Summary

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Overview

There are a number of reasons why a person with disabilities may need to request mental health services, including: the need for a psychiatric evaluation to see if a mental health condition exists, an assessment of behavior disorders, to follow up on possible warning signs for suicidal behavior, how to respond to stress reactions to critical incidents (such as the terrorist attack on 9-11) and ordinary life stresses. It may be that some signs or symptoms are part of the ?normal? reaction to stress and can be handled at home with simple interventions. However, sometimes the signs or symptoms an individual with disabilities experiences may require mental health treatment, in the form of counseling and/or medication. While children may have mental health needs, other symptoms of mental health may not appear until adulthood.

Access to Mental Health Services

Most Community Mental Health Centers (CMHC) serve both children and adults. Valley Mental Health, in Salt Lake County, is the only CMHC large enough to have a free-standing ?Children?s Outpatient Unit.?

The process for getting services from the community mental health centers (CMHC) is similar across the State. (A list of centers is in the Resource Section of this section.) On the first call to the CMHC main number, let the receptionist know you are requesting an Intake appointment for yourself or your family member. This request begins the Screening process, which will determine whether you will then be scheduled for a formal Assessment. The receptionist will ask a few screening questions about your address (to determine whether or not the person is eligible). You will also be asked about billings issues, such as insurance and Medicaid/Medicare eligibility, so you will want to have this information on hand. If you are uninsured, you will be asked to pay something for the services on a sliding scale.

After the phone screening, you may be given an appointment for an Assessment, which will determine which services are needed, and whether these services are available from this provider at this location. The Assessment is not a guarantee of further services, but will determine whether or not your need can be met by this provider.

Denial of Services

You may not be given an appointment for an Assessment; you may be told that you or your family member is not eligible for these services. If your request cannot be met at this location, or from this type of provider, you can request a full and respectful explanation of the reasons for the denial of services. For this explanation, you may need to be referred to someone at the center besides the receptionist and you may request this. Mental health funding can sometimes specifically exclude certain groups, such as those with developmental disabilities or traumatic brain injury.

Ideally, you should receive some information about where to go next to make your request. If you are fortunate enough to have Division of Services for People with Disabilities (DSPD) services, your Support Coordinator may help you locate other alternatives for the services you need. If you are on the waiting list for DSPD services, you may want to ask your DSPD intake worker if DSPD ?service brokering? funds are available to help with your situation.

If you have DSPD services, the Medicaid Home-and-Community-Based Waiver (HCBW) may fund some mental health treatment, such as medication management or counseling. You can check with your Support Coordinator to find out whether these services are available to you through DSPD funding. If so, you may be able to choose from a list of individual or private providers, instead of the community mental health centers. There is one specialized mental health treatment unit for people with disabilities, called the UNI-Home Project. This is administered by the University of Utah Hospital and has contracts with both DSPD and Valley Mental Health, the CMHC for Salt Lake County.

In the past, people have found that getting referrals from the field of disabilities to the field of mental health and vice versa has been difficult, and it may seem like there is no interaction between the two. This has come about because the funding for each of these fields comes from different sources and they each have their own set of guidelines and restrictions, which are in place to prevent overlapping services. Sometimes the professionals in one system do not have the skills required to diagnose people in the other system. For instance, some CMHC?s have professionals trained to treat the problems associated with intellectual disabilities, but many do not. While there may be a need for a person with disabilities to take medication to help with mental health issues, finding a psychiatrist that is familiar with all of these needs may be difficult; especially in rural areas. Some rural CMHC?s will accept clients with disabilities for ?medication management only,? which you can request.

Evaluations

Outside the CMHC?s, an evaluation may be done by private providers through the Medicaid or the waiver funding, through private pay, or sometimes may be covered by insurance. You may request an evaluation directly, or through your DSPD Support Coordinator, if you have one. The difficulty may be finding the professional who is trained to do psychiatric evaluations for a person with intellectual disabilities. In order to qualify for mental health services, the person with a disability must have a separate mental illness, not necessarily connected with intellectual or developmental disabilities. This is called ?dual diagnosis?, meaning that there are two conditions present: the intellectual/developmental disability and the mental illness. It is not always easy to tell the difference between the symptoms of an intellectual disability and the symptoms of mental illness. People with disabilities may not be able to communicate their needs in appropriate ways, and their symptoms may appear to be mental health issues when they may be a result of being unhappy with their circumstances or symptoms of their disability. It is important to distinguish whether or not the problems may be solved with medication or may respond better to behavioral interventions, meaning changes in the person?s environment. You may find it helpful to make a log of behaviors over time, with times of day, triggering events, the people involved, and any other facts that you feel may be pertinent. Very often, it is the behavioral interventions that are most needed, but these are not usually part of the training of the CMHC providers. They are found more readily in Qualified Mental Retardation Professionals (QMRP?s) with specialized behavioral training.

Sometimes, family members may be reluctant to fully describe the symptoms of the person?s behavior for fear that they may be blamed. Family members will be most helpful to the evaluation process if they describe the situation in detail and even admit feeling trapped in a never-ending cycle of negative behaviors. Health care professionals should not blame family members for these behaviors, but should assist them in learning how to prevent them.

If the situation involves physical harm and/or property damage, there is a greater likelihood that you will get a prompt referral for mental health treatment. Aggressive behavior (such as hair pulling, body scratching, bullying, destruction of property, etc.) or withdrawn behavior (such as frequent crying, preference to be alone, easily frightened, etc.) may be curtailed by using anti-anxiety or anti-depressive medications or by using more effective behavior management techniques. Sometimes an in-patient stay in a psychiatric facility for observation is required. This option is very expensive and often unavailable unless there is evidence that the person will do harm to themselves or others.

Warning Signs of Depression

Symptoms of depression are often experienced by primary caregivers. These can include feeling empty, a growing inability to enjoy anything, hopelessness, loss of sexual desire, loss of warm feelings for family and friends, feelings of self-blame or guilt, and loss of self-esteem. Changes in behavior and attitude can include a general slowing down, neglect of responsibilities and appearance, poor memory and inability to concentrate. Physical symptoms may include sleep disturbance, such as early morning waking, sleeping too much or insomnia; lack of energy; loss of appetite; unusual weight loss or gain; unexplained headaches or backaches, stomachaches, indigestion, or changes in bowel habits.

A caregiver experiencing these symptoms would have a good reason to seek a psychiatric evaluation and to begin anti-depressive medication, and/or mental health treatment. Some people are needlessly opposed to any kind ?medication.? New medications have been developed with very few side effects, and no anti-depressive medication is addicting. That is not true for the anti-anxiety medications, which should be used very temporarily.

Warning Signs of Suicidal Behavior

People are naturally frightened by the threat of a loved one committing suicide. Though individuals with more severe disabilities may not be able to plan and carry through with a suicide, this might be a possibility with someone with mild to moderate disabilities. Even if the possibility is slight, it is sometimes a real fear for the caretakers

or even a possibility for the caretakers themselves. Therefore, the following danger signs are provided below, in order to help identify the potential for self-harm and the need to intervene.

1. A severe reaction (or no reaction at all) to a recent loss of a close boy or girl friend, or divorce of one?s parents, or death of a loved one.
2. The anniversary date of the death of a loved one, especially if suicidal thoughts were associated with the loss in the past.
3. Sudden changes in personality functioning that don?t fit with what you have known about the person, especially if they are prolonged over many weeks: withdrawal in despondency, inability to communicate if this is new, over-reaction to seemingly minor problems and irritations that were tolerated before.
4. Feelings of severe guilt or hostility toward others which are then turned upon one?s self.
5. A sudden inability to sleep, or an extreme increase in sleep; crying spells for unknown reasons; loss of appetite, or neglect of personal appearance which was not the case previously.
6. Excessive use of alcohol and other drugs; repeated accidents, or increasing anxiety and panic accompanying increased responsibilities.
7. For teen-agers, chronic unresolved family arguments with escalating conflict; adolescent-parent crisis; romantic upsets; excessive statements about ?going crazy? or ?losing my mind.?
8. Increased dependency on others which was not demonstrated before; inability to carry out one?s responsibilities expressed by staying home from school or work; inability in securing a job (not a problem previously); or withdrawal from social groups (enjoyed previously).
9. The expression of a suicidal plan or preparation for an attempt including the collection of pills, the giving away of prized possessions, and the theme of death being prevalent in speech (or writing), directly or indirectly.
10. Expressions such as ?I wish I were dead,? and ?I?m no good to anyone,? or ?The world would be better off without me,? or ?Life is not worth living.?

We can help to prevent suicide.

Research shows no evidence that talking with a person about his or her suicidal feelings has increased the risk. In fact the reverse is true: talking about it and helping the person to process what is underlying these feelings is helpful. Avoid closing off remarks by trying to be ?upbeat? as in ?There, there, you?ll be OK!? If the person can communicate verbally, help by probing and allowing him or her to ventilate feelings. Most importantly, help explore other alternatives: is this the only way to deal with the situation? Why not try something else first? And second? And third?.? Make a plan to have someone stay with the person, if you feel it is necessary. Most suicidal crises have a time frame of only one or two days, but can be repeated. Severe or ongoing suicidal thoughts/actions would be reason for a course of mental health treatment, leading to psychiatric hospitalization if necessary.

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RESOURCES

The National Association for the Dually Diagnosed (NADD): NADD Web Site NADD is the leading North American expert in providing professionals, educators, policy makers, and families with education, training, and information on mental health issues relating to persons with intellectual or developmental disabilities.

DDMED Website by Alabama Department of Mental Health and Mental Retardation Web Site DDMED provides a roadmap for professionals and caregivers for persons with intellectual disability and other health problems such as mental illness or neurological disorders.

Attached is a Directory of Utah State Mental Health Services. Utah State Mental Health Directory.