Training & Continuing Education:
Crisis Intervention & Emergency Psychological Services 

By: Michael G. Conner, Psy.D, Clinical & Medical Psychologist

E-mail: Conner@OregonCounseling.Org
Resume: www.OregonCounseling.Org/Resume.htm
Phone: 541 388-5660

The following is a workshop presentation outline for mental health, school guidance and crisis intervention professionals. Supporting materials and handouts will be provided to participants including valuable checklists and references. This workshop is planned for July 2000 in Bend, Oregon. Exact date and location will be finalized. Please e-mail Dr. Conner if you are interested in participating, have questions or if you wish to be notified of the scheduled date and time. 


Presenting Problems

Angry

Aggressive

Abusive Threatening

Destructive

Violent

Dangerous

Homicidal

Self-harming

Self-abusive

Self-destructive

Self-mutilating

Suicidal

 


Service Continuum

Routine Services

Non-urgent

Broadest domain of Dx & Tx

Chronic, Acute & developmental

Crisis Intervention Services

Urgent

Broad domain of Dx & Tx

Acute & developmental

Emergency Psychological Services

Emergent

Immediate stabilization & disposition

Acute & immediate

 


Service Delivery (& Context)

Private practice

Outpatient mental health

Employee assistance programs

Hospital ED

Crisis centers

Work/Human resources

Emergicenters

Crisis hotlines

Inpatient medical

Inpatient psychiatric

Medical practices

Schools

Counseling centers

Guidance centers

Community mental health

Religious community organizations

Friends of family/Family of friends

People in your community

 


Service Delivery Interface

Medical

Triage

Screening

Examination

Lab work up

Imaging

Assessment

Diagnosis

Treatment/Procedure

Consultation

Disposition

Plan

Orders

Monitoring

Transfer

Referral

Routine admission

Direct admission

Discharge

Follow up

 

Psychological

Intake

Screening

Evaluation

Assessment

Diagnosis

Treatment/Intervention

Consultation

Plan

Monitoring/Observations

Referral

 

Termination

  

 


Risk Assessment

Immediate Risk

Context

Clinical

Statistical

Short Term Risk

Clinical

Context

Statistical

Long Term Risk

Statistical

Clinical

Context


Risk Management Issues

Legal

Civil or Tort law

Statutory law

Federal law

Licensing

Administrative rules

Professional

Confidentiality & Duty

.. Presumption of

.. Exceptions to

Treatment

.. Competence

.. Informed consent

Moral

Organizational

.. Managed care pressures

.. Fee-for-Service

Personal

.. Social organizational responsibility

.. Personal conscience

.. Level of caring

.. Commitment

.. Effort

Liability

Negligence & Malpractice (4 D’s)

Hind-sight bias

Reprehensibility

 


Risk Management Guidelines

Differential diagnostics

Evaluation/Examination

Risk assessment

Intervention framework

Consultation

Clear articulation

Documentation

 


Primary Differentials

Depression

Anxiety/Panic

Reactive/Adjustment

Personality Disorder

Functional

Organic

D/A

Dangerousness

 


Evaluation/Examination Clusters Bio-psycho-social-cultural-spiritual

"Triage"

Identifying information

Ethnicity/Culture

Appearance

LOC

Motor function

Behavior

Cooperation/Attitude

Problem statement

Orientation x4

Collateral

Vitals

Observations

.. Pupils

.. Skin

.. Breath

.. Mouth

NKDA

Physical complaints

Known medical problems

Current medical Tx & Rx's

Speech

Affect

"Mental Status"

Hx current problem

Symptoms

Insight

Memory

(Immediate, Short, Long term)

Thought content

Thought process

Perception

Tasks

(Names, Backwards, Objects

3 words, Presidents, Directions, Serials, Math, Geography, Similarities, Reading, Writing, Proverbs, etc…)

Intelligence

Judgment/Impulse control

Reliability/Honesty

Danger to self, others or property

.. Ideation, statements, behavior, Hx

Self care & basic needs

.. Unable to care for self

.. Unable to provide for essential needs

"History"

Marital

Children

Recent loss or trauma

Religious/Spiritual beliefs

Employment

Relationships

Education

Family of origin

Medical Hosp

Psychiatric Hosp

Family psychiatric

Past medication trials

Financial

Legal problems

Criminal

D/A

 


Suicide/Homicide

Epidemiology

Suicide attempts average 1 per minute in the U.S.

Successful suicides average 1 per 17 minutes

Oregon has the 7th highest rate of suicide

2x’s as many people die from suicide as homicide

10% of first time suicide "attempters" try again

Women attempt suicide 3x’s more often than men

Males succeed at suicide 4x’s more often than women

70% of all suicides are by male Caucasians

Blacks are 8x’s more likely to be murdered

30% of all suicides involve alcohol or other drugs (40% of all homicides)

65% of all suicides involve a depression

Suicide is the leading cause of death in adolescents

 


Immediate Risk

Behavior

Visual

Verbal

Progressions

Social/group

Triggering Influences

Chemical

Surrounding influences

Medical/Mental health

History

Recent

Past

Social

Mental health

Motivations

Mental and Emotional Status

 


Short Term Risk

Factors

Age

Sex

Race

Religious beliefs

Insight

Motivation/purpose

Mental & emotional status

Dx/Dx Impression

D/A

Ideation

Statements

Behavior

Hx of violence

Hx of suicidal behavior

Hx of loss, trauma or abuse

Self-sufficiency

Personal/social support

Ability to solve their problems

Resources to solve their problem

Health status

Self-care

Honesty/Reliability

Collateral opinions

 


Self-Harming & Suicidal Behavior (3 C’s & 3 P’s)

Motivations

Change

Choice

Control

Punish self

Punish others

Psychotic proc

 


Aggressive & Violent Behavior

Motivations

Justice, Revenge, Victim rage

Freedom (threats to or loss of)

Control (fear of loosing or anger at loosing)

Carry-over (ongoing aggression or violence)

Contempt; Sadism (expression of) Blaming,

Acting out (taking it out on others)

Image, Status, Role, Reputation (defending, altering, establishing)

Protection, Survival reaction (self, property, family, or friends)

Threat reduction, Aggressive precaution

Self-punishment; Guilt relief

Civil or rationalized disobedience

Exposure to violence and diffusion of individual responsibility (wilding)

Psychotic process

 


Factors Contributing to Crisis Resolution

Chemical detoxification

Positive transference

Emotional "detoxification"

Time within a safe "container" or "structure"

Support instituted or renewed

Change in relationships

Change in perspective

Change in behavior

Restored health and well-being

Biochemical gate keeping

 


Crisis Intervention Goals

Information/Knowledge

Symptom relief/elimination

.. Autonomic arousal

.. Psychomotor acceleration

.. ASE’s

Insight & understanding

Normalized perspective

Adaptive response/behavior

Can conceptualize a reasonable plan to recover

Restoring necessary self and other reliance

Can apply contingencies to "what if’s"

Reduced

.. Helplessness

.. Hopelessness

.. Isolation

 


Medication Interventions

Potential Benefits

Restore reality contact

Improve judgment

Reduced lability

Greater cooperation

Reduce resistance

Relieve symptoms

Persuasive/Instill hope

Behavioral restraint

Problems

Exacerbation and ASEs

Negative impact single trial learning

Medical crisis

Increased liability

Medication ASE's

Major to minor ASEs

Prophylactic treatment

Expectancy & contingency

 


Dispositions

Discharge/Release

Degree of collaboration in establishing plan

History and presentation of disorder

Availability of resources to support the discharge plan

Adequate contingencies

Response to intervention

Ability of others to support

Risk that others will undermine

 

Transfer/Admission

Medical vs Psychiatric

Full mental health evaluation

Medical clearance

Impression

Diagnosis

Goals for treatment

 


Referral to ED’s

Transport

… Clinicians

… Family

… Friends

… Taxi

… Secure transport

… Police

… EMS

Collaborate with ED

Participate in interview

Provide/FAX a copy of your evaluation

Involve family or friends to extent possible

 


Collaboration with Primary Medical Care & Psychiatry

Medical Screenings & Baselines

Therapeutic levels

CBC, WBC, … LFTs

Thyroid Ftn, Blood chemistry

Fasting glucose, Lytes

RFTs, Urinalysis, ECG

Urine drug tox screen, EKG

Rx’s

Antidepressants

Anxiolytics

Antimanics

Antipsychotics

 


Defusing Immediate Risk

Strategies

Mere presence

Establishing a relationship and using it

Use reason and rationality

Redirecting emotions and motivations

Manage, control or eliminate triggers

Give directive and set limits

Physical restraint, control and direction

Chemical restraint

Verbal Techniques

Calming

Persuasion

"Clarifiers" & rapport builders

Distraction

Questioning

Confrontation

 


Holds, Commitments & Investigations

Emergency transport 12 hour hold

Community mental health hold

Judicial/Magistrate

Two physician hold

 


Use of 911 & Police

Give only that information necessary

Answer questions

Provide useful information to 911 that is compelling

Anticipate possibility of over/under response

Get 911 incident number

Request/Insist to speak with the responding officer

Speak with officer and provide information that is compelling

Taking notes

Get last name and the BPSST number of the officer you speak with

Consider going to the hospital