Chapter 5: Crisis Case Handling

Principles Comparison Long-Term Therapy Crisis Intervention Diagnosis: Complete evaluation Treatment: Focus on underlying issues Plan: Focus on long-term needs Methods: Systematically effect short-term, intermediate, and long-term gains Evaluation: Validation is based on client’s total functioning Diagnosis: Rapid triage Treatment: Focus on immediate trauma Plan: Focus on immediate needs Methods: Use brief therapy to gain immediate control Evaluation: Validation is based on the return of pre-crisis level of equilibrium

Objectives Comparison Long-Term Therapy (order is irrelevant) Crisis Intervention (order is relevant) Prevent problems Correct etiological factors Provide systematic support Facilitate growth Re-educate Express emotional attitudes Resolve conflict Accept reality Reorganize attitudes Maximize intellectual resources Ensure client safety Predisposition Define problem Provide support Examine alternatives Develop a plan Obtain commitment Follow-up

Assessment Comparison Long-Term Therapy Crisis Intervention Intake data: Client is stable and provides comprehensive details Safety: Typically not the primary focus unless indicated Time: Ample time for formal and informal assessments Reality testing: Typically not needed unless indicated Referrals: Used to achieve long-term goals Intake data: Client may not be stable and crisis worker relies on verbal/visual cues Safety: Client and other’s safety is the first concern Time: No time for formal assessments Reality testing: Always assessed via verbal/non-verbal cues Referrals: Used to attain safety and stability

Assessment Comparison Cont. Long-Term Therapy Crisis Intervention Consultation: Available as needed Drug use: Assessed via intake data and throughout the course of therapy Disposition: Begin and end therapy with the same counselor. Therapy is usually voluntary Consultation: Sometimes available via specifically trained police officers or mobile crisis teams Drug use: Immediately assessed via verbal and non-verbal cues Disposition: Begin and end intervention with the same worker within hours to days. Initial intervention is often involuntary

Walk-In Crisis Facilities Types of Presenting Crises Chronic Crisis Community Mental Health Centers Act of 1963 Increased drug abuse and rates of crime Mental health centers shift focus to “developmental” issues Understaffed and underfunded mental health clinics Acute social/environmental crises Survivors of violent crimes or natural disasters, terminally ill, runaways, addicts, unemployed, etc. Precipitating events may be unexpected and may leave entire systems in disequilibrium. Combination types Types overlap The rule rather than the exception

Community Mental Health Clinic Entry Clients may admit themselves voluntarily or be admitted by their family, social service agency, or by the police. Commitment Clients may remain if they are stable or be hospitalized if they are a danger to themselves or others. Under no circumstances should a crisis worker transport a client. Intake interview Assess for client safety (degree of client lethality) and drug use Begin to define the presenting problem Apprise the client of their rights

Community Mental Health Clinic Cont. Disposition Proposed diagnosis and treatment recommendations are constructed Client has the right to accept or reject services Full clinical team meeting is held to adjust and confirm the treatment plan Anchoring The client is not left alone Therapist gives the client a verbal orientation Short-term disposition Short-term provisions are made for necessities such as food, clothing, shelter, and medication

Community Mental Health Clinic Cont. Long-term disposition Interdisciplinary team (psychiatrist, pharmacist, psychologist, counselor, and social worker) meet on a regular basis to review the client’s progress Twenty-four-hour service Crisis hotline Police Department Crisis Intervention Team Mobile crisis teams Operate to serve clients who are physically unable to transport themselves to receive services (i.e., elderly, physically disabled, or extreme cases of immobile clients) Typically equipped with sophisticated communication and information retrieval systems Often only available in urban areas

Police and Crisis Intervention Changing role of the police Instrumental vs. expressive crimes Police and the mentally ill Community Mental Health Act of 1963 Memphis Model Crisis Intervention Team (CIT) Program Concept CIT training De-escalation and defusing techniques Fishbowls with clients Success of CIT Suicide by police officer

Crisis Intervention Team (CIT) Program Concept Strong working alliance between the local police department and mental health community. Alliance is collaborative, systematic, and democratic. CIT training Trainees ride with an experienced CIT officer on a weekend evening prior to their formal 40 hours of training. Formal training

Formal CIT Training Cultural awareness of the mentally ill Substance abuse and co-occurring disorders Developmental disabilities Treatment strategies and mental health resources Patient rights, civil commitment, and legal aspects of crisis intervention Suicide intervention Using the mobile crisis team and community resources Psychotropic medications and their side effects Verbal defusing and de-escalating techniques Borderline and other personality disorders Family and consumer perspectives Fishbowl discussion

CIT Program Cont. De-escalation and defusing techniques Basic introductory techniques taught Basic exploratory skills Incorporate the conceptual with the experiential Role play scenarios with difficult clients (e.g. suicidal or severely psychotic) Fishbowls with clients Mental health professional sits in a circle with a client surrounded by CIT trainees and conducts a role play scenario.

CIT Program Cont. Success of CIT Suicide by police officer Increased volume of calls (more awareness of the program) Reduction in the time spent on each call Increased diversion from jail to hospitals Reduction in the use of force Hostage negotiation team is no longer needed In Memphis, only two fatalities have occurred since the development of the CIT program Suicide by police officer People who engage a police officer in a threatening manner and succeed in forcing the police officer to fire their weapon

Transcrisis Handling in Long-term Therapy Anxiety reactions Successful at achieving difficult goals, but struggles with a seemingly minor goal Regression When a client is overwhelmed and reverts in their cognition or behavior Problems of termination When a client suddenly discloses new problems just before termination Often a sign of dependency Successive approximation technique Crisis in the therapy session When a client gains insight from a deeply traumatic experience and then unexpectedly looses control Psychotic breaks Therapist’s priority is to remain calm and try to establish control of the situation

Transcrisis Handling Cont. People with Borderline Personality Disorder Presenting problems Chronic suicide ideation Dual diagnosis Self-destructive behavior Impulsive behavior Intense emotional reactions Extreme approach/avoidance relationships Therapeutic relationship Frequent misinterpretations of the therapist’s statements Constant attempts to cross boundaries Strong resistance to termination of therapy Often emotionally draining for the therapist

Counseling Difficult Clients Ground Rules Attend all sessions on time No physical violence Respect the person who is speaking Focus on the “here and now” Everyone participates The crisis worker will not take sides No retribution, retaliation, or grudges Client intoxication is not accepted Conflicts will be resolved in a constructive manner

Counseling Difficult Clients Cont. Confronting difficult clients Confrontation should be direct Use “I” statements Set limits and adhere to them In extreme circumstances termination may be necessary Consultation is suggested

Confidentiality in Case Handling Principles Bearing on Confidentiality Legal -> privileged communication (state laws may vary) Ethical -> general standards of conduct governed by one’s own profession. Moral -> personal principles Intent to harm and duty to warn Tarasoff Virginia Tech