Suicide Assessment and Crisis Intervention | NCMHCE Exam Review with Dr. Dawn-Elise Snipes

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 or unlimited live webinars for $40. Go to allce.com hey there everybody and I'd like to welcome you to this episode of the NCMHCE Exam Review Podcast. Today we're going to be talking about crisis assessment and I'm your host, Dr. Donnelly Snipes. For the next few minutes we're going to review crisis theory and the varying types of crises, describe the stages of crisis, identify the features of a general crisis assessment, differentiate between a crisis and a suicide assessment, identify factors associated with the high risk of suicide, briefly review legal and ethical responsibilities, and explore prevention and intervention strategies. So there's a lot of stuff that we need to cover. Now you remember this is still part of your assessment component of the ncmhce. And don't forget at the end of the presentation we will also talk about test taking tips. So let's get started. What is crisis? Well, that kind of depends. We talk about developmental crises. Like if you want to think about Erickson's stages, he said that you had to resolve these developmental crises to move forward. And he used that term not to mean something that was untenable necessarily, but a developmental objective or a developmental. What's the word I'm looking for? I can't find it right now. Something you got to do. When we're talking about this type of crisis, we're talking about a full out mental health crisis. It's a pivotal moment in which a decision must be made which involves both facing peril and promise. Crisis involves both risk and reward. That's something that we need to kind of keep in the back of our mind. Another definition of crisis is from Kaplan from 1961 who said that people are in a state of crisis when they face an obstacle to important life goals that is for a time, insurmountable by the use of customary methods of problem solving. So they're facing something that is keeping them from achieving their goals or getting their needs met and their prior coping skills and resources just ain't cutting it. What are the symptoms of crisis? Emotional distress, Physical distress. Think about your stress response there. You've got the HPA axis. You may have somebody's blood pressure up, their breathing is increased, etc. Cognitive disruption. When we are in crisis, we tend to not think real clearly that's partly because of some of the neurochemical stuff that's going on. And that's not something you need to know for this exam. But it is important to recognize that cognition is disrupted when people are in crisis. Their ability to concentrate, their ability to problem solve. And for some people, their memory, which can be frustrating in and of itself. For people who are in the middle of a crisis, they can't remember what they walked into a room to do. They feel like they're ineffective at activities of daily living. Or in the cases of people who have experienced a trauma, they may not be able to remember important aspects of the trauma, which can feel very frustrating to them because they lived through it and they should be able to remember it. And this can get exacerbated when they're being questioned by law enforcement, for example, about okay, what did the suspect look, I don't know. And they may feel very ineffective. We do want to be cognizant of that. About how other people and support systems and people that the person interacted with may compound their crisis and behavioral changes. When people are in crisis, they tend to have changes in their eating, changes in their sleeping, changes in the things they do day to day, encouraging them to identify changes that are specific to that crisis. So symptoms of crisis fall into four categories. Emotional distress, physical distress, cognitive disruption and behavioral changes. When people are prevented from meeting their basic human needs, it can precipitate a crisis. Those basic human needs, when I think about them, I think back to Maslow. Think of that Maslovian pyramid. Air, water, food, sleep, shelter, medical care, safety, love and belonging. Those lower levels of the pyramid of needs. But I also created a mnemonic that may help you remember what to assess during the assessment. And it's charges C is for connection. Connection to something bigger than oneself or a system of meaning to help us understand the world. When something happens that goes against our system of understanding the world and we're like, well, that's not how it's supposed to be. It can really throw us for a loop. Health and biological needs is H. When we are not able to get our medicine, when we're not able to get our food or our water or our shelter, that puts us under biological stress, but also emotional stress. If someone is living in a house and then suddenly they become homeless, that can be a huge stressor. Acceptance is the A. We all need love and belonging. We want to feel accepted by at least a group of people out there, whomever that group may be. It could be our family. It could be our support group. Whomever in line with acceptance and love and belonging is relationships. Most of us are programmed to want to be in some sort of intimate relationship. Not necessarily sexual, but intimate relationship where we've got someone who we know we can count on and it's a truly intimate relationship. Goals and Purpose we need goals and purpose in life. If you are prevented from achieving your goals, it can be very, very frustrating. If you feel like you're getting up day after day and you have no purpose in life, it can be depressing because you don't have any motivation. If there's no purpose, it's like, why am I doing this? This all relates to people's sense of identity. E is for Efficacy and Control People need to have a sense that they have a certain amount of control over their life, over their feelings, over what's going on, and over their ability to meet. If they don't feel like they have any control, then they are more likely going to be in a state of crisis. And safety is our final one. People need to feel safe, safe in their own heads from their own internal critic, but also physically safe from other people if they are in a domestically violent relationship, in an ab abusive relationship. If for some reason they do not feel safe, it can precipitate a crisis. I'll go back over that mnemonic real quick. Charges stands for connection to something bigger than oneself or a system of meaning. H stands for health and biological needs A stands for acceptance in relationships R stands for relationships, the intimate kind G stands for goals and purpose, our sense of identity E stands for self, efficacy, well, efficacy and control, a sense of efficacy and control and S stands for safety. There are a variety of different types of crises that can keep people from meeting their basic human needs. One type, and kind of probably one of the more common types, is a situational crisis. This is something that's not anticipated and usually outside of a person's. Now, some of these types of crises overlap. You don't need to get too bogged down in identifying what type of crisis it is, because I would be willing to bet you're not going to be asked to identify the type of crisis. You just need to know that it is a crisis Anyhow, situational crises involve physical crises, such as an accident that may disrupt life. It may hurt the person physically and cause them either temporary or permanent disability. An illness that can be acute or chronic, or even terminal prematurity and birth defects are other physical types of things, and that's not necessarily something wrong with that person but it's a physical crisis. When a parent gives birth to a child who is premature or, or who has birth defects, there is often a level of crisis that comes along with that. Figuring out how to meet this child's needs and being worried about them. Another type of situational crisis is interpersonal. Any sort of relationship crisis here, death of a person or pet. And yes, developmentally death happens. But if we're talking about death of somebody or something that's beyond, you know, they're not supposed to be dying yet, they're not 100 years old, then it could be unexpected and it could be a situational crisis. When we get down to maturational crises, you can also talk about death being a maturational crisis because, for example, as I've gotten older, I've recognized that, you know, my parents are eventually going to die off. So death of a person or a pet. I didn't want to put pet down in material because for some of us, pets are part family. But that can throw people. I know when one of our dogs got hit by a car, I was absolutely devastated. Abuse, divorce. Any type of interpersonal conflict can be situational, and it can keep people from getting their basic needs met. And you want to go back. And if you want to take time outside of the podcast and take the list of charges, connection, health and biological needs, acceptance, relationships, goals and purposes, efficacy and control and safety, and think about how each one of these things may block a person from getting one or more of those basic needs met. Might help you out. Cultural and societal crises are important because individuals often have even less control over these due to the fact that they're perpetuated by the action or inaction of other people. We're talking about a crisis that may be perpetuated by the political system, political unrest, discrimination and stigma in the environment, especially as it relates to gender, race, sexual orientation, etc. Or a culture that is supportive of violence. And that could be crisis invoking for people. And finally, maturational crises. We all go through these normal developmental changes, and these changes can produce developmental crises. Like I said, Erickson used that term a little bit loosey goosey. However, when these crises overwhelm a person's ability to cope, they may prompt a mental health crisis. The terms are getting a little gray and muddy here. What I want you to focus on is what we typically think about when we say crisis. We think about someone who is in a state of emotional distress. To successfully resolve developmental crises, people need support, energy and safety. These are the things we need to make sure they have. Some examples of maturational crises can be going from being a child to being an adult. When you're in high school and you're graduating and you're getting ready to go off to college, that is a big change. For some kids, it's a great thing. For other people, they feel very overwhelmed by this prospect. Empty nest is a crisis. You can see it coming. It's not unexpected. You know that your kids are eventually going to grow up and fledge from the nest. However, when they do that change, that adjustment can precipitate a crisis that may or may not be able to be dealt with by the person's current coping abilities. Childbirth is another maturational crisis. And I know most of us think of childbirth as, oh my gosh, this wonderful, amazing thing. For some people, especially if they didn't intend to get pregnant, it could be sort of devastating to them. Or as I said earlier, if you have a child who ends up premature or having birth defects, that can add to stress. Marriage is another maturational crisis. It could be the person is happy getting married and loving this transition. It could be that the person gets into a marriage, gets married, and realizes, oh, I don't really like this. This is not what I anticipated. And. Or the marriage could be unhealthy. So any of these normal developmental activities that we do as part of growing up can be considered maturational crises. Other maturational crises can include some of the things that people experience as they get older, the cognitive slowing and their bodies kind of breaking a little bit easier. That can be very frustrating to someone who was maybe an athlete in college. What do we do with this? Well, we know the types of crises now, and like I said, you probably don't need to be able to identify what type of crisis it is. Just know that there's a lot of different things that can cause a crisis. When you're taking the ncmhce, you want to determine which symptoms are expected reactions to a normal developmental transition. I'm going to say that again. Determine which symptoms are expected reactions to a normal developmental transition versus a sign of an emotional or mental health issue. For example, you have a person like myself whose child just graduated and left for college. There is a certain amount of expected bittersweet feelings about it, or a little bit of grief or whatever you want to say that is not unexpected. You know, it is a transition trying to figure out your new normal. Does it mean that every person who has a little bit of the emptiness blues has clinical depression? Or even an adjustment disorder? No, not necessarily. We really want to look at what's expected in terms of, quote, normal reactions and what is the impact it's having on the quality of this person's life. Remember, in the DSM they always say because it causes clinically significant distress in one or more areas of functioning, if it is not causing clinically significant distress, then it may be a phase that they're going to work through and their coping skills are going to keep them through it. If they are experiencing significant symptoms, then we may want to look at a diagnosable disorder. So adjustment disorder with depressed mood, anxiety, depression, and anxiety or behavior disturbances is conditional upon a particular situation, a life change or a stressor of some sort that precipitates the event, as opposed to clinical depression, which doesn't have a particular prompting episode. The difference between clinical depression generalized anxiety disorder is personality disorders is that an adjustment disorder has a particular identifiable situation stressor that caused the symptoms to start. That's an important thing to remember. We want to carefully, differentially diagnose between adjustment disorders, anxiety, depression, PTSD and personality disorders. Just be really familiar with the intensity and duration of each of those and some of the precipitating factors. One more time. If the symptoms have a very clear precipitating factor, precipitating stressor, it is more likely an adjustment disorder diagnosis than a diagnosis of major depressive disorder or generalized anxiety. Yada, yada. Not always, but use your clinical judgment. But that's a good rule to kind of keep in your mind. Now, with these developmental crises, we do want to normalize expected reactions to developmental transitions. We don't want to dismiss people. However, in these scenarios. We don't want to focus on something that's a normal reaction and try to make it something that it's not. So is it a normal developmental reaction or a mental health issue? One thing to recognize, and again, I'm just pointing this out so you can effectively differentially diagnose. Adjustment disorder with disturbance of conduct can include behaviors that are outside the norms of society, actions that violate the rights of others, outbursts of anger, attempts at revenge, substance use or abuse, and emotionality or mood swings that are acted upon. So a lot of that sounds kind of like conduct disorder in there. But it also could be adjustment disorder, which goes back to conduct disorder, is not going to have a single precipitating event where the symptoms didn't exist. And then all of a sudden, bam, you've got this disturbance of conduct. Factors affecting people's responses to stressors. Empty nest syndrome. I'll just use that one. It is a big deal for most of us, but for some of us we're able to cope with it, with our existing coping skills. Other people, it overwhelms their ability to cope for some reason and there are a lot of things that can go into that, but things that you want to think about when you're doing your assessment. The best I could come up with was a mnemonic called that I put who dares to perceive basic coping crap. And yeah, it doesn't make a lot of sense but work with me here. So for the who and the mnemonic for the who is dares. So we're going to look at demographics. A person's age may affect their response. If they are very young, then cognitively they may respond differently to a stressor than somebody who is middle aged. Or if they're very old and experiencing cognitive decline in some way they may also react differently or they may react differently because they've got 85 years of experience behind them and this just ain't a big deal to them. Age will affect their reaction, their religion. Sometimes religiosity can serve as a protective factor against depression and crisis. Their ethnicity based on for a lot of different reasons, ethnicity can contribute to their correlations between ethnicity and low socioeconomic status as well as culturally prescribed or culturally oriented coping styles and coping skills. For some cultures, especially ones that are very community oriented, ethnicity can be a great protective factor and situational and social supports that are available that helps you assess what's going on. People who have access to more resources, people who have access to more social support are likely going to feel less crisis from something than someone who is flapping out there in the breeze. DARES stands for demographics, age, religion, ethnicity and situational and social supports. The next area that impacts how people react to stuff to stressors is the perception of the event and how it impacts their ability to meet their needs, their biological necessities. And the mnemonic for this is basic biological necessities. Is it making them homeless? Could it make them homeless? Is it preventing them from getting medical care in some way? If they're out in the middle of the woods and they fall and they break their arm, that may be a bigger deal than if they're in the middle of the city and they fall and they break their arm because one place it's going to be hard to get medical care and that's going to be a much bigger crisis. Acceptance and belonging. If the event impacts their ability to feel accepted, to feel like they belong. Maybe they feel broken or they feel ashamed, or they feel like they're going to be rejected. It could be a huge factor similarity to prior traumas or crises. If someone's been through a situation that similar before and it hasn't navigated well, that's a risk factor for how they're going to deal with this one. If they have navigated it well, then that's a protective factor. Their interpretation or their worldview? How does this event impact their worldview or their interpretation of life? If this event makes them see the world as a very dangerous city, scary, awful place, then that's probably going to set them up to be at higher risk for crisis. And how does it impact their sense of control? How does it affect their ability to believe that they can keep themselves safe and get their basic needs met? And finally, crap the coping crap. You want to assess how many crises has the person experienced in the past six to 12 months? This gives us an idea about whether they have the resources to deal with this current stressor. What resources? What coping resources do they have? What strategies do they use in order to cope with the stress when it happens? Do they have a history of addiction or addictive behaviors that is an indication that their coping strategies are probably weaker and more of a risk factor? And do they have a history of psychiatric problems, mental health issues that also may indicate that they are struggling to cope? They were barely keeping it going before and this may be the straw that broke the camel's back. So your acronym here who dares to perceive basic coping crap? Who is your demographics, age, religion, ethnicity and situational and social supports? Perception of basic Is your biological needs biological or your human needs? Your biological necessities, acceptance and belonging, similarity to prior traumas, interpretation or worldview and your control, your sense of control and your coping resources or coping crap Crises in the past six months resources, coping skills that you have addiction, history of and psychiatric issues history of. And this makes more sense if you look at the notes for the podcast where you can see it all kind of spelled out or if you go to our YouTube channel@allce.com YouTube YouTube and you can watch the video. So you can see this in orange and white. Okay, so we've talked about the types of crises. We've talked about what may make somebody more predisposed to go into crisis over a particular event. Let's talk about the stages of crises. A crisis is the event that disrupts the person's ability to maintain homeostasis. We are constantly think about standing on a Bosu ball or on a teeter totter or something like that. We are constantly trying to keep our balance and whatever this is has completely thrown us off our balance and we're trying not to fall down. The next state is the vulnerable state in which the person tries to cope with the situation with their current resources and strategies. Think again. Standing on that Bosu ball, for those of you who don't know a Bosu ball, it's one of those. It's a platform on top of a ball that's kind of cut in half and you're just trying to balance on it anyhow. The crisis has knocked you off balance and you're trying to stand up. You don't want to fall on your bum. Well, this vulnerable state, you're, you know, trying to do everything not to fall. But if you fall, then you manage to move into the active crisis state. And that's what we're going to address. A crisis assessment. Here's another mnemonic coming up. I'm just bracing you. You probably want to look at this. Emergent assessment is conducted when the client expresses a sense of disequilibrium. When our clients express the fact that they don't feel. Feel, they feel like their world is out of control or they're in crisis or they can't go on anymore. You know, this is when we want to kick into gear. We want to identify the precipitating factor, identify the client's responses. What have you done so far to try to deal with this? Let me understand, let me figure out where you are along this path so I can join you. Identify all the ways the event has disrupted the client's life. And that goes back to the acronym basics behavioral, what they do affective, how they feel somatic, their psychological or their physiological reactions, and the impact interpersonal. How has this event disrupted how they relate to others and their support system cognitively? How has this event disrupted the client's problem solving, memory, perceptions and spiritual. How has this event disrupted a client's sense of belonging and system for understanding the world? Those are things we've already talked about, but we want to talk with the client about. Let's understand the impact of this event. Let me get the big picture then. Explore coping strategies the client has used in the past. We've already asked them about, okay, this event happened. You were in knocked off your equilibrium. Then you went into the vulnerability state and you tried to stay standing up. What did you try to do to handle this? Now we're going to Ask about in the past when you've had difficult situations, what has helped you? Let's start making a list. It may not be applicable now, but let's just start making a list of all the things that you've done to cope before. Then you want to start exploring current resources and supports. Who and what do you have available? And that's everything from finances to help them with respite, childcare or finding a new house or getting a new car or whatever it is they need to help attenuate this current crisis, to social supports, to even days off from work. You know, how much time do you have that you can take off from work if you need to have three days to kind of regroup, identify specific goals. The person has been knocked off their balance. We need to understand what does balance look like. What do you hope the resolution of this will look like? Assess the client's mental status and sobriety, if needed, in the crisis assessment. Make sure there's no alcohol or drug abuse going on that could be impacting their ability to think clearly and their impulsivity as well as you want to assess for any psychotic features or anything like that, make sure they're with you and assess for suicidality and homicidality. A crisis assessment doesn't necessarily mean a suicide assessment. Not everybody in crisis is become suicidal. A crisis assessment determines the cause of situational disequilibrium. Remember, it's something, there was a trigger point back there, there was a precipitating factor. A crisis assessment determines the cause of that disequilibrium and resources needed to help the client cope. A suicide assessment, on the other hand, is designed to determine the probability of a suicide attempt in the near future. It's ongoing. Since the suicide risk changes over time. They may be in your office and they are just in total crisis and you're able to help them de escalate. When they leave your office, you've got a plan. And then at 3 o' clock in the morning they're calling the crisis center because they are in crisis again and we need to do another assessment at that point in time because they have decompensated. Suicide assessment is comprised of input from collateral sources. If you're doing a thorough suicide assessment, you want their mental health assessment, you want input from medical doctors, you want input from significant others. If you're able to get it with releases of information, all that will give you some information. And there are two other issues or forms of suicide assessment. One is direct and that's asking the client, go figure do you feel like killing yourself right now? We're going to talk about what to ask the client in a direct assessment in a minute. But also indirect understanding. General risk factors that make it more likely that the person that you're talking to is at higher risk for suicide. What are these risk factors? Well, gender for one, and the numbers really vary a little bit depending on who you're talking to and what article you're reading. However, males over 75 are at a much higher risk of suicide. For males ages 45 to 60, their rate of suicide attempts and completions has increased over 43% since 1997. Females between the age of 45 and 64 are at a higher risk. And adolescents between the ages of 15 and 24. So you have this little window in there between 24 and 45 that there doesn't seem to be as much suicidal activity. That doesn't mean anything in the big scheme of things. You don't want to say, well, you're not the right age, so whatever. No, take every suicide indication very, very seriously. If they have prior suicide attempts, that's a risk factor. If they misuse or abuse alcohol or other drugs, the risk factor. If they have other mental disorders, particularly depression or other mood disorders or, or bipolar disorder. When people are coming out of a depressive episode of a bipolar disorder, they are at a super high risk for suicidality. It's important to recognize that they're coming out of that depression. But now they're finally having the energy that they could complete a suicide attempt. Don't assume that just because they seem to be happier or calmer is necessarily a good sign. It could be, but it also could be a warning sign. So take that with a grain of salt. If they have a history of abuse, it's a risk factor. If they have access to lethal means. The more lethal the means, the more risky it is. However, most people have knives and drugs in their house, like over the counter medications. And a lot of households also have guns, being aware of that. Exposure to someone who died by suicide, particularly a family member. But they're finding that when there are suicides that are highly publicized in the media, that also can increase risk. Social isolation or lack of social support. Chronic or major disease and disability. Recent childbirth or major surgery. Lack of access to behavioral health care. Go figure. Recent medication changes. If someone is on an antidepressant and they change their medication, or an atypical antipsychotic or even some physical health medications such as levothyroxine for thyroid problems. Changes in the Medication could change their mood to the extent that they may feel suicidal and stressful life events or anniversaries of stressful life events, such as the death of a spouse. Another risk factor is motivation. If somebody's motivation to die is to escape intolerable pain, then their risk is pretty daggom high. If their motivation to commit suicide is to impact another person, their motivation or their risk is a little bit lower. You don't want to say that. Well, they won't do it. They're just getting it, trying to get attention. No, take it seriously. Ethnicity and culture. The highest rates across the lifespan for suicide occur among non Hispanic American Indian and Alaskan Natives and non Hispanic white populations. Do be aware of that. That is something that they'll throw in there on the test. The ethnicity of the person as a risk factor. Veterans, military personnel and workers in certain occupational groups are also at increased risk, as are sexual minority youth, due to prolonged stress resulting from prejudice and discrimination. I told you, we talk about this direct assessment. What do we ask a client? Well, hopefully this is old hat to you, but we're just going to go over it real quick. Have they communicated intent? Do you want to die? Frequency, intensity and duration of suicidal thoughts? Is this something that just popped into your head and kind of goes out or are you perseverating on it? And what's the frequency, intensity and duration? Do you have prior attempts? Is there a family history of suicide attempts? What things might prevent you from killing yourself? What are some reasons why you might not want to die? And this could be their family, their pets, their children, whatever. We want to elicit some mitigating factors if we can. Do they have a plan? If so, how specific is it? If they're saying, well, you know, I'd probably just drive my car really fast and wrap it around a tree. That's a plan and it's kind of specific, but I probably would do. This is different than tonight. I'm going to, however, take it seriously. Do they have the means? Well, do they have a car? Do they have a whatever they're planning to use in their plan? And I know that sounds counterintuitive since there are probably four methods available in any one household. But if they decide they are going to die by overdose, then they are more likely to wait until they have access to the method that they want to die by. Part of that may be to reclaim some of their control. Not something that you want to say, well, they don't have the means, so no problem. Obviously they could choose something else. But if they have a plan that's specific, they have a time and they have access to the means, we need to be really, really worried. And the level of lethality, if they're saying, I'm going to take five Tylenol now, that could wreak some serious havoc on their liver. Is it going to be lethal? You know, depends on the size of the person and a whole other bunch of factors. If they say they are going to shoot themselves in the head, then obviously the level of lethality is much higher. Things to listen for somebody talking about the desire to die, hopelessness, no reason to live. They feel like a burden or they feel trapped. They're experiencing unbearable pain, and that could be emotional pain or physical pain. They are talking about using substances more. They've told you that they're learning more about different ways to kill themselves. They are withdrawing from activities and friends, they're experiencing sleep changes, especially if they go to sleep, then they wake up in the middle of the night and they can't get back to sleep. That tends to be a much higher risk factor because they're awake when nobody else is and there's nobody to help buffer their distress. If they start saying goodbye or tying up loose ends. If they are telling you that they are fatigued all the time, if they have symptoms of depression and. Or anxiety, those are, you know, things to listen for and be aware of as maybe indicating some. Some suicidal ideation may be there. And again, they may also indicate a sudden improvement or a sense of calm. And this can be when they made their decision and they've decided that this is how it's going to be. Don't assume that this improvement or sense of calm is necessarily a good thing. So what are our legal and ethical responsibilities? Well, Tarasoff, which we've all heard about, the California Supreme Court held that under certain circumstances, therapists had a duty to warn others that a patient under the therapist's care was likely to cause personal injury to a third party. Now, in Tarasoff, there was hospitalization involved. Where a therapist knows that a patient is likely to injure another, and where the identity of the likely victim is known or readily discoverable, the therapist must use reasonable care to prevent his patient from causing the intended injury. Such care includes, at the least, informing the proper authorities and warning the likely victim. Okay, we know that one backwards and forwards, but then there's Bella versus Greenson, and basically Bella was an outpatient client who talked about committing suicide, went to start seeing the psychiatrist because of suicidal ideation, and ultimately killed herself. And the court ruled that the Tarasoff decision in this case did not apply to threaten self harm, but established a legal duty for therapists to take reasonable steps to prevent the suicide. Breaching confidentiality in this case requires that you determine the client is an imminent threat to self well, okay. And that a breach of confidentiality will prevent the danger. And there are a lot of different steps to take and ethical questions about what is reasonable and at what point is it ethical to involuntarily commit someone? Indications for Hospitalization here's the mnemonic. Limps lack of available support system A medical issue that's causing suffering or significant symptoms Intoxication psychiatric comorbidity A suicide risk that is high in any of these cases. It is preferable to refer for hospitalization and evaluation by a medical doctor. Indications for outpatient if the person's risk is low if the precipitating crisis has been averted if they have adequate supports Even if somebody is feeling relatively suicidal sometimes it's appropriate if you're able to bring in their social support so you know they're not going to be sitting home alone by themselves at 7 o' clock at night or 2 o' clock in the morning whenever. Then it may be an indication for outpatient management. It depends on their social supports and if the client agrees to a safety contract. Now, there's a lot of research that indicates the safety contracts really aren't worth the paper they're written on. However, still write one that indicates what the client is going to do when they start feeling a certain way and indicating checkpoints, for example, that they need to call the crisis hotline at these different times or whatever so you can demonstrate that you and the client did talk about ways to get them through on an outpatient basis. But do remember that just because they sign it doesn't mean they're going to follow it. Interventions According to the American Counseling association guidelines I put together the mnemonic. It's not one that they came up with. It's pieced med P is for provide emergency numbers I is for increased frequency of counseling sessions and and possible phone check ins E explore and mobilize available resources such as family support, friends, support groups, community resources, or even the crisis team. C is for contract get that safety contract going E encourage voluntary commitment if you feel it's warranted, but get the client hospitalized if you feel it's necessary and D is develop a plan to deal with potential weapons, medications, drugs, etc. That could be used as a method for suicide Med stands for decide if the client needs a medication assessment. Other interventions that you can use. Tell the client you don't want them to harm themselves. This is when you throw therapeutic neutrality out the door. Consult and document. Consult with another professional because liability wise, you're going to be held to the standard of another reasonable professional in your field. So talk with another reasonable professional and get their opinion. And if you can, encourage the client to wait until the precipitating crisis has passed to make a decision about suicide. Maybe it's the anniversary of the death of their spouse and they are just completely, completely inconsolable, as you know, I can imagine. Can you wait until tomorrow? Today is the anniversary and it's like ripping the scab off a wound. Can you or will you for me, agree to wait until tomorrow and see if you can convince them to get a little bit of time between them and the precipitating event. So, in summary, people generally come to counseling when they're experiencing some level of crisis. Crisis is often caused when people cannot meet their basic needs and those basic needs go back to the acronym charges. There are many factors that contribute to a person's reaction to a precipitating event, which we have the mnemonic who dares to perceive basic coping crap. Hospitalization may be indicated in some circumstances, and the mnemonic for that was limp. When conducting a suicide screening, remember the mnemonic pieced MED in order to remember what you're supposed to do as far as interventions for someone who is expressing suicidality. Again, all of those mnemonics are on the PowerPoint. You can see those in the video on allce.com YouTube and you go to the video for NCMHCE Exam review Episode 5 on crisis assessment and you can see all that. You can also get it from the notes from the podcast. All right, and as promised, your test taking tips. Remember that an answer choice may be wrong simply because it leaves no room for exception. If something says always or never, we're dealing with humans. There's rarely anything that always or never exists. You notice I didn't say never or always. So if something uses extreme words, that's a clue that it's probably not the right answer. Accept the situation in the problem at face value. Don't read too much into it. If the person is depressed, don't start thinking, well, I wonder if that depression is caused by underlying substance abuse or maybe they have a history of trauma. No, the person is presenting with depression. You are going to diagnose them with depression. Don't be distracted by an answer choice that is factually true but doesn't answer the question. So again, if the vignette is talking about a client who has clinical depression and then in the answer options they say which things do you need to assess? And substance abuse is one of them, that's probably not going to be a correct answer because substance abuse doesn't have anything directly to do with depression. If you look at the criteria for diagnosing depressive disorder, it doesn't say substance abuse in there. So let's try a little scenario here. Sally is a 30 year old woman who has never been married and is estranged from her family. She's been living in a supported living home for the past two years due to the diagnosis of disorganized schizophrenia. Her intellect is normal and her daily functioning is high. Go Sally. She has held a job at the local supermarket for a year. You are supposed to evaluate her continued eligibility for services in the facility. Does she still need to be in supported living? There have been at least five episodes of decompensation in the past five years, but she has no psychotic episodes in the past 22 months. Now, I'm a visual learner, so I'm going to summarize this for you here. She's been living in supported living for 24 months and has had no episodes in 22 months. So you know there's something going on there that's positive. So the question asks which of the following would you need to assess to determine if she still met the criteria for disorganized schizophrenia and continued services? We're going to make the assumption that for continued services, her disorganized schizophrenia either has to be active, in partial remission or at high risk of decompensation if she leaves the housing. So would you evaluate current stressors, quality of existing family relationships, employment history, educational history, current and past addictive behaviors, family history of psychosis, past and current medications, medication compliance, mental status and or the frequency and nature of psychotic episodes. Remember, on the NCMHCE they will say check all that apply, but you don't want to check too many because if you check some, they will actually count against you. So you can gather too much information. So let's look at each one of those things. Current stressors. Yes, we would assess that because stressors could contribute to decompensation. And since we know that she's estranged from her family, if she's got a lot of current stressors, then it's probably risky to boot her out of supported living. The Quality of existing family relationships? No, we already know that she's estranged from her family. Employment history? No, it was already stated in the vignette. Do not ask for more information on things that are already in the vignette. It will count against you. Her educational history? No, that's irrelevant. Current and past addictive behaviors? No, it's irrelevant. Now, in regular clinical practice, we probably assess for it because we know that addictive behaviors can contribute to psychotic episodes. But most likely on the ncmhce. That's too deep. So when we're assessing her level of mental health stability, we're not looking into addictions. We're not trying to dig up something that we don't know about already. We're just trying to verify what's there. A family history of psychosis? Probably not. You're not deciding if she has schizophrenia? We already know that. We're deciding whether it's in remission or not. Past and current medications? Yes, we want to know what she's on and her medication compliance? Yes. This will help us evaluate whether she will reliably take her medications and independent living. Her mental status. Again, in clinical practice, I would do the mental status, but most of the vignettes will say no because the vignette already indicates she's currently high functioning. She's not coming to you in a decompensated state. She's coming to you after she got off work and going, hey, how you doing? So you're likely not going to ask for more information on the mental status in order to verify or identify the status of her schizophrenia and the frequency and nature of psychotic episodes? Yeah, you want to ask about that. To determine the precipitating factors, what caused the other ones? How frequent were they? Was it, you know, once a month or was it every other year? What was going on? And, you know, get an idea of what may have led up to the 22 month remission, which conveniently is at basically the same time she's been living in supported living. Those are the things that you would probably assess and the reasons why you would ask for the things that you ask for and the reasons why you wouldn't ask for the others. You may disagree with those. However, using clinical judgment for this test, you're taking it on face value. Don't try to read for stuff that's not just right out there. The NCMHCE Exam Review Podcast will no longer be in the Counselor Toolbox podcast feed. So if you want to get more episodes of the NCMHCE Exam Review Podcast subscribe to it on your favorite podcast player in order to get notified when we release future episodes, which should be every other week. Thanks for being with me. Take care. Thank you for joining me today. Subscribe to the NCMHCE Exam Review Podcast to be notified when new episodes are released. And while you're at it, subscribe to CounselorToolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.