1. Chapter 5: Crisis Case Handling

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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