Crisis Intervention with Potentially Dangerous Individuals

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Crisis Intervention with Potentially Dangerous
Individuals

• Working with clients who pose a danger to either
  themselves or other people.

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Suicide Facts Figures

• 25,000-50,000 Americans commit suicide every
  year. Suicide may be more common than homicide.
• 300,00-600,000 suicide attempts annually 15 of
  those who attempt suicide will eventually
  succeed.
• Attempt to complete ratio is approximately 101.
• 1/3 of Americans will experience suicidal
  ideation during their lifetimes.
• Most common methods of attempting suicide
  overdosing (80) followed by cutting wrists
  (10).
• Most lethal method firearms (60 of completed
  suicides).

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• Males are 4-5xs more likely than females to
  complete suicide females are more likely than
  males to make non-lethal attempts.
• Highest Demographic Risk White males over age
  65.
• 80 of those who complete suicide had previously
  communicated this intention to another person.
• As many as 15 of clients with chronic depression
  or alcohol dependence will eventually commit
  suicide 10 rate for those with BPD or
  schizophrenia.

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• Alcohol is involved in 15-50 of suicide
  attempts.
• Most people who commit suicide were experiencing
  a mental disorder at the time.
• 20-50 of mental health professionals will lose a
  client to suicide.

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Risk Factors Warning Signs

• Direct verbal warnings.
• Suicidal Ideation or Plans.
• Family History.
• Prior hx. of self-destructive behavior.
• Prior psychiatric hospitalization.
• Chronic physical illness.
• Depression especially hopelessness insomnia.
• Personality Disorder.

• Recent loss (divorce, unemployment).
• Alcohol drug problems.
• Finalizing ones affairs.
• Lack of social support.
• Poor impulse control.
• Tunnel vision.
• Poor problem-solving skills.

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Psychological Intent for Suicide

• Hopeless Suicide pessimistic view that life is
  unbearable will not get any better view
  suicide as the only solution.
• Psychotic Suicide tired of battling a chronic,
  psychotic disorder person may also experience
  command hallucinations delusions.
• Rational Suicide view suicide as a reasonable
  solution to a terminal illness desire relief
  from current or future suffering.
• Impulsive/Histrionic Suicide driven by a desire
  for attention, revenge, or stimulation they hope
  attempt will change other peoples behavior
  toward them.

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Level of Dangerousness

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Assessing Suicide Funneling

• Complete thorough assessment focus on risk
  factors, mood, psychiatric history, A D use,
  support system, outlook on the future.
• Inquire specifically about past and present
  suicidal ideation, plans, or attempts.

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• If suicide is a concern, obtain additional
  information
• Frequency/intensity of thoughts.
• Specificity lethality of plan.
• Availability of means.
• Probability of rescue.
• Expectation of attempt.
• Identify barriers (reasons to live) or resources
  that might prevent suicide. What has stopped
  you from committing suicide?

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Example Questions(Zuckerman, 1995)

• Has it crossed your mind that death would
  relieve you or end your pain?
• Have you felt my life is a failure or my
  situation is hopeless?
• Have you thought about how you might kill
  yourself?
• Have you made any plans to hurt or kill
  yourself?
• What would prevent you from killing yourself?

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Overdosing

• Frequently Used Drugs
• Anxiolytics Sleeping Pills.
• Tricyclic Antidepressants (e.g., Elavil).
• Aspirin.
• Acetaminophen (i.e., Tylenol).
• As a very general rule of thumb, 10xs a normal
  dose of a dangerous drug is lethal.

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Special Issues with Adolescents

• Suicide rate among adolescents has increased in
  recent years, but continues to be lower than
  adult rates.
• Reluctance to confide in adults collateral
  information can be very valuable.
• Younger adolescents may not fully understand the
  irreversibility of death.
• Personal Fable Mentality.

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Intervention Strategies

• Develop a crisis management plan, including
  emergency procedures.
• Remove dangerous objects (guns, pills).
• Develop a Care Team to monitor client at home.
• Consider hospitalization, psychiatric
  consultation, or intensifying treatment.
• Closely monitor care.

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. . . .

• Work with clients strengths reasons for
  living.
• Help client identify specific alternatives to
  ending his or her life.
• Improve problem solving coping skills.

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No-Harm Contracts

• Objective client makes a commitment to not harm
  himself for a specific period of time.
• Components
• Emergency contact numbers.
• Steps to follow in the event of an emergency
  (e.g., call crisis line, go to ER).
• Prevention Plan, include practical coping skills.
• Identify who can provide social support.

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Self-Mutilation Other Parasuicidal Behaviors

• Definition inflicting harm on ones body without
  any intention of death or serious injury.
• Typical sufferer young female (15-25) with a
  history of childhood abuse or neglect.
• Manifestation (1) scratching, cutting or burning
  ones arms, wrists, face, legs, genitals, etc.
  or (2) preventing wounds from healing.
• Co-Morbid Problems eating disorders, mood
  disorders, BPD, chemical dependency.

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• Duration chronic compulsive course lasting
  10-15 years.
• Ironically, sufferers typically feel little pain
  while engaging in self-mutilation.

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Why do people self-mutilate?

• Tension reduction.
• Coping with negative emotions (e.g., turn
  emotional pain into physical pain).
• Interpersonal communication (e.g., manipulation).
• Atonement for perceived sins.
• Hatred toward ones body or sexuality.
• Self-stimulation (to feel something).
• Feel more powerful in control of ones life.
• Psychosis.

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Coping Strategies to Reduce Self-Mutilation

• Engage in non-harmful sensation-seeking (e.g.,
  submerge arm in ice water).
• Destroy something non-living invaluable.
• Use a red marker rather than a knife.
• Response Prevention.
• Direct verbal expression of feelings.
• Distraction.
• Social Engagement.
• Physical movement or Exercise.
• Relaxation Techniques

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Potentially Violent Clients Risk Factors

• History of violent or impulsive behavior.
• Family conflict.
• Low frustration tolerance.
• Former or current legal issues.
• A D Use.
• Plan for committing violence.
• Means for carrying out violence.

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Gravely Disabled Clients

• Responsibility to protect people who cannot care
  for themselves because of cognitive impairment.
• Examples psychotic disorders, Alzheimers
  disease, dementia, or other organic brain
  disorders.

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Legal Issues

• Legal duty to provide ordinary and reasonable
  care.
• Negligence unreasonable failure to adhere to
  professional standards.
• Objective Test What would the average and
  reasonable helper of similar training and
  experience have done in the same or similar
  situation?