Practical Skills for Working Effectively with Clients with Mental Health Issues

1. 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

2. Agenda • Overview of RPCs • Implementation of RPCs • Identifying Diminished Capacity • Maintaining a normal client-lawyer relationship • Interviewing skills • Mental Health Issues • Determining Diminished Ability Columbia Legal Services

3. Rules of Professional Conduct • 1.14 Client with a Diminished Capacity • 1.6 Confidentiality of Information • 1.4 Communication • 1.2 Scope of Representation

4. 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

5. Identifying Diminished Capacity - Comment 6

6. Possible Signs of Impairment Cognitive Signs Behavioral Signs Delusions Hallucinations Grooming/Hygiene Difficulty with activities of daily living • Short-term memory loss • Comprehension Problems • Communication Problems • Lack of mental flexibility • Calculation Problems • Emotional inappropriateness

8. 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

9. 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.

10. The Communication Process – Principles and Techniques • Context • Structure • Basic Interviewing Skills • Additional Considerations

12. Structure • Roadmap • Outline the process – what will happen • Your role • Client’s role • Time constraints • Objectives • Yours • Clients • Expectations

13. LEEP - Four Basic Interviewing Skills • Listen • Engage • Express • Problem Solve

14. Listen • Demonstrates the interviewer is paying attention and cares • Encouragement to talk • Relevant note taking • Intentional silence King County Bar Association

15. 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

16. 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.”

17. 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?

18. 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

19. Engage Client • Interaction 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

20. 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?

21. 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)

22. Express • Giving 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

23. 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

24. 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

25. 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

26. Problem Solving • Interrupting • Communication Issues King County Bar Association

27. 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?” King County Bar Association

28. Interviewer Communication Issue • Bothered by client behavior • Respond v. React • Keeping in touch with your emotions • impulsivity

29. 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 King County Bar Association

30. Cont’d • Mistakes • Admit • Repair errors or oversights King County Bar Association

31. De-esculation Techniques • Verbal cues • Tone of voice • Volume of voice • Rate of speech King County Bar Association

32. 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 Columbia Legal

33. Do • Empathize • Accept client’s feelings, thoughts and behavior even if outside of “norm” • Compassionate but firm • Announce your actions and movements King County Bar Association

34. Specific Mental Health Issues • Delusional/Paranoid • Severe Trauma (PTSC, DV) • Borderline • Suicidal King County Bar Association

35. 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 King County Bar Association

36. 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 King County Bar Association

37. 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 King County Bar Association

38. 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! King County Bar Association

39. Next Steps - Level of Impairment

40. 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

41. 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

42. 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)

43. 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 King County Bar Association

44. 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

45. 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! King County Bar Association

46. 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

47. 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.

49. 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 King County Bar Association

50. [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.”