Crisis intervention 2014

◦ Dr. Dawn-Elise Snipes, PhD, LMHC, CRC, NCC
AllCEUs.com Unlimited CEUs $99/year

 Define crisis
 Explore general principles of crisis management
 Identify methods for effectively screening for
crisis
◦ In therapy sessions
◦ In the community
 Identify the steps in crisis management
 Identify risk factors for suicide

 All clients perceive events uniquely
 All clients participate in care that is respectful and non-
judgmental
 Reflection and empathy is most effective
 Ego strength is variable among individuals and is influenced
by past experiences and social support
 All clients and families are actively involved in collaboration
and decision-making

 Stress is a normal part of existence and can foster self-
development and growth
 All clients are capable of assuming personal responsibility
 All clients grow and change in an environment of
acceptance, trust and empathic understanding
 Sustained change occurs when clients feel ready & supported
 People have a need for self-mastery and control
 Crises can be construed as danger or opportunity for growth

Change causes crisis and crisis causes change

 Crisis intervention is an active process that focuses on the
immediate problem
 Crisis intervention is time-limited
 Client advocacy is essential
 The focus is always on increasing the client’s level of
social, emotional, cognitive and behavioral functioning

 A precipitating event
 Perception of the event
◦ Emotional reactions
 Anger
 Fear/Helplessness
 Hopelessness
◦ Cognitive conceptualization (what does this event
mean/represent)
 The client’s usual coping methods

 Think about the following common precipitating
events your clients experience
◦ Relationship ending
◦ Job loss
◦ Legal issues
◦ Financial problems/Bankruptcy
◦ Death of a friend
◦ Relapse
 Why do some clients become suicidal and others do
not? (Hint: Refer to previous slide)

 Prevention is always best
 Levels
◦ Primary—Prevent the problem (suicidality)
◦ Secondary – Detect and treat pre-suicidal changes
(depression, hysteria)
◦ Tertiary– Reduce the impact of the problem

 What types of primary, secondary and tertiary interventions
could be implemented?
◦ Relationship ending
◦ Job loss
◦ Legal issues
◦ Financial problems/Bankruptcy
◦ Death of a friend
◦ Relapse

 Develop rapport & maintain contact
 Identify the problem
 Assess risk to life
 Explore coping, strengths and supports
 Negotiate an action plan
 Implement the plan
 Follow up on the plan

 Sources
◦ The patient
◦ Family members
◦ Friends and others in the patient's support network

 Four necessary components identified for the
development of rapport
1. An appropriate knowledge base
2. A range of behaviors essential to effective performance
3. A positive attitude and valuing of communication
4. Availability of opportunities to communicate
 How do you develop rapport with an unknown person

 Build trust
 Establish mutual respect
 Note that the patient's relationships indicate the patient's
potential to form a strong therapeutic relationship.
 Empathy and understanding help the patient feel emotionally
supported, and increases the patient's sense of possible
choices other than suicide.
 Empower the patient while still addressing safety

 Guard against the role of constant savior
 Suicidal patients may wish to be taken care of unconditionally
or, alternatively, to assign others the responsibility for keeping
them alive.
 By producing false or unrealistic hopes, you may ultimately
disappoint the patient.
 Taking responsibility for a patient's care is not the same as
taking responsibility for a patient's life.

 Suicidal patients can also activate a clinician's own latent emotions
about death and suicide.
 Remain aware of
 Feelings of hate and anger at suicidal patients
 Avoidance of patients who bring up anxieties surrounding suicide
 Overestimating the patient's capabilities creates unrealistic and
overwhelming expectations for the patient.
 Be aware of becoming enveloped by the patient's sense of
hopelessness and despair then responding by becoming discouraged.

 Address the patient's immediate safety
 Develop a comprehensive differential diagnosis to further
guide planning of treatment.
◦ Biological, Safety, Relationship, Self-Esteem
◦ Remember that suicide assessment scales lack the predictive
validity necessary for use in routine clinical practice.

 Order observation of the patient on a one-to-one basis
or by continuous closed-circuit television monitoring
 Remove potentially hazardous items from the patient's
room and secure the patient's belongings
 Ask the patient what he or she needs while awaiting
the treatment team/emergency services etc.

 If the patient is (or is likely to become) dangerous to him-
or herself or to others and the patient will not consent to
interventions that aim to reduce those risks, then the
psychiatrist is justified in attenuating confidentiality to the
extent needed to address the safety of the patient and
others.
 In an emergency situation, necessary information about
the patient can be communicated with police and with
emergency personnel, including medical staff and
emergency medical technicians.

 Patient's current presentation
 History
◦ Mental Health
◦ Substance Abuse
◦ SI/HI Ideation and attempts including information about
frequency, timing, intent, method, consequences
◦ History of prior treatment
 Individual strengths and weaknesses
 Psychosocial situation (current stressors)

 Opportunity to fortify the patient's social support
network
◦ Note: If necessary to protect patient safety, it is often permissible
to share such information without the patient's consent
 Cultural/religious beliefs, particularly as they relate to
death/suicide
 If ideation is present, request more detail about plans
◦ Simply asking about suicidal ideation does not ensure that
accurate or complete information will be received

 Elicit the presence or absence of a suicide plan.
◦ If the patient does not report a plan, ask whether there are certain
conditions under which the patient would consider suicide.
◦ If the patient has access to a firearm, discuss the importance of
restricting access to, securing or removing this and other weapons.
◦ Document in the medical record, being sure to include, any instructions
that have been given to the patient and significant others about
firearms or other weapons.
 Assess the degree of suicidality, including suicidal intent and
lethality of plan.

 Behavior suggesting suicidal ideation, plans or intentions
◦ Future Plans
◦ Tying up Loose Ends
◦ Plan
◦ Means
 Identify specific modifiable factors and features
◦ Increase risk (exacerbating)
◦ Decrease risk (mitigating)

 Identify specific psychiatric signs and symptoms
 Assess past suicidal behavior and self-injurious acts
 Review past treatment history and treatment relationships
 Identify family history of suicide, mental illness, and dysfunction
 Identify current psychosocial situation and nature of crisis
 Appreciate psychological strengths and vulnerabilities of the
individual patient
 Identify any potential social supports
 Develop a biopsychosocial action plan

 Consideration may be given to:
 The presence of psychiatric illness
 Specific psychiatric symptoms such as hopelessness, anxiety,
agitation, or intense suicidal ideation
 Unique circumstances such as psychosocial stressors and
availability of methods
 Other relevant clinical factors such as genetics and medical,
psychological or psychodynamic issues

 Once factors are identified, determine if they are
modifiable
 Past history, family history, and demographic characteristics
are examples of non-modifiable factors.
 Financial difficulties or unemployment can also be difficult to
modify, at least in the short-term.
 List risk factors and identify modifiable and unmodifiable

 Serves as the framework by which the patient and
psychiatrist will collaborate
 Includes
 Establishing and maintaining a therapeutic alliance
 Attending to the patient's safety
 Determining the patient's psychiatric status, level of
functioning and clinical needs
 Arriving at a plan and setting for treatment

 Depends on:
◦ The estimate of patient's current risk to self/others
◦ Medical and psychiatric co-morbidity
◦ Strength and availability of psychosocial support network
◦ Ability to provide adequate self-care, give reliable feedback
and cooperate with treatment
 Benefits of intensive interventions must be weighed
against their possible negative effects.

 Be aware of emotions and reactions that may interfere
with the patient's care.
 Consultation or supervision from a colleague:
◦ Affirming the appropriateness of the treatment plan
◦ Suggesting alternative therapeutic approaches
◦ Monitoring and dealing with countertransference issues

 Patients with suicidal thoughts, plans, or behaviors will
benefit most from a combination of medication and
therapy.
 Goals:
 Pharmacologic treatment = acute symptom relief
 Psychosocial interventions:
 interpersonal relationships
 coping skills
 psychosocial functioning
 management of affects

 Antidepressants
 Evidence for a lowering of suicide rates is inconclusive.
 Efficacy of antidepressants in treating severe mood disorders
 Select an antidepressant with a low risk of lethality on acute
overdose, such as SSRI
 For patients with prominent insomnia, a sedating antidepressant or
an adjunctive hypnotic agent can be considered.
 Antidepressant effects may not be observed for days to weeks.
 Patients should be monitored closely early in treatment and
educated about this probable delay in symptom relief.

 Benzodiazepines
 To treat insomnia, agitation, panic attacks, or anxiety
 Long-acting agents often being preferred over short-acting agents
 The benefits of benzodiazepine treatment should be weighed against:
 Their occasional tendency to produce disinhibition
 Their potential for interactions with other sedatives
 Their potential for abuse
 Benzodiazepines being discontinued after prolonged use should be
reduced gradually and the patient monitored for increasing symptoms of
anxiety, agitation, depression, or suicidality.

 Clozapine
 Associated with significant decreases in rates of suicide attempts for
individuals with schizophrenia and schizoaffective disorder.
 Should be given serious consideration for psychotic patients with
frequent suicidal ideation, attempts, or both
 Benefits of clozapine treatment need to be weighed against the risk of
Agranulocytosis and Myocarditis
 Other second-generation antipsychotics (e.g., risperidone, olanzapine,
quetiapine, ziprasidone, aripiprazole) are preferred over the first-
generation antipsychotic agents

 Efficacious in the treatment of non-psychotic major
depressive disorder and borderline personality disorder
 Interpersonal psychotherapy and cognitive behavior
therapy have been found to be effective
 Cognitive behavior therapy may be used to decrease
hopelessness and suicide attempts
 Psychodynamic therapy and dialectical behavior therapy
are associated with decreased self-injurious behaviors

 AKA "no-harm contract"
 Is not a substitute for a careful clinical assessment
 Patient's willingness (or reluctance) to enter into a suicide prevention contract
should not be viewed as an absolute indicator of suitability for discharge
 Not recommended for use with patients who are agitated, psychotic, impulsive
or under the influence of an intoxicating substance
 Are dependent on an established physician-patient relationship
 Not recommended for use in emergency settings or with newly admitted or
unknown inpatients

 Contract should include
◦ Social supports
◦ Phone numbers for suicide prevention hotline; 911
◦ Specific plans to get the person through the next
24 hours
◦ Specific follow-up plan
◦ Warning signs of danger and interventions

 The patient's willingness (or reluctance) to enter into a suicide
prevention contract should not be viewed as an absolute
indicator of suitability for discharge (or hospitalization).
 It is overvalued as a clinical or risk management technique.
 It is not a legal document and cannot be used as exculpatory
evidence in the event of litigation.
 It cannot and should not take the place of a thorough suicide risk
assessment.
 Although suicide prevention contracts are commonly used, no
studies have shown their effectiveness in reducing suicide.

 Providing optimal treatment involves a
multidisciplinary treatment team.
 Useful strategies for coordination in any treatment
setting include:
◦ Clear role definitions
◦ Regular communication among team members
◦ Advance planning for management of crises

 Facilitating adherence begins with initially establishing the
physician-patient relationship and the collaborative
development of a plan of care.
 Side effects and requirements of treatment are common
causes of non-adherence.
◦ Financial constraints
◦ Scheduling or transportation difficulties
◦ Perceived differences of opinion with the clinician
◦ Misunderstandings about the recommended plan of treatment

 While symptomatic, patients may:
◦ Be poorly motivated
◦ Be less able to care for themselves
◦ Be unduly pessimistic about their chances of recovery
◦ Suffer from memory deficits or psychosis
◦ Have reductions in insight about having an illness or needing
treatment

 Community members are in a prime position to screen and provide
early intervention
 Topics
 Psychiatric disorders are real and effective treatments are both necessary and
available.
 The role of stressors and other disruptions in precipitating or exacerbating
suicidality or symptoms of psychiatric disorders.
 Risk factors for suicide
 How to identify symptoms that may indicate decompensation
 Methods for involving the police for involuntary evaluation.
 How to react to suicidal behaviors

 Between age 10 and 24 years, suicide rates are approximately 13 per 100,000.
 After age 70, rates again rise to almost 20 per 100,000.
 Thoughts of death are more common in older adults but as people age they
are less likely to endorse suicide.
 Self-destructive acts by older people are more lethal due to.
◦ Reduced physical resilience
◦ Greater social isolation
◦ Greater determination to die
 Suicidal elders give fewer warnings.
 A suicide attempt in an older person indicates a greater risk of suicide later

 Death by suicide is more 4x as frequent in men than in women.
 Men who are depressed are more likely to have co-morbid alcohol
and/or substance abuse problems.
 Men are less likely to seek and accept help or treatment.
 Women have several protective factors:
◦ Lower rates of alcohol and substance abuse
◦ Less impulsivity
◦ More socially embedded
◦ More willing to seek help

 Among African American women, rates of suicide are remarkably low
due to religion and social support.
 Women have higher rates of depression and respond to
unemployment with greater and longer-lasting increases in suicide
rates than men.
 Women who are pregnant or have young children are less likely to kill
themselves.
 With a history of depression/suicide, postpartum women’s attempts
are at greater risk for poor outcomes.

 Other Risk Factors
◦ Women of lower socioeconomic status
◦ Women hospitalized with postpartum psychiatric disorders
 Rates of suicidal ideation and attempts are also increased in
individuals with
◦ Borderline personality disorder
◦ Those with a history of domestic violence or abuse.

 Suicide in whites and in Native Americans are approximately 2x those
observed in Hispanics, African Americans and Asian-Pacific Islanders.
 For immigrants, in general, suicide rates mirror the rates in the country of
origin and converge toward the rate in the host country over time.
 Racial and ethnic differences in culture, religious beliefs and societal
position may influence the rates and values about suicide.
◦ Suicide can be considered a traditionally accepted way of dealing with shame,
distress and/or physical illness.
◦ Knowledge of and sensitivity to common contributors to suicide in different
racial and ethnic groups as well as cultural differences in beliefs about death
and views of suicide.

 Single people commit suicide twice as often as married ones
 Divorced, separated or widowed individuals have rates four to
five times higher than married individuals.
 The presence of another person in the house protect by:
◦ Decreasing social isolation
◦ Engendering a sense of responsibility toward others
 Young married couples may have increased risk and the
presence of a high-conflict or violent marriage can be a
precipitant rather than a protective factor for suicide.

 Gay, lesbian and bisexual youths have a higher risk of suicide
attempts than matched heterosexual comparison groups.
 The female-to-male ratio for reported suicide attempts in the
general population is reversed in lesbian and gay youths, with
more males than females attempting suicide.
 Risk factors/stressors unique to being gay, lesbian or bisexual:
◦ Disclosure of sexual orientation to friends and family
◦ Experience of homophobia, harassment and gender nonconformity

 Dentists and physicians have been consistently found
to be at higher risk for suicide
 Also increased among nurses, social
workers, artists, mathematicians, and scientists
 Farmers may be at somewhat higher risk
 Rates of identified suicide among police officers are in
line with or slightly higher than the norm

 More than 90% of persons who die from suicide meet
criteria for a psychiatric disorder. (Screen at every visit)
 Patients who died by suicide were more likely to have:
 Panic attacks
 Severe psychic anxiety
 Diminished concentration
 Global insomnia
 Moderate alcohol abuse
 Severe loss of pleasure or interest in activities

 Suicidal ideation and a history of suicide attempts increase risk
 Suicide in patients with schizophrenia is about 8.5-fold higher.
 In schizophrenia or schizoaffective disorder
◦ Psychotic symptoms are often present during a suicide attempt.
◦ Command hallucinations account for a relatively small percentage of suicides.
◦ Patients with schizoaffective disorder appear to be at greater risk for suicide than
those with schizophrenia.
 Suicide risk is increased in those who
◦ Recognize a loss of previous abilities (Helpless, Loss)
◦ Are pessimistic about treatment (Hopeless)

 Anxiety disorders are associated with a 6- to 10-fold
increase in suicide risk.
◦ Phobias
◦ GAD
◦ PTSD

 Abuse of substances including alcohol may be the second
most frequent psychiatric precursor to suicide.
 Alcohol abuse or dependence is present in 25%–50% of
those who died by suicide.
 Impending interpersonal losses and co-morbid psychiatric
disorders have been specifically linked to suicide in
alcoholic individuals.
 Full-time employment appears to be a protective factor in
alcoholics.

 Individuals with personality disorders have an
estimated 7x increased risk for suicide.
 Especially borderline, antisocial personality disorders,
avoidant and schizoid personality disorders
 Personality disorders exist in approximately 30-40% of
those who attempt or die by suicide.

 Employment
 Religious beliefs
 Psychosocial support
 Reasons for living, including children in the home
 Individual psychological strengths and vulnerabilities

 Anxiety
 Hopelessness
 Command hallucinations
 Impulsiveness and aggression
 Alcohol intoxication
 Past suicide attempts
 History of childhood physical and/or sexual abuse

 History of domestic partner violence
 Treatment history: Greater treatment intensity is
associated with greater rates of eventual suicide
 Temporal: Risk increases after changes in tx setting or
intensity
 Physical illness
 Family history

 Suicide’s multiple motivations:
 Anger turned inward
 A wish of death toward others that is redirected toward the self
 Revenge
 Reunion
 Rebirth
 Relief
 A sadistic internal object so tormenting that the only
possible outcome is to destroy to the tormentor through
suicide

 Suicidal behavior has been associated with:
 poor object relations
 the inability to maintain a stable, accurate, and emotionally
balanced memory of the people in one's life
 Other important psychodynamic concepts are
 Shame
 Worthlessness
 Impaired self-esteem

 Patients may be in the midst of an acute suicidal crisis or display the
symptoms and disorders that typically lead to increased suicide risk.
 There do not appear to be specific risk factors that are unique to the
inpatient setting.
 Fewer than half of the patients who die by suicide in the hospital were
admitted with suicidal ideation.
 Extreme agitation or anxiety or a rapidly fluctuating course is common
before suicide.
 Each suicidal crisis must be treated as new and assessed accordingly.

 Initial evaluation should be comprehensive and include a suicide
assessment including strengths, vulnerabilities, and stressors.
 Be aware that suicidality may wax and wane in the course of treatment.
 Sudden changes in clinical status (positive or negative), require that
suicidality be reconsidered.
 Risk may also be increased by:
 Lack of a reliable therapeutic alliance
 Patient's unwillingness to engage in treatment
 Inadequate family or social supports

 Suicide assessment is an integral part of the psychiatric evaluation in an
emergency setting.
 Most patients in emergency psychiatric settings have diagnoses
associated with an increased risk of suicide.
 Over time be alert for symptoms of physical trauma or toxicity.
 Monitoring of vital signs is important to detect adverse events or signs
of substance withdrawal.
 Assessment cannot be completed until patients are sober.
 Collateral information is important in emergency settings.
 How the patient arrived can provide information about insight into the
need for treatment.

 Indirect self-destructive acts are found among both men
and women and are a common manifestation of suicide in
institutional settings.
 Factors Associated with Increased Suicide Risk
◦ Physical illness
◦ Functional impairment
◦ Pain
◦ Hopelessness
◦ Personality styles that impede adaptation to a dependent role

 Suicide is a leading cause of death in correctional settings.
 Persons who die by suicide in jails tend to be young, white,
single, intoxicated.
 Suicide in correctional facilities generally occurs by hanging.
 Isolation may increase suicide in correctional facilities.
 Suicidal behaviors increase:
 Immediately on entry into the facility
 After new legal complications (e.g., Denial of parole)
 After inmates receive bad news about loved ones
 After sexual assault or other trauma

 Crisis intervention is client centered and comprehensive.
 Crisis intervention uses patients’ strengths and resources.
 Empathy and genuineness are key factors.
 Treatment modalities and settings are based on the client’s level of
functioning, dangerousness to self and availability of supports and resources.
 Documentation is essential throughout the process, not just at assessment.
 Pharmacological interventions are used to provide acute symptom relief and
enable the patient to focus on psychosocial interventions.
 All clients have the ability to help themselves.

Crisis intervention 2014

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Crisis intervention 2014