Chapter 5 – Crisis Case Handling 1

LONG TERM CASESCRISIS CASES 1. Broader in Scope 2. Methodological treatment 3. Continuous feedback 4. Leisurely/weekly 5. More background info. 6. More psycho-educational 7. Seeking to change residual, repressive and chronic modes of thinking, feeling and acting 8. Personality change 1. Compressed scope 2. Best guess or set procedures 3. Here and now 4. Minutes/hours 5. Specific crisis info 6. Quick determination of coping skills, resources, 7. Movement to stability 8. Restoration of functioning See Tables 5.1, 5.2, 5.3, 5.4 2

WALK-IN’S - TYPES OF PRESENTING CRISES 1. Chronic Mental Illness (often multiple problems with inconsistent care) 2. Acute Interpersonal Problems in Social Environment (runaways, crime victims, violent events, unemployed, etc.) 3. Combination of the two (fairly common) Note: Often with financial problems prohibiting private care 3

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC 1. Entry Disposition of the case Possible isolation Case history Thinking processes Threats to self or others Drug abuse Psychiatrist may be needed 4

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 2. Commitment to inpatient facility may be needed Voluntary Involuntary (physician orders/evaluation and crisis trained transportation) 5

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 3. (If Coherent) Intake Interview Written and verbal Define the problem Assess for client safety Apprise the client of rights Usually standardized intake sheet Degree of lethality and drug use 6

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 4. Disposition proposed diagnosis treatment recommendations Discuss with client Client chooses to accept or reject Next steps/therapists/clinical team meeting 7

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 5. Anchoring Never left alone Gain feeling of care and support Structured/methodical orientation Establishing rapport, support, encouragement, sense of security 8

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 6. Short-term Disposition (basic physical needs) 7. Long-term disposition (psychiatric or pharmacological evaluation) With objectives, goals, and therapeutic plan and regular review of plan hour telephone service/hotline Evaluating and referring 9

CASE HANDLING AT COMMUNITY MENTAL HEALTH CLINIC (CONT) 9. Mobile Crisis Teams/Police When client is out of control and unwilling or unable to go to the clinic Jail is frequent 10

CRISIS INTERVENTION TEAM (CIT) Train Patrol officers to deal with the mentally ill and emotionally disturbed Utilizing Mental Heath Experts and Providers Including relationships with other community and medical resources De-escalation and diffusing techniques Fishbowls (Trainees observe discussions with patients and mental health professionals) 11

SUICIDE BY COP People who do not quite have the courage to kill themselves Engage police in threatening manner Getting themselves shot The cops complete the suicide 12

CIT TRAINING Has helped many police become more caring crisis workers 13

TRANSCRISIS IN LONG-TERM THERAPY Behavior Regression to pre-therapeutic functioning Anxiety (Cognitive irrationality, Fear of failure) Suggestions: deep-breathing, role play, review of other successes, support system, security net Regression (maladaptive but familiar ways of behaving, feeling, thinking) Suggestions: Interpreting, reality based confrontation 14

TRANSCRISIS - LONG-TERM THERAPY (CONT) Problems of Termination Dependency issues Preparation may be needed Crisis in Session (opening can of worms?) Stay in control to model appropriate behaviors Psychotic Breaks Delusional or dissociative break with reality Client name, keep client in reality, repeat requests 15

TRANSCRISIS - LONG-TERM THERAPY (CONT) Manipulative clients (avoiding engagement in new behaviors) Testing the counselors credibility Borderline Personality Disorder Set clear limits, empathic support, caring confrontation, stick to principles Professional detachment and keeping cool Counselor refusing to be ‘used’ and ‘doing all of the work’ 16

DIFFICULT CLIENTS May need set of Printed Rules (Ex: p. 111) Confront behavior directly (assertive and directive) Termination Consultation with other professionals 17

CONFIDENTIALITY IN CASE HANDLING The limits of confidentiality and privileged communication come under scrutiny when a case involves the potential for violent behavior. Legal Principles (limited for counselors) Ethical Principles (code of professional conduct) Moral Principles (personal and may be in opposition to ethical codes and legal statutes) 18

DUTY TO WARN Convey to client early on Liability insurance document If unsure: Consult with other professionals Victim identity?, Motive?, Means?, Plan? Client is out of control Doesn’t understand what he or she is contemplating Incapable of collaboration 19

DUTY TO WARN If client is concretely stating a threat – warn authorities Invite client to participate Surrender weapons Inform those who need to know Check State statutes. 20