The Role of Mental Health in Preventing Gun Violence in Job Corps

1. The Role of Mental Health in Preventing Gun Violence in Job Corps Valerie Cherry, PhD Lead Mental Health Specialist Humanitas, Inc.

2. Mental Illness and Violence • TRUE OR FALSE? • Individuals with mental illness are no more likely to engage in violent behavior than the general population.

3. The McArthur Study • The McArthur Violence Risk Assessment Study Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods • 1,136 patient discharged from hospitals at 3 sites • Monitored violent behavior every 10 weeks for one year after discharge • Compared to 519 people in community

4. The McArthur Study • Three Predictors of Violence • History of past violence, whether or not a person has a serious brain disorder • Drug and alcohol abuse, whether or not a person has a serious brain disorder • Failure to adhere to treatment or take medication

5. The McArthur Study • Other Indicators of Potential Violence • Antisocial personality disorder • Neurological impairment • Type of delusions (e.g., paranoid delusions - feeling that others are out to harm the individual and a feeling that their mind is dominated by forces beyond their control or that thoughts are being put in their head) • Type of hallucinations (e.g., command hallucinations)

6. Elbogen and Johnson Study • The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. • National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) conducted by the National Institute on Alcohol Abuse and Alcoholism. • A total of 34,653 subjects.

7. Elbogen and Johnson Study • The incidence of violence was higher for people with severe mental illness, but only significantly so for those with co-occurring substance abuse and/or dependence. • Other variables such as environmental stressors, and history of violence.

8. Oxford Studies (Fazel) • Longitudinal data from a Swedish registry of hospital admissions and criminal convictions. Rates of violence compared Percentage of people convicted of at least one violent crime, 1973–2006

9. Violence and mental illness — How strong is the link? (Friedman) • Some psychiatric patients do in fact pose a small risk of violence. • Contributes very little to the overall rate of violence in the general population. • People with no mental disorder who abuse alcohol or drugs are nearly seven times as likely as those without substance abuse to report violent behavior. • Violence in people with serious mental illness probably results from multiple risk factors in several domains.

10. Tom Insel, Director of the National Institute of Mental Health • “Mental illness clearly doesn’t lead directly to violence. However, people with untreated serious mental illness are 15 times more likely to be involved in violence, including suicide than those whose conditions are treated.” • 90 percent of the 38,000 suicides each year involved mentally ill people. • “The logical first step, therefore, should be toward early, systematic identification of people at risk. Next should come appropriate, evidence-based treatment and follow-up care.” Senate committee hearing on January 24, 2013

11. President Obama’s Gun Violence Reduction Plan: Mental Health • To increase access to mental health services for young people, we should: • Provide “Mental Health First Aid” training to help teachers and staff recognize signs of mental illness in young people and refer them to treatment. • Support young adults ages 16 to 25, who have the highest rates of mental illness but are the least likely to seek help, by giving incentives to help states develop innovative approaches. • Help break the cycle of violence in schools facing pervasive violence with a new, targeted initiative to provide their students with needed services like counseling.

12. What Does This Mean for Mental Health? • “We are going to need to work on making access to mental health care as easy as access to a gun.” • The Affordable Care Act • President will issue a letter to state health officials to clarify that mental health parity rules apply also to Medicaid.

13. What Does This Mean for Mental Health? • National dialogue on mental health • To provide additional resources for school mental health services, including training for teachers. • Offer training to non-physicians, teachers and counselors to identify mental-health problems in young people and to learn how to de-escalate crisis situations if necessary. • Mental Health First Aid Training

14. What Is Mental Health First Aid?Gatekeeper Training • Created in Australia in 2001 (University of Melbourne) • Four published randomized control trials and a qualitative study (in Australia) • Study on 33 US college campuses 2009-2011 • Increases mental health literacy • Expands individuals’ knowledge of how to help someone in crisis • Connects individuals to needed services • Reduction in social distance (decreased stigma) • www.mentalhealthfirstaid.org

15. How Mental Health First Aid Can Help • Early, systematic identification of people at risk. • Demystifies mental illness, including realistic information about violence, which helps reduce stigma. • Helps people understand the various kinds of illnesses and how to approach individuals with mental illness without fear. • Not a substitute for counseling, medical care, peer support or treatment.

16. What Do You Learn • The signs and symptoms of mental health disorders such as anxiety, depression, bipolar, ADHD, psychosis, OCD, eating disorders, and addiction. • How to approach someone in a mental health crisis. • How to be supportive, diffuse the situation and encourage professional help. • What to do if someone is suicidal, harming themselves or others, or refuses help.

17. First Aid StrategiesA.L.G.E.E. • Assess for risk of violence, suicide or harm to self or others • Listen nonjudgmentally • Give reassurance and information • Encourage appropriate professional help • Encourage self-help and other support strategies Write these down for later!

18. Job Corps Action Plan • WHAT WE DO NOW • Applicant File Review Process • Appendix 609 Direct Threat Assessments • Appendix 610 Health Care Needs Assessment • Social Intake Form • Within 48 hours for early identification and referrals • Case Management Meeting • Regular meetings among the CMHC and Counselors to review students • Medical Separation Process

19. Job Corps Action Plan • PRH Requirement to provide mental health promotion and education. Training for staff and students using components of Mental Health First Aid—Early Identification—ALGEE! • Mental Health 101—FACT SHEETS/CHRONIC CARE MANAGEMENT PLANS/MHFA GuidelinesLearn the basics of mental illness and how our students struggle with this challenge: understand their symptoms, triggers, actions and how to offer help. • Before the Violence (Gun, Suicide, Harm to Self or Others) Learn how to spot warning signs, potential threats and how to report them. • Working with Emotionally Distressed StudentsHow to approach someone in a mental health crisis; How to be supportive, diffuse the situation and encourage professional help.

20. A—Assess for Risk of Violence, Suicide, or Harm • Some Urgent Warning Signs of Violence: • Inappropriate fascination with guns and/or weapons • Depression: comments about suicide • Essays or creative work that indicate extremes of hopelessness, social isolation, despair, rage • Attempts to bring and/or talks about weapons on center • Some Warning Signs of Suicide: • Threatening to hurt or kill oneself • Seeking access to means to hurt or kill oneself • Talking or writing about death, dying or suicide • Feeling hopeless • Acting recklessly or engaging in risky activities • Increased use of alcohol or drugs • Withdrawing from family, friends, or society • Appearing agitated or angry • Having a dramatic change in mood

21. L—Listening Nonjudgmentally • Verbal and nonverbal skills to engage in appropriate conversation • You are not there to judge the problem. • Is your posture open and inviting (e.g., are your arms/legs crossed)? • Are you making eye contact? • No foot tapping, drumming fingers, etc. These indicate impatience. http://www.nami.org/Content/Microsites316/NAMI_PA,_Cumberland_and_Perry_Cos_/Home310/NAMI_On_Campus5/LISTENING_When.pdf

22. G—Give Reassurance and Information • Examples of the types of reassurance that you could provide are: • that you do not feel differently about them because of their illness • that they are not crazy (if they say that this is how they feel) • that you are not judging them • that this is not their fault • that there is help available

23. E—Encourage Appropriate Professional Help • There are staff members and mental health and substance use professionals who can offer help when someone is in crisis or may be experiencing the signs of symptoms of a mental illness. • On center • Counselor • Center Mental Health Consultant • TEAP Specialist • Center Physician • Health and Wellness Manager • Safety and Security • Any staff member • 911

24. E—Encourage Self-Help and OtherSupport Strategies • Exercise • Relaxation and meditation • Participating in peer support groups • Self-help books • Engaging with family, friends, faith, and other social networks

25. What does ALGEE look and sound like? http://www.mentalhealthfirstaid.org/cs/what_you_learn

26. First Aid Strategies • Assess for risk of violence, suicide or harm to self or others • Listen nonjudgmentally • Give reassurance and information • Encourage appropriate professional help • Encourage self-help and other support strategies

27. Scenario • You are outside the cafeteria when you notice a student behaving strangely. He is walking in circles and having a heated argument with someone who is not there, but has stopped and is now sitting by himself. • Approach him directly, standing squarely in front of him and making clear eye contact. Put your hand on his shoulder and be assertive, telling him he needs to leave the area and go see his counselor. Notify Safety and Security. • If you feel safe and able to approach him non-confrontationally, ask if he’s OK and what help he might need. Assess the situation for risk of harm to yourself or others. Ask can you walk over together to talk more at the Health and Wellness Center. • Leave him alone. He’s probably just upset about something. Not a problem as long as he doesn’t come anywhere near you or other students.

28. The ALGEE Action Plan: 1. Assess the risk of suicide or harm • ASK: “Are you having thoughts of suicide or hurting someone else?” • If YES: • Follow the center’s operating procedure for students with suicidal thoughts or who express harm to others. • If NO: • Move on to the next action.

29. The ALGEE Action Plan: 2. Listen non-judgementally • Always stay calm and do not express judgement. • Understand the symptoms for what they are and they are real to the student. • Do not try to dismiss or minimize the hallucinations or delusions.

30. The ALGEE Action Plan: 2. Listen non-judgementally • If you suspect psychosis: • Don’t ignore signs - ask the student about what is happening right now. • Before you start to ask more questions, consider your own state of mind: • Can you stay calm? • Can you help without saying something which may cause further hurt? • Can you cope with the student’s answer? • Ask the student if you can help them find a way to feel better.

31. The ALGEE Action Plan: 3. Give reassurance and information • What you are experiencing can be scary and sometimes young people your age go through this. • There is help so you can cope with what is going on right now. Things can get better. • I would like to help you and keep you safe.

32. The ALGEE Action Plan: 4. Encourage professional help-seeking • Ask the student, have they ever felt this way before and if so what did they do that was helpful. • Is there a staff person the student feels comfortable talking with? • Tell them what help is available on center. • Tell them how a health and wellness staff person can help.

33. The ALGEE Action Plan: 5. Encourage self-help strategies • Talk to someone next time these feelings start to happen. • Talk about benefits of exercise and encourage student to develop their own methods for reducing stress.

34. Keeping Safe • Always want to be positioned where you can easily exit if needed. • The situation may escalate or the student does not want help • Get assistance!

35. Scenarios How would you use ALGEE? • A student seems to be anxious, suspicious and irritable most of the time, especially this weekend. He has the most bizarre plans for the future. Another student reports to you that he keeps mentioning different types of guns and he is acting as if he has not slept for a week.

37. ALGEE Training Resources • Depression • Suicidal Thoughts and Behaviors • Non-suicidal Self-injury (NSSI) • Panic • Traumatic Events (Adult)       • Traumatic Events (Child) • Eating Disorders • Psychosis • Problem Drinking • Problem Drug use • Problem Cannabis use https://www.mhfa.com.au/cms/mental-health-first-aid-guidelines-project/#mhfaesc

40. Guidelines for Training Staff and Students • How do I know if someone is experiencing a mental health crisis? • What are the signs and symptoms of mental health disorder? • How should I approach someone who may be experiencing a mental crisis? • How can I be supportive? • What doesn’t help? • Should I encourage the person to seek professional help? • What about self-help strategies? • What if the person doesn’t want help? • What if the person is suicidal, violent or is harming themselves?

41. Training Resources and Media Clips • Mental Health First Aid Guidelines • http://www.mhfa.com.au/Guidelines.shtml • The Pain of Depression • http://www.youtube.com/watch?v=tVuVorQ9YSY • The Truth about Suicide- Real Stories in Colleges • http://www.youtube.com/watch?v=JaIwuprJbcY • Become a fan of Mental Health First Aid USA on Facebook • Get updates and information on a variety of mental health topics • Sample Role Play Scenario using ALGEE • http://www.mentalhealthfirstaid.org/cs/what_you_learn • Story of Hope and Courage—OCD • http://www.youtube.com/watch?v=Rd5wFzVm-co • Spin the Bottle: Sex, Lies, and Alcohol • http://www.youtube.com/watch?v=DqHYeCLBG6s

42. References Elbogen, E.B. & Johnson, S.C. (2009). The Intricate Link Between Violence and Mental Disorder. Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 66(2):152-161. Fazel, S., et al. Bipolar Disorder and Violent Crime: New Evidence from Population-Based Longitudinal Studies and Systematic Review. (2010). Archives of General Psychiatry , Vol. 67(9), 931–938. Fazel, S., et al. (2009). Schizophrenia, Substance Abuse, and Violent Crime. Journal of the American Medical Association, Vol. 301(19), 2016–23.

43. References Friedman, R. (2006). Violence and mental illness — How strong is the link? New England Journal of Medicine, 355, 2064-2066. Monahan, J., Steadman, H.J. Silver, E., et al. (2001). Risk assessment: the MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press. Shern, D. & Lindstrom, W. (2013). After Newtown: mental illness and violence. Health Affairs, 32(3), 447-450. Steadman, H.J., Mulvy, E.P., Monahan, J.,et al (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry, 55, 393–404.

44. References Swanson, J. Mental illness and new gun law reforms: The promise and peril of crisis-driven policy. (2013). JAMA, Feb 7:1-2. Teplin, L.A., McClelland, G.M., Abram, K.M. & Weiner, D.A. (2005). Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey. Arch Gen Psychiatry, 62(8), 911-921.