NCMHCE Counseling Exam Review: Assessment of Dangerousness and Abuse

Welcome to the NCMHCE Exam Review Podcast. I'm your host, Dr. Donnelly Snipes. This podcast is brought to you by Counselor toolbox podcast and allce.com counselor continuing education, where you can get unlimited on demand CEUs for $59 or unlimited live webinars for $40. Go to allce.com hi everybody, and welcome to today's presentation on dangerousness and abuse as part of the NCMHCE Exam Review podcast. I'm Dr. Donnellice Snipes. Today we're going to identify the characteristics of a dangerousness assessment, factors associated with high risk for violence and steps in preventing danger to others. Or also going to take a look at some special cases that may show up on the ncmhce, including assessing domestic violence, child and elder abuse, substance abuse, and eating disorders. For your dangerousness assessment, if you have somebody who is in your office or even on the phone, the first thing you want to do is try to identify the cause of the crisis and the probability the client will hurt someone. This is sort of your big thing that you need to determine. You're going to gather information using a mental status exam. It's important to know that because on the NCMHCE you're regularly asked, what types of information would you gather here? A mental status exam would be one of them. Also the client's history of violence and the client's support system factors associated with a high risk. These are buzzwords you're going to look for in the vignette. It doesn't that, you know, people who don't fall into these criteria aren't at risk for dangerousness. But do know that men tend to be at higher risk for homicidal or dangerous behavior than women. Alcohol abuse, especially if they're currently under the influence of alcohol. A history of violence or threats of violence, a history of antisocial behavior, being the victim or perpetrator of child abuse, if there's been some sort of recent provocation, and when we talk about recent provocation, it could be related to this particular incident or it could be a lot of things that are building up and they're getting provoked when they're watching the news and they're getting provoked at work and they're just feeling like they're getting provoked from a lot of different places. And then there's something that's sort of the straw that broke the camel's back. But if they indicate that they're being provoked and you know, everybody's ticking them off, something to be aware of, if they have A diagnosis of a substance use disorder, schizophrenia, personality disorders, mania or intermittent explosive disorder. They may be at higher risk. If they are currently agitated, using louder abusive speech, indicating poor impulse control, or demonstrating emotional ability, then they are likely at higher risk for dangerous behavior. They're upset, they're in that fight or flee state of mind. And unfortunately, it appears they might be in that fight state of mind. And when they're in that state of mind, they're in a more primitive protective framework, which means that there's likely also poorer impulse control. They're not using their higher order cognitive processes to say, you know, in the big scheme of things, is this really worth it? So if you see someone who is in that extreme fight or flee sort of place, it's important to recognize that they may be at higher risk for dangerousness. If we come across somebody who is high risk for dangerousness, then obviously we already talked about suicide assessment in the prior podcast. We're talking about homicide and dangerousness to breaking property or injuring other people. Our duty to warn comes in if there's a reasonably identifiable victim and a credible threat of imminent danger. So those are three criteria that it has to meet before we can breach confidentiality. Reasonably identifiable victim, a credible threat. Not just a passing, you know, offhanded comment. An imminent danger. Something's going to happen, you know, very, very soon. Not six months from now or a year from now. If those criteria are met, you need to contact law enforcement and the intended victim, but divulge only the information necessary. Such as? Such as your name, the client's name, and the exact threat. Information about precipitating factors in the client's diagnosis and all that kind of stuff are likely not important in this particular situation. You also need to work with the client. If the client's in your office or on the phone and you know, you've got contact with the person, provide a calm, controlled environment. Don't get all freaked out, just okay, you know, you are really irate right now. I get it. Allow the client to vent feelings and build self esteem. Help them see how they've handled other challenging situations in the past. Whatever you can do to help the person get a sense of self efficacy. A lot of times when people are in crisis, it is an opportunity for them to grow. But when they're in crisis, they're feeling out of control and they're feeling overwhelmed. So if you can help them feel in control and not overwhelmed, you're going to be able to help them de escalate. Explore options for addressing the issue other than violence. Help them mobilize support systems. Help them understand the cause of the crisis. If they're able to get into that place where they can think critically, clearly clear the adrenaline and they get from their emotional mind into their wise mind. Help them examine the cause of the crisis that might not happen that day. That may be future appointments, but eventually you want to look at the cause of it so you can prevent it in the future. Make a no violence contract with the client. Ensure the client is calm prior to leaving. You don't want to excuse them while they are still having difficulty with emotional dysregulation and impulse control. If the client is unable to regain composure, encourage voluntary commitment. Sometimes that's not going to work either. They're not going to want to go to the hospital and involuntary commitment may be a last resort. You don't always assess for violence and run into somebody who's homicidal. You may be doing an assessment and learn about domestic violence. When you're interviewing a victim, look for or interviewing someone who may be a victim. Look for injuries at various stages of healing. It's not just going to be one. I mean, I went out this weekend and I was pruning black BlackBerry bushes back and working in the garden and I had short sleeves and shorts on. So my arms and legs are kind of a disaster right now. But they're all in about the same, same stage of healing. I don't have other bruises or anything on me. You want to see various injuries in various stages of healing. You don't want to see that, but if you do, that's an indication of domestic violence. If the person is complaining of depression, anxiety, insomnia, nightmares, or symptoms of acute stress disorder, then something's going on. We're not sure necessarily if it's domestic violence, but it could be. If they have vague somatic complaints, they're achy, or they're fatigued, pay attention. If they have complaints of relationship issues, such as a sport that drinks too much or has anger management problems, that should be one of those big warning signs. Just like the injuries. If they indicate an over dependence on their partner, they feel like they can't leave because the partner pays all the bills, or they're stuck for some reason. If there's a history of substance abuse in the client and or the the partner, or if there are behavioral problems that have suddenly begun in children and when I say suddenly, it kind of corresponds with when the domestic violence began. If kids are in the house, it's going to be important to assess for Child abuse. When you're doing your assessment and your intervention, use open ended questions. Instead of saying did your spouse do this to you? Ask a question like how did you get that bruise? Or wow, it looks like you've got a lot of bruises right now. How did those happen? Be curious, not accusatory. If the perpetrator is present, assess that person for substance abuse. In domestic violence situations, the perpetrator may not let the victim be interviewed independently and and your agency may or may not have policies that help you with that. But it is important to recognize that if the perpetrator is in the session with the victim, the victim may be choosing their words very carefully in order to avoid triggering the perpetrator. So what do we want to do for the victim? We see all these bruises or injuries, we want to get them medical treatment as needed. You know, refer them to a physician, get them to the ER if needed. Probably not going to be the ER necessarily if they're in your office for an outpatient visit. But you know, be aware and get medical treatment as needed. Help the victim protect himself or herself by talking about available referrals and escape plans. Obviously you're not going to do this in front of the perpetrator, but if you can get that victim alone, you're going to do that. Challenge the victim's denial and self blame. Help the client understand the situation, the cycle of violence and their options. Sometimes you can do this with both the victim and the perpetrator in the room. Sometimes it's not going to go well. You do want to be cognizant of the risk that the perpetrator will retaliate against the victim when they're out of your office. So do you know, use due caution and potentially make a support group referral for the victim, for the perpetrator. You want to break through denial. Way easier said than done. Get a commitment to a no violence contract. Teach anger management skills. Provide referrals to support groups. Now, before you start working with clients who have a domestic violence history, you know, this was a review for the exam. Before you actually sit in a room with clients who have an ongoing issue with domestic violence, it is imperative that you get continuing professional education on how to handle that in the safest way to prevent retaliation by the perpetrator against the victim when they get home to help the victim stay safe, yada yada. There's a lot more to it than what we're going over here. If you are doing an assessment and you think that there might be child abuse, what things Are you going to be looking for or what things are you going to be looking for in vignettes? If the child evidences a sudden change in behavior, excessive clinginess, regression to an earlier phase like started bedwetting or sucking their thumb and it's not age appropriate, suicidal behavior or antisocial behavior, if they show a fear of adults, especially their caregivers, if they demonstrate overly sexualized behavior, if they have sleep disturbances, if they have a childhood pregnancy or STD or school problems, these are all indicators of possible abuse. Just because there's a childhood pregnancy does not necessarily mean there was sexual abuse in the home, but it is an indicator in adults. When you're doing this assessment, if the caregiver is unconcerned about the child's injuries or provides false explanations for what happened, you know, the kid fell down on his bike or whatever, walked into the corner of a wall, the standard explanations for any kind of bumps and bruises. Be wary if the adult tries to conceal injuries. And so the child comes in and it's the middle of July and the child is wearing long sleeves and long pants and you know, maybe a scarf or something. Those are things to be aware of. If the adult uses harsh discipline and or has overly high expectations for the child, then there may be some indication of abuse. Now remember, abuse can be physical, emotional or sexual. If the adult was abused as a child, acts extremely jealous or overprotective of the child, or lack social support outside of the family, these are other indicators that or risk factors for abuse. So what do you do? Well, the first thing is mandatory reporting. In every state abuse reporting is mandatory and to the best of my knowledge, abuse reporting for children and elders or disabled adults is mandatory in every state. So mandatory reporting, medical treatment, ensure safety, that's with domestic violence, that's with child abuse and that's with elder abuse. Mobilize family support systems to get the caregiver the support they may need in order to diffuse this situation. Refer parents to support groups and clarify events that caused the crisis. What happened that made you lose your temper, Build self esteem and reduce shame and blame in the client as well as potentially the parents support and validate positive behaviors in the parents or the caregivers if they are, you know, they're bringing the kid to counseling. So that's, that's a great step. You know, they're trying to figure out how to fix the situation, teach parenting skills or if you don't have the time or ability to do that, refer and increase parents understanding of the triggers and dynamics of abuse so they understand what sets them off and what they can do in order to prevent it. So vulnerability prevention as well as distress tolerance and interventions to make sure that abuse doesn't continue. For elder abuse, you are going to either see the abuse, the client's going to tell you about the abuse, or you're going to observe physical injuries that quote, clearly indicate abuse, which you know that that one's a little bit harder. But again, if you see injuries in multiple stages of healing, now remember, older people tend to bruise easier. So just because someone has a bruise doesn't necessarily mean that they're being abused. You want to use your best clothes. Clinical judgment. If the caregiver will not let you see the client alone, that is one of those big warning signs. And if the client appears afraid of the caregiver, if the caregiver comes in and the client, you know, shirks down or seems to become very submissive when the caregiver is present, that is an indication that you need to potentially explore a little further. With elders, not only do you have emotional, physical and sexual abuse, but you can also have financial abuse. What do you do again? Get medical assistance. Make sure they're safe. Mobilize support system and resources. Be empathetic and validating. A lot of elders feel a lot of shame surrounding any abuse they may be experiencing and or they may feel like they deserve it because they are a burden on the caregiver. We want to make sure to validate how they're feeling, but also build self esteem and help them again see how it's not their fault. Explore events leading up to the current crisis and help clients and caregivers identify alternate coping strategies and resources which could prevent future problems. If you are working with a client, for example, who has Alzheimer's disease and it's advancing at a rapid clip, then potentially some of the behavioral and cognitive struggles that the caregiver is experiencing with that client could be overwhelming and the caregiver may need some respite time in order to be able to be as helpful as they want to be. In the case of severe eating disorders or addiction, conduct a mental status exam, see where they're at. Assess the client's support system. If the eating disorder is severe enough that you're worried about their physical health or the addiction. Encourage voluntary commitment to either a psychiatric facility or a detoxification unit, depending on the problem and if needed, and if appropriate, you may need to seek out involuntary commitment after the crisis is stabilized. Then you're going to proceed with treatment which can include referring the client to a physician for a medical evaluation or a psychiatrist for psychotropic meds. You may also in both cases consider involving a dietitian as a clinician in this early intervention period. One of the things that you really want to do is instill hope. If you get a crisis call from a non client, you know you're just doing your paperwork one day the phone rings, you answer it and somebody on the other line is suicidal or in crisis of some sort of. Alright. The first thing you want to do is get their name, the phone number and their address if possible. As much of that as you can get from them. Assess the caller's level of crisis and ability for self management. If they are thinking clearly enough that they can take steps to protect themselves, they can figure out how to get to the emergency room or they can figure out how to call law enforcement or at the very least they can tell you where they're at and they're willing to so you can call law enforcement or someone to go pick them up and take them to a safe place. This is what you're going to assess for. Be directive and advocate for steps to ensure the caller's safety and consider offering an appointment as soon as possible. Generally, if they're in crisis and they're calling you, they may need to get to some higher level of care sooner. But sometimes you have a client call and they're just, they're extremely distraught, they're not suicidal. So you want to assess are they safe and what can they do to stay safe and when could you possibly get them in for an emergency appointment? It's imperative for clinicians to be prepared for dealing with clients who may be violent or in abusive situations. Know your ethical imperatives regarding mandatory reporting and get additional training on safety practices for working with victims of abuse. If confronted with a call from someone who's in crisis but not your client, it is your responsibility to provide initial triage and assist the individual in getting to safety or staying safe. Now as promised, we will go through some test taking tips. Today we're going to go through a little vignette about Sally. Sally's a 25 year old graduate student who was recently raped. She was referred to you by a victim services. Her father, a doctor whom she is estranged from, calls your office wondering how Sally's doing. So that's all you get for the vignette. What do you need to make a diagnosis? And I'll read some things off to you. Think about what you would need to make a diagnosis. Information about substance abuse history, developmental history, sleep patterns, dissociative symptoms, mood, cognitive functioning, daily functioning, suicidal or homicidal ideation, flashbacks, eating patterns, and the date of the rape. So some of those are necessary, some of them aren't. Which ones are you going to choose? Well, the possible diagnoses that you might be seeing in this person with what little information you have so far include generalized anxiety disorder, acute stress disorder, ptsd, major depressive disorder, or adjustment disorder. So what information, again, do you need to make the diagnosis? And I want you to remember what you're doing is making a diagnosis. You're not looking for other things. She was recently raped. Well, so we want to know the date of the rape. Because ASD and ptsd, one of the big differences is how long ago the trauma happened. You want to know the date of the rape, you want to know her daily functioning, her cognitive functioning, to get an idea about how clearly she's thinking through things and how much this trauma is impacting her, including how, how well she's able to concentrate and if she's having negative perceptions. You know, that's one of those criteria in there for ptsd. You're going to get information about her mood, any dissociative symptoms, and her sleep patterns. Flashbacks is another thing you're going to ask about. So you're really, you know, she comes in and the key word in that vignette is rape. When you hear rape, you're looking probably for acute stress or post traumatic stress. So, okay, so let's look for the symptoms of ASD or PTSD and figure out what's going on with this client. So you determine that Sally has acute stress disorder. The rape wasn't very long ago. Which of the following would be appropriate? An attorney, law enforcement, a physician, a psychiatrist, family therapy, or the financial aid office? Well, an attorney, that's kind of irrelevant. She was referred from victim services. They've probably handled all that already. Law enforcement. Well, if she's coming from victim services, again, they've already handled that. If she was going to make a report, she's already made it. A physician, she's already had her rape exam or whatever is going to be happening. She's not indicating any physical problems, so that's probably not necessary right now. A psychiatrist. Well, since she's having difficulty and you find out later she's having difficulty sleeping and has a lot of anxiety, she may be referred to a psychiatrist for short course of medication, so that might be an appropriate referral. Family therapy. She's estranged from her dad. We don't know about the rest of the family. We weren't asked about it. But this is not the time to start handling this estrangement with her dad. Right now what we're treating is the acute stress disorder. We're not treating the other stuff. And the financial aid office, yes, she's a graduate student. Yes, she may be struggling in her classes right now, but that may. That's really not something that is going to be appropriate to address in this particular scenario because there was no indication that she was flunking out and no indication that she was having difficulty with finances. In order to monitor Sally's progress, which of the following would you want to monitor? Her grades and class attendance, her finances, her affective functioning, her sleep quality, her energy level, her socialization with her family members, follow through on referrals, continuing flashbacks and nightmares, and substance use. Those are your options. So let's go through each one of them. Well, yeah, we're going to look at her grades and class attendance because that kind of goes to daily functioning. And if she's able to attend classes and is relatively keeping her grades up, you know, that's a good thing. That's one of the things that we want to see in terms of recovery. Her finances, again, that wasn't an issue to begin with. So we don't need to be looking at that. Her affective functioning, we did find out that she's having problems with, or she was having problems with anxiety. So we want to monitor that to make sure that that anxiety is going down. Her sleep quality, she had indicated that she was having difficulty sleeping, having some nightmares. And so sleep quality is something that we would want to continue to monitor. Now, remember, when you go through the criteria for ASD and ptsd, basically you're looking for those symptoms or evidence that those symptoms are remitting energy level. Neither ASD nor PTSD really talks about energy level that much. So that's probably not something that we're going to look at. Her socialization with family, we know they're estranged, so that's not really something we're concerned with in this scenario. Her follow through on referrals, well, yeah, that might be something that we want to monitor in order to figure out how motivated she is and whether the treatment plan that we're implementing is working. Continuing flashbacks and nightmares, you know, those are key symptoms. Obviously we want to see the frequency and intensity of those decrease. And substance use, you can argue now, you can make the argument that you should monitor it because if she was experiencing anxiety and went to the psychiatrist, and the psychiatrist put her on benzos, then she could potentially abuse the benzodiazepines, your Xanax, your Valium, those sorts of things. That's a stretch. You could argue against it because Sally didn't have any history of substance use, and we don't even know that the doctor put her on any benzos. So why would you monitor substance use? So that one's kind of iffy, but the rest of them, again, when you're doing your vignettes, you're going to read it. And in this first vignette, it talked about her father, who's a doctor. You know, that's lots of information, but it's really irrelevant. Those are distractors. She is estranged from him. Okay. And he calls your office wondering how Sally's doing. You know, that really doesn't come up in the rest of the vignette. So that was sort of a distractor. Except for the fact that we know that family therapy is probably. Or that's probably not going to be part of her support system. You want to focus on the diagnosis. The diagnosis was acute stress disorder. What are we going to. What symptoms are we expecting to see? What symptoms? How are we going to verify that those symptoms are there? What kind of information do we need and what are we going to track to monitor the resolution of those symptoms? Okay, I hope that was helpful, walking through yet another scenario. And I will talk to you on the next episode. Thank you for joining me today. Subscribe to the NCMHCE Exam Review podcast to be notified when new episodes. And while you're at it, subscribe to Counselor Toolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.