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Greg Gibson, M.A.H.S.,
Coordinator, Homeless Services
Texas Department of Mental Health Mental Retardation
Human service managers are frequently faced with new demands to provide quality services. People who access residential services often arrive with little more than the clothes on their back. Many have recently experienced moderate to severe psychosocial stressors, and they may be confused, disoriented, and despondent. Some may have a history of psychiatric illness and substance abuse.
Residential service staffs often have limited experience in assisting people who have mental disabilities. The facilities are often not very well designed to provide its customers with opportunities to relax. Transportation to behavioral healthcare services may be unreliable or impractical. The public transportation system is frequently non-existent or highly inconvenient.
Given these challenges, it is likely that the human service manager will be faced with managing behavioral crises. Psychiatric emergencies in residential settings can be a challenge that must be faced by the human services program manager.
There are many causes of behavioral health crisis in residential facilities. Customers of these facilities often have experiences that are beyond the normal experiences that residential staff has witnessed. However, some residents may have a diagnosable mental illness.
Mental illnesses are clusters of symptoms or patterns of behavior that cause distress and impair functioning. These illnesses, if untreated, may cause death, pain, and loss of freedom for the individual. The characteristics of these symptoms can be ordered and classified. Some of the more commonly encountered mental disorders that may be encountered in facilities are psychotic disorders, mood disorder and personality disorders.
Psychotic disorders are characterized by gross disturbances in thoughts, feelings and relating to the world. In psychotic Disorders, delusions and hallucinations are present. The delusions and hallucinations may be related to a theme, such as an unwarranted feeling of persecution. An individual's response to others may be inappropriate (e.g., as laughing upon receipt of bad news or sexual inappropriateness in public). Social impairment and oddities of behavior are common. Loosening of associations between thoughts and within conversations may occur. When trying to carry on a conversation with a person who has a psychotic disorder, it may be difficult for that person to focus and stick to a topic.
Mood disorders are characterized by a disturbance in the way people feel about themselves, others, and the activities in their lives. With a Major Depressive Disorder, a depressed mood or a loss of interest or pleasure in nearly all activities occurs. The person may have a serious impairment in attending to things that may be of importance such as work or family. The person often describes their mood as depressed, sad, down in the dumps. Feelings of worthlessness, excessive guilt, indecisiveness, or suicidal thoughts may be present. Disturbances in sleep and concentration can be observed. Weight loss (or gain), poor personal hygiene, and decreased energy is often reported. To others, the person may appear sad, irritable, tearful, obsessive, and appear to worry excessively. Bipolar Disorders, also a disorder of mood, are characterized by one or more manic episodes in addition to features associated with depressive episodes. Manic episodes are characterized by euphoric, elevated, or expansive moods that last at least a week. The person may have an inflated sense of self-esteem or grandiosity, decreased need for sleep, and be more talkative than usual. Their thoughts may race along, and may be easily distracted. Excessive involvement in pleasurable activities that may be harmful may also be observed. People who are in a manic episode may not recognize their mood. They may be impulsive, making bizarre changes to their dress, giving away possessions, suddenly traveling long distances.
Personality Disorders are enduring patterns of behavior and thoughts that may be very different from what is expected in their culture. These patterns of behaviors are typically stable over time, are observed to be inflexible, maladaptive, and lead to distress and impairment. Personality Disorders can be grouped into three clusters. Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals in this grouping appear odd or eccentric. Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these Disorders appear dramatic, emotional, or erratic. Cluster C includes the Avoidant, Dependent, and Obsessive Personality Disorders. Individuals with these disorders appear fearful or anxious.
The presence of a mental illness does not tell one the extent that the illness impairs a person's ability to perform daily activities that may be important to quality of life. The presence of a mental illness does not necessarily preclude a person from accepting responsibilities for his/her actions. Behavioral health clinicians often utilize a tool known as the Global Assessment of Functioning (GAF) scale to assess the persons functioning. This scale is scored on a range of 0 - 100. A score of 10 on this scale would indicate that the person presents a persistent danger to themselves (suicidal) or danger to others (homicidal, frequently violent). Inability to maintain minimal personal hygiene would also score a ten. A score of 50 would indicate that serious symptoms are present such as difficulty in keeping a job, suicidal thoughts, no friends, or frequent involvement with law enforcement (i.e. shoplifting). A score of 90 indicates that minimal symptoms may be present, but he/she may still be socially effective with no more than ordinary problem. In order to receive public mental health services in Texas, a person must be a member of the priority population. In order to be a member of the priority population an adult must be diagnosed with a serious mental illness (Schizophrenia, Bipolar Disorder or Major Depressive Disorder) and must have a GAF score of 50 or below. A different set of criteria exists for people under 18 years old.
Almost 2.6 million Texans -nearly one in six people-have some form of mental illness. Approximately 340,000 are members of the "priority population." Due to limited resources, TDMHMR is only able to serve about 115,000. Funding from the Texas Department of Mental Health and Mental Retardation (TDMHMR) assists individuals most in need of mental health services. Services in Texas are generally provided by Community Mental Health and Mental Retardation Centers, which are organized by county, local, or state governments. Individuals access services by first contacting the nearest community-based program. The community-based program determines eligibility for services, service needs, and service locations.
Thirty-five community MHMR centers are located across the state. These centers contract with the Texas Department of Mental Health and Mental Retardation to provide core services. Many provide additional services using non-state funds.
Individuals contacting a community-based program may also be referred to a state facility for services. State facilities offer core services in local communities as well as residential services provided on the facility campus. Nine state hospitals provide services to people with mental illness, and 13 State schools serve individuals who have mental retardation and related conditions. Three State centers provide both mental health and mental retardation services; two provide mental retardation services only.
Community Mental Health and Mental Retardation Centers should be able to provide assistance to the staff and customers of a residential facility. Community Mental Health Centers are required to provide core services in the county or regions that they serve. One of these core services is assessment. Assessment is the process of obtaining and evaluating historical, social, functional, psychiatric, developmental, or other information from the individual and family seeking services sufficient to determine priority population eligibility, level of need (including urgency), specific treatment needs, and personal strengths (including the preferences of the person seeking services). Another core service is Service Coordination. Service Coordinators facilitate access to resources and services as needed and coordination of the individual's treatment with the individual, family, and collateral providers, as appropriate. Often, Service Coordination is provided by a single continuity of care staff person responsible for each individual served.
Community Mental Health and Mental Retardation Centers can assist residential service providers with persons who have a mental illness and who may be residing in their facility. However, a behavioral crisis is not readily predictable, and some crises may not be due to an underlying, serious mental disorder.
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