Mental Health Related Disabilities

There is a strong relationship among people who experience violence, abuse, and neglect related traumatic events—and their behavioral and/or mental health. For some people, that impact can be long term. As many as 1 in 5 people meet criteria for a diagnosable mental health related disability. Mental Health America (MHA) reports that nearly two-thirds (67%) of this population receive little or no help with recovery and/or healing.

Without supports/treatment, people who experience unmet mental health needs are at increased risk of experiencing dependence on social service systems, self-harm, suicide, and difficulties interacting with the criminal justice system.

Common indicators of mental health related needs can include: constant worry or anxiety; difficulty performing activities of daily living; loss of interest in things they used to find enjoyable; isolating; sleep disturbances; sadness and feelings of depression; panic attacks; irritability and/or angry outbursts; risky behaviors with drugs and alcohol; self-harm; and suicidal thinking.

Be suspicious about things that many people regard as innocent.

Seem intoxicated or high when they are not.

Have fragmented thoughts, share pieces of ideas, or be unable to finish thoughts.

Respond to something only they see, hear, and believe.

Seem withdrawn, anxious, untrusting, depressed, and paranoid. Be aware that for some victims, what seems to be paranoia, is actually a trauma-informed survival skill that serves to anticipate danger— in hope of preventing additional harm. This is sometimes viewed as hypervigilance.

If a person feels challenged and has a history of trauma and mental health related needs/symptoms, theymay do the opposite of what is in their best interest.

Avoid assuming that something is wrong with a person because of negative behaviors. Instead, recognize that something wrong may have happened to them. Behavior may be the only way a person can express that something traumatic happened. All behavior is communication.

It may be difficult for people with mental health related disabilities and/or histories of violence to readily trust you or any other social service professional.

Under stress, people with mental health related disabilities may come across as disrespectful. This can look like challenging authority. Try not to take it personally.

Find out what, if any, medications the person is taking and how the person might be impacted. For example, is the person taking medication that can impact their alertness, communication, or memory/recall? You can also ask if there are words, situations, or questions that are particularly difficult and distressing to the person.

Do not assume anything. When responding to crime victims, focus first interactions based on trauma-informed and person-centered approaches.

Prioritize safety, clear communication, and building trust. Do not make promises unless you are 100% certain you can fulfill them.

Allow extra time for building connection and rapport.

Approach any victim/survivor of violence with compassion. Ask if there is anything you can do to help them feel more comfortable or safe.

Keep your expression kind and neutral, rather than overly sympathetic. Realize that eye contact may be difficult.

Interact in a calm, patient, and slow manner. Don’t rush. Be predictable and kind.

Be mindful of language. When you say I’m not going to hurt you, people with disabilities may hear and respond to the word hurt. Instead, say something like: I’m here to help.

Again, only make promises you are 100% certain you can keep. It’s not helpful to tell a person with disabilities that everything is going to be all right, or that they are OK. It can invalidate the person’s own experiences of reality and erode trust. Instead, let the person know you are advocating for and want to work with them to increase their safety.

Provide direct answers to the person’s questions and tell the truth. Don’t try to make things sound better than they are. Even small exaggerations can lead to distrust. Be honest about what you can and cannot do.

Avoid concealing your hands or making sudden movements.

Extreme anxiety and fear can result in someone shutting down. This doesn’t mean the person is uncooperative or disrespectful.

Let the person know there are other people who can help them moving forward. Many people with disabilities do not know about or have reliable access to traditional victim services for healing and recovery.

Tell people with disabilities it is OK to feel upset when something dangerous or scary happens to them or to someone they know or care about.

Being genuine and caring is more important than saying perfectly or exactly the right thing to people with disabilities who have experienced a violence related traumatic event.

Speak clearly and plainly, using short sentences. Avoid sarcasm, metaphors, or jokes.

Try not to be fearful or react to the way people with disabilities may be demonstrating grief, loss, and trauma.

Withhold judgments. Everybody’s experience is different. Understand you are entering a new situation. The person with disabilities may know more about what is and has been happening.

Be direct and clear about who you are and what your role is.

Explain what you will do and talk about and how long it will take.

Allow the person to control the situation as much as possible. For example, allow people with disabilities to decide where they want to sit and when they want a break. Avoid power struggles.

Spend time getting to know the person to build rapport. Even a little bit goes a long way in establishing trust.

Ask questions that are not direct at first. After you get to know the person a bit more, ask what they like to do, instead of “How was your day”?

Ask: What kinds of music do you listen to? What do you like to do for fun? What’s your favorite thing to do on the week-end?

Keep the meeting space free of distractions. Leave a clear path to the exit and make sure they are facing the exit and do not feel trapped. Keep doors open when possible.

Panic attacks are unexpected and repeated episodes of intense fear, sometimes accompanied by: chest pain, heart palpitations, and shortness of breath, sweating, dizziness, or abdominal distress, according to Mental Health America.

These symptoms can mimic a heart attack or other life-threatening medical conditions. Many people with a panic disorder develop intense anxiety, worrying when the next episode will happen. Effective treatments have been developed for panic disorder.

If a care attendant, family member, or staff member knows that the person you’re seeing has panic attacks and knows the symptoms, 911 may not be necessary.

However, do call 911 if there is any concern of a medical condition including a heart attack, or if nobody knows what’s happening and the person/victim cannot communicate what they need.

Remain calm and use a reassuring and firm voice.

Speak to the person clearly and slowly. Use short, clear and direct sentences.

If the person has had panic attacks before, ask what has been helpful.

Let the person know that while the fear terror is real, the panic attack symptoms will pass.

If the person is breathing rapidly, model a normal breathing rate yourself.

Don’t ask the person to breathe into a paper bag. They may become unconscious from breathing their own carbon dioxide.

During a psychotic episode, a person’s thoughts and perceptions are disturbed or distorted. The person may have difficulty understanding what is real and what is not real (a loss of contact with reality as most people see it), according to the National Institute of Mental Health. Symptoms of psychosis are characterized by hallucinations (sensing things that are not there) and delusions (strongly held and seemingly irrational beliefs).

A person’s thinking and speech may be fast, disorganized, disjointed, and incoherent, and their behavior may be inappropriate for the current situation. Other behavioral changes can include neglect in personal hygiene, social withdrawal, and extreme changes in their usual daily activities.

The person may also be experiencing feelings of depression, anxiety, difficulty sleeping, social withdrawal, lack of motivation, and difficulty functioning in general.

Hallucinations can be experienced as hearing, seeing, smelling, tasting, or touching something not actually there, or losing a sense of balance or position in space. People who experience hallucinations may hear voices no one else can hear or smell things or feel things that no one else is smelling or feeling. A person may also have sensations and/or feel things that are not observable by others (something crawling on/under their skin).

A delusion is holding firmly to beliefs that are not or cannot be proven to be truth, such as being related to a famous person, believing that a particular person is planning to do them harm, or that someone is sending them special messages through the TV. It’s fairly easy to see how a person’s experiences of violence and betrayal by trusted persons can impact beliefs.

Hallucinations and delusions can occur at the same time as experiences of abuse. Take care not to dismiss reports of violence, because there are hallucinations and delusions occurring at the same time. For example, someone may describe a person coming out of the wall when they actually came through a door, or they may describe a person as a celebrity because that person share some features with the celebrity.

Some of the mental health related experiences we’re sharing: capacity to communicate; difficulty with trust; panic attacks; self-harm and suicidal thinking; medication side-effects; delusions; and hallucinations [auditory, visual, sensory]); are included in the diagnostic criteria for major depression, bi-polar disorder, schizophrenia, traumatic brain injury, and trauma and stressor related disorders.

Do not dismiss, argue, or laugh about the person’s beliefs or what they are seeing, hearing, smelling, or experiencing. Remember that it is real to them.

If you determine a person is in danger of harming themselves or others, make sure they are evaluated by a mental health professional as soon as possible.

A person experiencing psychosis may understand what you are saying, even if they are not responsive.

The same person can also still interact with others, although at times they may not be able to speak or think clearly.

Keep in mind— just because someone describes something out of sync with a factual timeline—it does not mean “nothing really happened”. A trauma reminder – can bring up memories and/or the re-experiencing of something that has happened in the recent or distant past.

Use short sentences and repeat things if necessary. Give easy to understand, clear, and immediate directions.

Understand and be sensitive to a person’s often overwhelming feelings of anxiety and fear.

Say neutral things like: I can see you are upset. This must be scary for you.

Techniques for developing a sense of connection to their body and the environment (Example: I am sitting on a brown chair, I can feel my legs, and I can move my fingers, I see a picture on that wall.)

Staying in touch with and naming feelings.

Writing or drawing.

Meditating with visual imagery.

Reality checks are about what is happening and how a person may be viewing/interpreting what is happening. Reality checks can help a person tell the difference between their thoughts and feelings, and what they are hearing, and seeing. And, that can be very different from what others are thinking, feeling, hearing, and seeing.

Practically, the goal for a reality check is to see a situation like it really is rather than what a person may be thinking, feeling, hearing, or seeing.

One example of a reality check can be “walking into a room and seeing your best friend— turn away with a frown”. One person may see (perceive) and interpret (thinking) this event as disturbing evidence their best friend is upset with them. A second person may (perceive) and interpret (thinking) this event as evidence their best friend just didn’t see them. The reality may be the best friend did see you enter the room. Then, they turned away to answer a disturbing call from their child’s teacher.

For a trauma survivor— without intervention and healing supports, their story or reality can continue to be heavily influenced by the reality of victimization and betrayal.

People with disabilities who have auditory hallucinations (hearing voices from inside their own head or voices coming from outside of the person’s own head that nobody else is hearing) can use many of the same prevention and management techniques listed above, with the addition of talking to themselves to distract from the message of the other voices. (Adapted from National Council for Behavioral Health & Akers, Schwartz, & Abramson, 2007; 2020)

Don’t discourage this self-talk. If what you hear the person saying becomes concerning or threatening, it is okay to ask what the person is hearing and how you can help.

Bring in or consult a professional with experience supporting people with hallucinations or delusions if you are unsure how to engage with what the person is experiencing.

For more information about responding to distressed people with disabilities see the above: All People with disabilities – Responding to Distress.