Individuals with developmental disabilities have co-occurring mental disorders two to three times greater than the general population.  According to Dr. Robert J. Fletcher, DSW, ACSW (2007, Diagnostic Manual-Intellectual Disability, NADD and America Psychiatric Association), it is estimated that 30 to 40 percent of individuals with a developmental disability also have a mental health condition or a mental illness.  The medical term is known as dual diagnosis.  This means they have a developmental disability and a mental health condition.  Mental health conditions are often missed because the actions associated with the mental health condition are often attributed to the developmental disability.  According to the Department of Mental Health, the most common class of mental disorders for persons with dual diagnoses is psychotic disorders. 

Mental health conditions include:

• Depression (extreme or prolonged episode of sadness);
• Bipolar or Manic-Depressive Disorder (alternating episodes of mania "highs" and depression "lows");
• Anxiety Disorder (severe fear or anxiety associated with certain objects or situations);
• Schizophrenic Disorder (hallucinations, delusions, and thought disorders); and
• Obsessive-Compulsive Disorder (pattern of obsessive or repetitive thoughts or behaviors).

Involuntary Psychiatric Hospitalization

In California, involuntary psychiatric hospitalizations vary between 70 to 132 times per month for out-of-home placement consumers.   

When an individual is overwhelmed or stressed they may be in crisis. They may become dangerous to themselves or others or destroy things or property. When this occurs, the support person may need to call 9-1-1 for assistance from the police or paramedics. The individual may be hospitalized to provide them with a safe place to recover. At the hospital the individual will be evaluated and receive treatment. The individual may return home from the hospital the same day or they may be kept at the hospital for up to 72 hours. Staying in the hospital allows mental health staff to do a thorough assessment and provide treatment to stabilize the individual. If the person is still in crisis, the mental health staff can ask a judge to have the individual hospitalized for treatment for 14 days or longer.

As a support person, you may notice warning signs.  Warning signs are a heightened state of the behavior the individual may normally exhibit. These may indicate an individual may be in a mental health crisis and may need support.  Warning signs to watch for include the following:

• The individual is acting in a strange or frightening manner. They may threaten other people. They  become agitated for no apparent reason. They seem angry or hostile.
• The individual appears to be unusually sensitive when interacting with others. They seem suspicious or paranoid.
• The individual seems overwhelmed by their ordinary daily routine. They worry constantly about everyday events such as eating, dressing or their performance at work.
• The individual talks about hurting themselves or others.
• The individual is irritable or restless. They are unable to concentrate.
• The individual’s sleep pattern changes dramatically. They have difficulty sleeping.  Or, they want to sleep all the time and may be difficult to wake up.
• The individual may experience hallucinations. They may imagine people are talking to them (hearing voices inside their head).
• The individual may take action based on delusions or imaginary thoughts.
• The individual talks or laughs to themselves.
• The individual seems to be fearful. They express panic or anxiety. They talk about feeling threatened.
• The individual refuses to eat, bathe, or participate in a planned program.
• The individual may sit for long periods of time without doing anything. 
• The individual shows signs of increased depression with withdrawal and eating less.
• The individual seems excessively sad or excessively elated. 

Crisis Intervention Tips

To help the individual through their mental health crisis safely, you can:

• Use positive communication to diffuse the situation and build rapport.  Positive communication means listening actively, asking open-ended questions, and using receptive body language.
• Rule out basic needs: Hunger, thirst, pain, medical or dental issues.
• Drop all demands and requests.
• Eliminate a power struggle; the individual is trying to regain some control of their environment. 

Individuals with a mental health condition may become upset due to stressful situations in their lives.

Stressors may include the following¹:

• Transitional phases or changes in routine:
  • Change of home, school, or work place.
  • Change of route to home, school, or work place.
  • Developmental landmarks (e.g., becoming a teenager, turning 18 or 21 years of age, becoming an adult).
• Interpersonal loss or rejection:
  • Loss of parent, care giver, friend, or roommate.
  • Breaking up with a boy or girlfriend
  • Being fired from a job or suspended from school.
• Environmental:
  • Overcrowding, loud noise, disorganization.
  • Boredom.
  • Lack of privacy at home.
  • Stress from work or school.
• Parenting and social support problems:
  • Lack of support from family, friends, or partner.
  • Upsetting visits, phone calls, or letters.
  • Neglect or isolation.
  • Hostility.
  • Physical or sexual abuse.
• Illness or disability:
  • Chronic medical or psychiatric illness.
  • Serious acute illness.
  • Seizures.
  • Challenges associated with their developmental disability.
• Frustration:
  • Due to inability to communicate needs and wishes.
  • Due to lack of choice about residence, work situation, diet.
  • Taunts, teasing, exclusion, being bullied or exploited because of disability.
  • Because of realization of deficits or of things the individual is unable to do.

You can assist the person you support by planning ahead for times when they may experience increased stress.

By planning ahead, you can respond to the warning signs and prevent involuntary psychiatric hospitalization.

Identify which of the individuals you support have chronic mental health or behavioral conditions.

Observe for situations or critical events (stressors) which cause stress for the individual.

Observe the individual for changes in their behavior.

• If an individual is taking antipsychotic medications, observe for side effects. Discuss any side effects with the individual’s physician and the Regional Center Service Coordinator.
• If an individual has a history of behavioral emergencies, monitor their behavior. Discuss unusual behaviors with the Behavioral Consultant and Planning Team. Notify the Regional Center Service Coordinator if you see significant changes in behavior.

Provide the individual with support, structure, and guidance. 

Encourage the individual to avoid certain stressful situations and plan alternatives.

• Help reduce stressors by helping the individual participate in activities for shorter periods of time.   Plan rest periods.
• Plan events with fewer people. Identify which people cause the individual stress. Plan activities or events with people who are not as stressful for the individual.
• Assist the individual in scheduling counseling or therapy sessions with a mental health professional.
• Work with the Regional Center Service Coordinator to locate appropriate resources for the individual.
• Teach the individual how to manage stress with relaxation exercises and meditation.
• Encourage the individual to use positive “self talk.”  Make a list of things they do well and enjoy.
• Encourage the individual to seek help from support staff, family members, and friends.
• Provide advocacy training for the individual. Teach them how to request changes to a stressful situation.  Assist the individual to leave the stressful situation. 

Reduce temporary high stress levels.

This can be done by:

• Lowering demands on the individual and activity levels:
  • Follow a familiar routine while minimizing changes.
  • Keep expectations realistic.
  • Provide the individual with a safe, calm, and predictable environment.
  • Acknowledge appropriate behavior.
• Help the individual become calm:
  • Suggest preferred or favorite activities.
  • Provide social support.
  • Provide the individual with time alone.
  • Suggest the individual listen to favorite music or watch favorite DVDs.
  • Engage the individual in relaxation activities.
  • Suggest the individual exercise or go for a walk. 

Remain calm. Demonstrate a calm and controlled manner for the individual .

Assist the individual in calling for help.

• Give the individual your telephone number.
• Make sure the individual knows how to call their Regional Center Service Coordinator.
• Talk to the Service Coordinator about possible crisis services that are available and how to access them. 
• The National Suicide Prevention Lifeline is a free, 24-hour hotline available to anyone. If the individual is thinking about hurting themselves, you can assist them in making the call. The call will be forwarded to a crisis center near you. Call 1-800-273-TALK (8255)
• Assist the individual in locating the local County Mental Health Crisis Intervention Service. These are 24-Hour services. Click here for a list of telephone numbers.
• Assist the individual in calling Network of Care for more ideas about resources groups in their area. The Network of Care is a web-based community resource center that provides useful information to individuals with disabilities and their support persons. Click here to find resources in California.

Contact emergency support services if necessary.

Sometimes it is not possible to avoid hospitalization. If the individual is dangerous to themselves or others, the support person should call 9-1-1.

The police and/or paramedics will respond. 

• If the individual appears to be calming down, the police or paramedic may advise them to call their psychiatrist, physician or Regional Center Service Coordinator for help and assistance.
• If the individual continues to appear dangerous to themselves or others, the police or paramedic will take the individual to an emergency psychiatric hospital.

At the hospital, medical staff will evaluate the individual and their mental health condition.

• If the individual appears to be rational and calm, the hospital staff may counsel them or provide medication. They may call the support staff and tell them the individual is ready to come home.
• If the individual continues to be a danger to themselves or others, the hospital staff may place the individual on a 72-hour hold. This means the individual is in a crisis and in need of inpatient mental health care.

The hospital will notify the Regional Center Service Coordinator to have a team meeting. The meeting will help determine if the individual needs further mental health treatment after 72 hours. This treatment may be in an inpatient setting such as a psychiatric hospital.  Or, it may be treatment the individual can receive in the community after returning to their own home.

As a support person, you will want to stay in contact with the individual.

• Talk to the individual on the telephone. 
• Offer to bring personal items to the hospital, including clothing or special personal objects. Check with hospital staff regarding what you can take to the individual.
• Call the hospital and ask about visiting hours. Visit the individual. Let them know you are available for them when they return home.
• Work with the Regional Center Service Coordinator to plan how to reduce stress on the individual when they return home. 
• Ask the Regional Center Service Coordinator about additional supports in the community you can help the individual use when they return home.

When the individual returns home, assist them in making a plan to avoid the next crisis.

Remember! Prevention is our number one priority!

Other Resources

• Identifying and Supporting Consumers at Risk, Supporter Tool
• Winter 2007, SafetyNet Newsletter: Understanding Mental Health Conditions
• Mood Disorders
• Stress and Anxiety

 

¹American Journal on Mental Retardation Special Issue. Expert Consensus Guideline Series: Treatment of Psychiatric and Behavioral Problems in Mental Retardation.  May 2000, Volume 105, Number 3, pp. 159-228.