5 crisis case handling


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5 crisis case handling

  1. 1. Chapter Five
  2. 2. Principles Comparison Long-Term Therapy Crisis Intervention Diagnosis: Complete  Diagnosis: Rapid triage evaluation  Treatment: Focus on Treatment: Focus on immediate trauma underlying issues  Plan: Focus on immediate Plan: Focus on long-term needs needs  Methods: Use brief therapy Methods: Systematically effect to gain immediate control short-term, intermediate, and  Evaluation: Validation is long-term gains based on the return of pre- Evaluation: Validation is crisis level of equilibrium based on client’s total functioning
  3. 3. Objectives Comparison Long-Term Therapy Crisis Intervention (order is irrelevant) (order is relevant) Prevent problems  Ensure client safety Correct etiological factors  Predisposition Provide systematic support  Define problem Facilitate growth  Provide support Re-educate  Examine alternatives Express emotional attitudes  Develop a plan Resolve conflict  Obtain commitment Accept reality  Follow-up Reorganize attitudes Maximize intellectual resources
  4. 4. Assessment Comparison Long-Term Therapy Crisis Intervention Intake data: Client is stable  Intake data: Client may not be and provides comprehensive stable and crisis worker relies on verbal/visual cues details  Safety: Client and other’s Safety: Typically not the safety is the first concern primary focus unless indicated  Time: No time for formal Time: Ample time for formal assessments and informal assessments  Reality testing: Always Reality testing: Typically not assessed via verbal/non-verbal cues needed unless indicated  Referrals: Used to attain safety Referrals: Used to achieve and stability long-term goals
  5. 5. Assessment Comparison Cont. Long-Term Therapy Crisis Intervention Consultation: Available as  Consultation: Sometimes needed available via specifically trained police officers or Drug use: Assessed via mobile crisis teams intake data and throughout  Drug use: Immediately the course of therapy assessed via verbal and non- Disposition: Begin and end verbal cues therapy with the same  Disposition: Begin and end counselor. Therapy is usually intervention with the same voluntary worker within hours to days. Initial intervention is often involuntary
  6. 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. 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. 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. 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. 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. 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. 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. 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. 14. CIT Program Cont. Success of CIT  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. 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. 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. 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. 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. 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