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Crisis intervention strategies chapter 5

Chapter 5 – Crisis Case Handling

1


LONG TERM CASES
1.
2.
3.
4.
5.
6.
7.

8.

Broader in Scope
Methodological treatment
Continuous feedback
Leisurely/weekly
More background info.

More psycho-educational
Seeking to change
residual, repressive and
chronic modes of thinking,
feeling and acting
Personality change

CRISIS CASES
1.
2.

3.
4.
5.
6.

7.
8.

Compressed scope
Best guess or set
procedures
Here and now
Minutes/hours
Specific crisis info
Quick determination of
coping skills, resources,
Movement to stability
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

Entry

1.








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)

Commitment to inpatient facility may be
needed

2.



Voluntary
Involuntary (physician orders/evaluation and
crisis trained transportation)

5


CASE HANDLING AT COMMUNITY MENTAL HEALTH
CLINIC (CONT)

(If Coherent) Intake Interview

3.







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)

Disposition

4.






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)

Anchoring

5.





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)

Short-term Disposition (basic physical
needs)
Long-term disposition (psychiatric or
pharmacological evaluation)

6.

7.


With objectives, goals, and therapeutic plan and
regular review of plan

24 hour telephone service/hotline

8.


Evaluating and referring

9


CASE HANDLING AT COMMUNITY MENTAL HEALTH
CLINIC (CONT)

Mobile Crisis Teams/Police

9.




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





Crisis in Session (opening can of worms?)




Dependency issues
Preparation may be needed
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



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