Week 3 Discussion: Client Case, Summary & Reflection Chapter 4,5&6

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

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 conf lict  Accept reality  Reorganize attitudes  Maximize intellectual resources

 Ensure client safety  Predisposition  Define problem  Provide support  Examine alternatives  Develop a plan  Obtain commitment  Follow-up

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

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

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

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

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

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

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

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

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

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.

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

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

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

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  Conf licts will be resolved in a constructive manner

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

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