Is Your Crisis Assessment Strategy Setting You Up For Disaster?

Prevention, assessment and intervention in crisis and suicide. This is Sessions 43 and 44 of the licensed Alcohol and Drug Counselor curriculum, but it can also be used for recertification for suicide assessment as well as just regular CEUs. So let's go ahead and get on with today. In the next couple of hours we're going to define a mental health crisis, review the goals of crisis services, identify essential skills in the triage and screening process, recognize the components of a crisis screening as opposed to any other kind of screening, and understand crisis intervention strategies and application. Additionally, we will define what is involved in the crisis intervention process. Review, active listening, minimal encouragement, emotional labeling and validation. I know for a lot of us that's counseling 101. It's a good review. And if you happen to be somebody who's a volunteer at a crisis line, this may provide you some information that you haven't gotten until now. So we will also enhance knowledge regarding crisis plans and follow up measures and define risk factors for suicide. And there's a lot of them. Finally, we'll explore substance use in conjunction with depression or crisis and why that's a double whammy. And and one plus one equals like six, not two. And identify basic guidelines for working with someone who's potentially violent to themselves or to others, or worse yet, maybe to you. So a crisis is an intensive behavioral, emotional or psychiatric situation which if left untreated, would likely result in deterioration of functioning and activities of daily living. It represents a system out of balance, requiring additional assistance. So let's talk about that. Everybody has crises. We have crises, little crises, big crises. Most of us have small little hiccups on a day to day basis. A crisis doesn't necessarily have to mean someone's going to become suicidal. Part of a crisis is the person's internal assessment of that situation in addition to how many other stressors they've been experiencing and any other vulnerabilities that may make that crisis the straw that broke the camel's back. So we need to remember that what is not a crisis on one day for somebody, maybe a crisis on another day based on vulnerabilities. And if you've done work with dialectical behavior therapy, you're aware that vulnerabilities are those things that sort of create vulnerabilities. What's another word? Weaknesses or stresses out enough so we're already kind of barely getting by and then this happens and it just kind of pushes us over the edge. Certain vulnerabilities can be changes in life, circumstances, not sleeping well, chronic pain, There's a variety of things that can, can be vulnerabilities that generally just make it harder to deal with life on life's terms on a day to day basis. The important thing to remember is crisis represents a system out of balance. We like to maintain equilibrium, we like to maintain some sort of balance. That's why when we talk about therapy and wellness, we talk about grounding. You want to feel like both feet are on the ground. I remember when I was little, I used to go out on the boat with my daddy and my uncle and I used to love it when there were waves because you were constantly trying to maintain your balance. That's what life is like, constantly trying to maintain your balance. Unfortunately, when you hit a big crisis, it's like one of those six foot waves comes at you and comes over the bow. So we want to make sure that we can help people understand that this is potentially and most probably a normal reaction to a situation that's abnormal. A bunch of things added up to kind of push you over and get that sense of disequilibrium or one big thing. So we've got to take it on a case by case basis. Now it's important in a little extent to differentiate developmental events with situational events. Developmental crises are those things that occur as a result of, you got it, development. So as somebody ages, as somebody goes through life, there are going to be changes. Births of children, marriages, moving out of mom and dad's house, kids moving out of your house, midlife crises. There are a lot of situations where your normal day to day activities suddenly change, which causes disequilibrium. So developmental events are sort of what we can call expected crises. Some people deal with them very, very well and it's a crisis, but it doesn't result in deterioration. It's something the person can handle. On the other hand, some people already have so many other stressors and we'll talk about those as we go through the course that these things that might normally not cause them problems throw them into a tailspin. So we want to consider what's going on with the person. And if it's a developmental event, we need to figure out how to help that person integrate that situation. We can't avoid developmental events. Situational events represent a change in the person's situation that is unexpected or that doesn't necessarily result out of natural development. If you're diagnosed with a terminal illness, if you get fired from a job, not everybody gets fired from jobs. Everybody at a certain point grows up, moves out of mom and dad's house, at least most of the time. So developmental crises are those that are sort of unavoidable but can be dealt with. Situational events are things that not everybody experiences. Regardless, whatever is causing that person's crisis at that point in time is a crisis. It doesn't really matter whether it's developmental or situational. They're out of balance. And our goal is to assess whether they can deal with it on their own and how to help them get their footing back, whether or not we need to intervene or just provide information and referral. So known risk factors for suicide include depression, hopelessness, and pessimism. A lot of times when we talk about risk factors for suicide, you will look at a whole laundry list of different characteristics. It reads like the diagnostic criteria for major depressive disorder. Changes in eating habits, changes in sleeping habits, loss of pleasure or interest in most things, most of the time. Sense of hopelessness, helplessness, and a foreshortened future, difficulty sleeping. All of these things, your characteristics of major depressive disorder can be a huge risk factor. Now, I do want to point out, and we'll talk more in a few minutes about it, but as people start coming out of a major depressive episode can be much more dangerous than when they're in the throes of their major depressive episode. Why? Because they finally have the energy to get out of bed and do something about their pain, which sometimes means suicide attempts. So we need to make sure we don't discount and say, oh, well, John's getting better. He's doing a lot better, so we don't need to pay attention anymore. Now, actually, when John's getting better is when we need to pay the most attention, because we need to make sure that he is feeling like he's moving forward and feeling hopeful and energetic and all that kind of stuff. Not okay, I've got enough energy and I can't ever go back down there again. It hurt too much. So I'm just going to end it all right now. Well, I'll talk about bipolar when we get to the next slide. Substance use and abuse. We know that in many cases, substance use is a disinhibitor. It makes people more impulsive or they don't have that filter on. So those natural impulsivities, there's nothing in their brain going, no, that's a bad idea. Smoking. Now, this is one that is new to me. When I created this presentation, I looked at a lot of different research, which you will find on the last two slides that indicated that smoking Cigarettes, not necessarily anything else. But smoking cigarettes is actually a huge correlator with suicide attempts. Who knew? Well, I guess a bunch of researchers did know. So we want to consider if the person is a smoker, that that's one thing we want to look at that for one reason or another, they may be more likely to attempt suicide. A history of suicide attempts in the self, in the family, or in someone's close friends or relatives. We're going to talk at the end of this presentation about a young woman whose best friend committed suicide and a year later she ended up committing suicide. There's not necessarily a contagion effect, if you will, when one person commits suicide, it doesn't mean that everybody else around them is going to commit suicide, but it does mean that that peer group or that social group may have more positive thoughts towards suicide or a greater sense of hopelessness and helplessness that may result in those kinds of behaviors. So we need to look and say, have you done it before or has someone in your peer group or family done it before? Obviously we're talking about attempts because you're not going to commit suicide twice. But that will give us an idea about kind of where their head is in terms of the acceptability of suicide and suicidal ideation. A history of abuse. Physical, emotional, sexual. This is long been known as being a factor for suicide attempts. People who are living with flashbacks on a daily basis of abuse that they suffered or experienced when they were younger, or maybe even abuse that they're experiencing now. But a history of abuse can make a person's life feel untenable. They can't get away from those flashbacks, they can't get away from those memories, except for by trying to commit suicide. We want to recognize suicide most of the time is the last ditch attempt at making an untenable pain go away. It's just unbearable. If the person has a history of aggression towards themselves, towards others, towards small animals, they may have a greater tendency of harm towards self or others. Major life changes, especially losses. And this can be jobs, this can be faith in other people, this can be relationships, foreclosure on your house. There was an article that came out the other day that said that over the past five years, more than 10,000 suicides in the United States and Britain have been associated with the declining economy. So there are a lot of life changes. Another one that comes up, and this isn't necessarily what you would consider a loss, is pregnancy and childbirth. The one thing you lose here is sleep. Remember how we talked about vulnerabilities well, you have somebody who has recently given birth, they're not sleeping a lot. You throw in maybe some postpartum depression or, and, or a history of abuse that may be triggered by having this young baby around, and they can feel completely out of control. So we need to not just look for tragedies in a person's life. We need to evaluate all major life changes to see kind of what's going on with them. Legal problems. If you're facing jail time, you may not want to go to jail. So legal problems can also mean a lot of different things to different people, but they can mean jail time, they can mean loss of esteem, they can mean loss of career. If you are a physician and you're facing jail time for Medicaid fraud, that means you're probably going to lose your license, you may lose your family because you go to jail and you can't earn anymore and your whole world falls apart. So legal problems can be huge barriers to accessing treatment. Another risk factor. Well, if you've got major depressive disorder, you're feeling hopeless, you're feeling out of control, you've got this untenable pain, and you can't actually access anyone who can help you. That's a problem. Think about the VA crisis. Right now we've got a lot of veterans who are really struggling to deal with life on life's terms because they experienced a bunch of stuff. It wasn't abuse, but it was traumatic stuff off. And they're not able to access treatment. They're put on these long waiting lists and are not able to get help when help is needed from somebody who understands. And that's one of the keys. Dealing with certain populations requires special training. So if you're in a rural area and you're having problems with suicidal ideation, ptsd, flashbacks, drugs, trauma from childhood abuse, and there are not people who know how to deal with that particular issue. That's a barrier to accessing treatment. It doesn't mean there are no counselors there. It means there's nobody who knows how to help you with your particular issue. So it's important to make sure that we have resources available. Even if it's telehealth. If you can connect somebody with a specialist who can help them out, you're going to be doing them a great service. Isolation. People are a lot more likely to commit suicide if they feel emotionally isolated, if they're physically isolated, if they are living by themselves. We want to take a look at that. Have they withdrawn from family and friends recently? That's another concern. As I said earlier, pregnancy is a risk factor for suicide. Now, there's a lot of different reasons. It's not just your hormones go wonky and all of a sudden you're crazy. No, that doesn't happen. People may feel some mood changes, especially those who have pre existing depressive or anxiety conditions when they become pregnant. But there's a lot of other issues that pregnancy can trigger. Fear of not being able to be a good parent, inability to support the child. Finding out that you're bringing a life into this world may trigger memories from the past, may trigger doubts about yourself. There's a whole bunch of stuff that pregnancy can trigger. So we don't want to just push that to the side and go, oh, it's just hormones. There's a lot more to it than that. And easy access to means. Now, I always find this a little bit odd because if someone is determined to commit suicide, pretty much anywhere, anytime they can do it. If you're at home, I'm sure you have knives in your kitchen. If you're not at home, people can run out into traffic. Not that I'm advocating for any of that. But if somebody is determined to commit suicide, the means are there. Now, if someone is has a plan to commit suicide and they're going to do it, for example, by overdosing and they don't have the pills available to them, well, then that's not easy access to means. So we want to look at if they have a plan, how do they plan to do it? But don't assume that they're going to stick to that plan because if that pain becomes bad enough, they can resort to to much more aggressive or violent means to make it happen. Special considerations. Bipolar disorder. If someone is in a manic episode, they tend to be more impulsive, tend to feel 10 foot tall and bulletproof. They may become somewhat more aggressive. We see a lot of hyper. Fill in the blank when somebody is manic. I. Hypersexuality, hyper aggressiveness, hyperactivity. So if someone is in a manic episode and they start to feel overwhelmed, they start to feel angry, they can become more violent towards themselves or others and more impulsive. Not always. People go through manic episodes every day and don't try to commit suicide or homicide. But it is a risk factor. Depression. Okay, if you're in manic. If you're in bipolar disorder, you have bipolar disorder, you're in a manic episode, you're cruising along. Maybe your manic episode is, you know, really pretty good or it's hypomanic, so there's not even any psychotic features. And you've just got a lot of energy and you feel great. Then you start to go into this depressive episode, which is the complete antithesis, and you hit bottom and it's unbearable. Misery, depression, lack of energy. As that person starts coming up, they remember the manic episode and they're like, oh, that was really awesome. But I can't bear those lows again. Again. Once they start having more energy, not even necessarily going into another manic episode, maybe going into a state of remission, they may have a tendency to be more likely to commit suicide. Personality disorders, borderline and narcissistic personality disorder are much more highly correlated with sort of impulsive suicide attempts than some of the others, like histrionic or dependent personality disorder. So if someone tends to have borderline characteristics or narcissistic characteristics, we want to be on alert that they may have an agenda in self harm or harming others and or they may have more difficulty controlling their impulsivity. We know that people with borderline disorder, borderline personality disorder can turn on a dime. One moment you are the greatest person in the world, the next moment you are the antichrist. So remembering that they can do that about themselves as well can give us some insight into how vulnerable is not the word I'm looking for, but how dangerous it can be in their head. Substance use alcohol we know is a disinhibitor. Alcohol is associated with a huge number of suicide attempts and completed suicides. Benzodiazepines is your anti anxiety medication. Now you've got actually three kind of whammies here. If somebody takes a benzodiazepine in order to control anxiety, they can potentially try to overdose on it or they can control that anxiety long enough. So they are, or they believe they are not afraid to commit suicide. Benzodiazepines also have a protracted half life or protracted withdrawal symptom. So they go through this withdrawal if they've been on benzodiazepines for a long time, and then about a month later they could start feeling these withdrawal symptoms again. So we need to be aware of how people are feeling, whether they're withdrawing, how it's affecting, affecting their mood. Opiates. I've worked with a lot of patients on opiates and some patients feel like opiates make them feel like they're uber selves and it gives them energy and yada yada yada, and they feel great. Other people call opiates their I don't give a flip pill. And it takes that anxiety, takes that caring away. A lot of my patients that I've been most worried about committing suicide who are opiate addicted are the ones who feel like it's their I don't give a flip pill because they will push it to the nth degree to feel that high. And if they die, they don't really care. That's a problem. If somebody espouses this idea that, you know, if I live, I live, if I die, eh, that's a concern. Huge concern. Ambivalence can be used to help people find hope, faith, courage to survive. But it also can work in the opposite direction, especially if somebody is abusing substances where the high and that feeling of a rush that they get or that feeling of euphoria that they get outweighs their desire to live. So when we're working with people who are suicidal or homicidal, it is said that generally they have one or more of three wishes to die or stop suffering. That's the one we already talked about, to be killed or stop suffering. Some people don't have it in them to commit suicide themselves, or they don't believe spiritually, culturally, religiously that suicide is okay. So they get somebody else to kill them or to kill or to make suffer. To kill others, obviously that's homicide. But to make suffer can be committing suicide to make sure that those people that harmed you feel bad and they feel as much pain as you're feeling right now. So one or more of those three wishes is probably in play when someone is suicidal. The one I've seen the most is, number one, the people who are coming to counseling, they want the pain to stop, they need it to stop or they can't take it anymore. The other two are definitely out there. We see them in suicide by copying, and we see them in criminal acts and those sorts of things. Be aware, along with three wishes, there are three assumptions. The survivor, the person that you're going to help move through the situation and integrate it, believes the world is benevolent, it's meaningful, and they are worthy. They're worthy of breathing the air. Now, I know a lot of people who aren't suicidal that don't believe all three of those. So we're not taking it to the extreme, but we do want to focus on what things in the world are happening that are okay, that are good. Sometimes we have to get out of that big scope of things because there's a lot of nastiness and pain and despair in the world and focus on their small world right now. What is good and benevolent in your world? It can be your puppy, it can be the birds outside, it can be your kids, it can be your best friend. What is it that is actually working for you that you don't want to give up on? The world is meaningful. There's a reason for you to be here. There's a purpose to what you're doing, where you are, yada yada, yada. And the self is worthy. You're worthy of breathing the air. You're worthy of being here. You're needed in this meaningful world to help keep it benevolent. Your goodness will help keep the goodness in the world. The victim believes the world is hostile and it's hateful, it's unpredictable, it's chaotic and the self deserves to suffer. I've done so many horrible, awful things or I am such a horrible, awful person that I deserve to suffer. I deserve to die. The world would be a better place if I weren't in it. We've heard those words before from a lot of our patients. We need to help them move over more towards the survivor. What good things have you done? What strengths have helped you get to this point right now? So the goals of crisis services are to promote safety and emotional stability. Somebody calls us and they are in crisis. We need to really quickly assess what are the risk factors. Where is this person with this crisis at this point? Like I said, wasn't a crisis yesterday, maybe a crisis today, because maybe they didn't sleep all night and they got a call this morning from their boss that they're fired or they're laid off. Then all of a sudden, whatever this other thing was is just this huge albatross. We want to minimize further deterioration, assist in enhancing and developing stronger coping skills and support systems, connect them with ongoing care as appropriate and encourage services in the least restrictive environment. So to do this, it's sort of a four step process, triage and screening. The person calls, maybe they call your office to make an appointment and you hear that they're really distraught and the receptionist transfers it to a clinician who can help them or hands it off. Or maybe you're answering a crisis line, you make contact with this person one way or another and you triage the situation. Where is this person in terms of being safe? If you determine that yeah, it's a crisis, but they are not suicidal, they're not homicidal, they just need some extra support. They need to be connected with some resources. You can make that referral and Then you follow up later. If you determine that their situation could become worse without intervention, then you refer them for a full assessment or you do a full assessment. And when I say refer, I don't mean next Tuesday. I mean you find somebody in the building who can do an assessment right now. So if you are the receptionist, you may not be trained on doing it, but you need to get someone who is. We'll talk about some of those phone skills in a little while. One of the things that I will tell you, don't put the person on hold and don't transfer them to a voicemail intervention. Somebody is in this state where you think they're going to deteriorate or there's a likelihood that they could deteriorate. So some sort of intervention needs to be put in place. It could be as simple as a 30 minute phone call with a trained volunteer or a clinician to help them kind of get their land legs back. It could be as intensive as face to face interventions followed by involuntary commitment. So there's a whole scope of interventions that we can look at. Regardless of whether you just do a triage screening, things seem to be going, okay, I'll link you with some resources or involuntary commitment. Regardless of where you end up sort of placing this person on the continuum, it's vital that you follow up. Vital that you follow up. One of the things that a lot of people who are suicidal feel is that they are alone, they are isolated. So if you just kind of push them off to somebody else and you don't follow up, guess what? You've just confirmed they're alone. Don't do it. Always, always, always follow up. Make an appointment. When I worked at the crisis center in Florida, we had a whole board in there and there were little cards. And when we told somebody that we were going to follow up, we followed up. Now it wasn't necessarily the same clinician, but so if I talk to somebody at three in the morning, I may have the day shift clinician follow up at 7am just to see how the person's doing and make sure they're going to get to their therapy appointment that morning or whatever the case may be. So there are a lot of different ways to make sure you follow up. But following up either face to face or on the phone is crucial. A letter doesn't do it. Follow up, make that human contact. So screening, we've done a triage or we've contacted the person, now we've got to do the triage. Screening determines the problem, strengths, resources and needs of the individual at that point in time. So they call and they are just hysterical crying. We need to kind of understand what's going on. Are they safe? What is the presenting issue at this point in time? There's probably a whole symphony of other issues going on. But what is it right now that this person is focused on? What resources do they have, including is anybody around or are they alone and isolated? And what do they need? Do they need an appointment tomorrow? Do they need somebody to go out and talk to them right now and consider a voluntary or involuntary commitment? Do they need crisis stabilization? What is it that they need? The screening provides guidance for crisis prevention and early intervention. So the person calls, you do the screening, and you can determine at that point whether what level of services the person needs. If someone is calling because they just got served papers because from an attorney and they're going to get divorced, they're going to be upset. Most likely they may be distraught. They may not be thinking of killing themselves, but they may not know what to do next. They may feel completely out of control. We're probably going to handle that differently. Then we handle somebody who says, I just received divorce papers and if I can't be married to this person, life isn't worth living and you know, I'm planning on killing myself. Very different ways of handling these things. Make a determination as best as you can and be willing to change that determination as the call or contact goes along. Because sometimes the person will de escalate. Sometimes they will escalate. Your first reaction, your first determination when you triage, the person is going to be what you start with. The screening may be formal and direct via phone, contact or appointment. So the person is contacting you, they're either calling you on a crisis hotline or, or you're their therapist and they're calling going, I need an emergency appointment. Whatever the case may be, or it may be informal or indirect, such as a family member, supervisor, friend calling and saying, okay, I know you can't say anything because of that whole HIPAA stuff, but John Smith, who happens to be one of your patients, is in crisis right now and has consumed a fifth of alcohol and is contemplating suicide. I don't know what to do next. I need your assistance. Now, we probably can't confirm or deny, but when we hang up with that person, we know what we need to do. We need to follow up with the patient and say, okay, John Smith, let me try calling him. If I can't call him, do I need to call law enforcement and have them go out and do a well being check. Don't get in your car and drive to John Smith's house. If he may be suicidal or homicidal, drive to his house by yourself and try to intervene. Okay? Always make sure you're safe, but do what you need to do as far as due diligence is concerned. Sometimes you'll get a call from family members who are in another state as well and they're like, again, John Smith is your patient. I'm in South Carolina, he's in Virginia where you are. And I can't help him right now, but I know he's struggling. We can reach out to John Smith at that point in time.