practical skills for working effectively with clients with mental health issues

PRACTICAL SKILLS FOR WORKING EFFECTIVELY WITH CLIENTS WITH MENTAL HEALTH ISSUES

MERF EHMANCOLUMBIA LEGAL SERVICES

BASED ON MATERIALS FROM THE

NEW ENGLAND TRAINING CONSORTIUM

1

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

IDENTIFYING DIMINISHED CAPACITY - COMMENT 6

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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LEEP - FOUR BASIC INTERVIEWING SKILLS

Listen

Engage

Express

Problem Solve

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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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King County Bar Association 14

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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PROBLEM SOLVING

Interrupting

Communication Issues

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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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CONT’DMistakes

• Admit• Repair errors or oversights

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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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NEXT STEPS - LEVEL OF IMPAIRMENT

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.”

practical skills for working effectively with clients with mental health issues

Documents

reflectpurposereassures

client communication

reasonable client expectations

diminished capacity

diminished capacity1

clients messageexample

adequacy of communication

clients overall requirements