
Client’s best interests
Intruding to least extent possible,
maximizing client capacities
Respecting client’s and families social connections
CONFIDENTIALITY AND PROTECTIVE ACTION
Can reveal information necessary to protect client’s interests
BUT
Only to the extent necessary to protect client’s interest
RPC 1.6 still applies!
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CONFIDENTIALITY RPC 1.6
Prohibits revealing information related to the representation
Client can give informed consent to reveal
Lawyer SHALL reveal to prevent reasonable certain death or substantial bodily harm
MAY reveal:• Prevent commission of a crime• Secure legal advice about ethical rules• Additional
SCENARIO
Client states she is being followed by the FBI. She has a bag of mail with her that she says contains valuable proof. She says they have all of her money and will give her none of it until they see inside her body.
You know from the intake sheet that she has a Social Security disability benefits issue.
CASE LAW – COURT PROCEEDINGS Vo v. Pham, 81 Wn.App. 781 (1996)
• “court has a duty to act to protect the rights of a litigant who appears to be incompetent”
• inherent duty and power to make a determination regarding mental competency
• conduct a hearing• opportunity to present evidence on the question of mental
competency
Flaherty v. Flaherty, 50 Wn.2d 393 (1957)
• Opposing party duty to apprise court of incompetency of adversary if known
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[Vo's Counsel]: Your Honor, I have nothing further.THE COURT: Okay. All right, Ms. Partridge?MS. PARTRIDGE: Yes, sir?THE COURT: Do you want to testify?MS. PARTRIDGE: What does mean?THE COURT: Do you want to sit up here and tell me-and offer your exhibits?MS. PARTRIDGE: Yeah, I like go up there. (Laughter.) My need to talk to Judge. After you Judge and I judge myself, sir, (inaudible) up there. (Screaming.)THE COURT: Ms. Partridge?MS. PARTRIDGE: Judge, sir? I sit up here? (Laughter.) Now I sit here, Judge. I like that.THE COURT: Ms. Partridge?MS. PARTRIDGE: Yes, sir?THE COURT: Would you please stand? Raise your right hand. Do you solemnly swear or affirm that the testimony you give in this matter will be the truth?MS. PARTRIDGE: Yes, sir.THE COURT: All right. Please be seated.[Vo's counsel]: Your Honor, could I request that if she's in her Barbara phase that maybe she be sworn in as Barbara also?THE COURT: No, I don't want to hear Barbara. I want to hear Susan Partridge.The court was unable to get Susan to speak. “Barbara” spoke at some length regarding Vo's mistreatment of Susan while the court repeatedly asked for Susan to say her name. “Barbara” also threatened to kill Vo. The court then called a recess for nearly two hours and stated that it wanted “to see Susan at 1:30.”