Crisis Intervention with Potentially Crisis Intervention with Potentially Dangerous IndividualsDangerous Individuals

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

people.people.

Suicide: Facts & FiguresSuicide: Facts & Figures

• 25,000-50,000 Americans commit suicide every year. 25,000-50,000 Americans commit suicide every year. Suicide may be more common than homicide.Suicide may be more common than homicide.

• 300,00-600,000 suicide attempts annually; 15% of 300,00-600,000 suicide attempts annually; 15% of those who attempt suicide will eventually succeed. those who attempt suicide will eventually succeed.

• Attempt to complete ratio is approximately 10:1.Attempt to complete ratio is approximately 10:1.• 1/3 of Americans will experience suicidal ideation 1/3 of Americans will experience suicidal ideation

during their lifetimes.during their lifetimes.• Most common methods of attempting suicide: Most common methods of attempting suicide:

overdosing (80%) followed by cutting wrists (10%). overdosing (80%) followed by cutting wrists (10%). • Most lethal method: firearms (60% of completed Most lethal method: firearms (60% of completed

suicides).suicides).

• Males are 4-5x’s more likely than females to Males are 4-5x’s more likely than females to complete suicide; females are more likely than males complete suicide; females are more likely than males to make non-lethal attempts.to make non-lethal attempts.

• Highest Demographic Risk: White males over age 65. Highest Demographic Risk: White males over age 65. • 80% of those who complete suicide had previously 80% of those who complete suicide had previously

communicated this intention to another person.communicated this intention to another person.• As many as 15% of clients with chronic depression or As many as 15% of clients with chronic depression or

alcohol dependence will eventually commit suicide; alcohol dependence will eventually commit suicide; 10% rate for those with BPD or schizophrenia.10% rate for those with BPD or schizophrenia.

• Alcohol is involved in 15-50% of suicide Alcohol is involved in 15-50% of suicide attempts.attempts.

• Most people who commit suicide were Most people who commit suicide were experiencing a mental disorder at the time. experiencing a mental disorder at the time.

• 20-50% of mental health professionals will 20-50% of mental health professionals will lose a client to suicide.lose a client to suicide.

Risk Factors & Warning SignsRisk Factors & Warning Signs

• Direct verbal warnings.Direct verbal warnings.• Suicidal Ideation or Plans.Suicidal Ideation or Plans.• Family History.Family History.• Prior hx. of self-Prior hx. of self-

destructive behavior.destructive behavior.• Prior psychiatric Prior psychiatric

hospitalization. hospitalization. • Chronic physical illness.Chronic physical illness.• Depression: especially Depression: especially

hopelessness & insomnia.hopelessness & insomnia.• Personality Disorder.Personality Disorder.

• Recent loss (divorce, Recent loss (divorce, unemployment).unemployment).

• Alcohol & drug problems.Alcohol & drug problems.• Finalizing one’s affairs.Finalizing one’s affairs.• Lack of social support.Lack of social support.• Poor impulse control.Poor impulse control.• Tunnel vision.Tunnel vision.• Poor problem-solving Poor problem-solving

skillsskills..

Psychological Intent for SuicidePsychological Intent for Suicide

1.1. Hopeless SuicideHopeless Suicide: pessimistic view that life is : pessimistic view that life is unbearable & will not get any better; view suicide as unbearable & will not get any better; view suicide as the only solution.the only solution.

2.2. Psychotic SuicidePsychotic Suicide: tired of battling a chronic, psychotic : tired of battling a chronic, psychotic disorder; person may also experience command disorder; person may also experience command hallucinations & delusions.hallucinations & delusions.

3.3. Rational SuicideRational Suicide: view suicide as a reasonable solution : view suicide as a reasonable solution to a terminal illness; desire relief from current or future to a terminal illness; desire relief from current or future suffering.suffering.

4.4. Impulsive/Histrionic SuicideImpulsive/Histrionic Suicide: driven by a desire for : driven by a desire for attention, revenge, or stimulation; they hope attempt attention, revenge, or stimulation; they hope attempt will change other people’s behavior toward them.will change other people’s behavior toward them.

Level of DangerousnessLevel of Dangerousness

C urren t A ttem pt

A ctive S u ic ida l Idea tion

P ass ive S u icida l Idea tion

H ope lessness

D ep ress ion o r R ecen t Loss

N o D anger

Assessing Suicide: Assessing Suicide: FunnelingFunneling

1.1. Complete thorough assessment: focus on Complete thorough assessment: focus on risk factors, mood, psychiatric history, A risk factors, mood, psychiatric history, A & D use, support system, & outlook on & D use, support system, & outlook on the future. the future.

2.2. Inquire specifically about past and present Inquire specifically about past and present suicidal ideation, plans, or attempts.suicidal ideation, plans, or attempts.

3.3. If suicide is a concern, obtain additional If suicide is a concern, obtain additional information:information:

• Frequency/intensity of thoughts.Frequency/intensity of thoughts.• Specificity & lethality of plan. Specificity & lethality of plan. • Availability of means.Availability of means.• Probability of rescue.Probability of rescue.• Expectation of attempt.Expectation of attempt.• Identify barriers (reasons to live) or resources that Identify barriers (reasons to live) or resources that

might prevent suicide. “What has stopped you might prevent suicide. “What has stopped you from committing suicide?”from committing suicide?”

Example QuestionsExample Questions(Zuckerman, 1995)(Zuckerman, 1995)

• ““Has it crossed your mind that death would relieve Has it crossed your mind that death would relieve you or end your pain?”you or end your pain?”

• ““Have you felt ‘my life is a failure’ or ‘my Have you felt ‘my life is a failure’ or ‘my situation is hopeless’?”situation is hopeless’?”

• ““Have you thought about how you might kill Have you thought about how you might kill yourself?”yourself?”

• ““Have you made any plans to hurt or kill Have you made any plans to hurt or kill yourself?”yourself?”

• ““What would prevent you from killing yourself?What would prevent you from killing yourself?

Overdosing Overdosing

Frequently Used DrugsFrequently Used Drugs

• Anxiolytics & Sleeping Pills.Anxiolytics & Sleeping Pills.• Tricyclic Antidepressants (e.g., Elavil).Tricyclic Antidepressants (e.g., Elavil).• Aspirin.Aspirin.• Acetaminophen (i.e., Tylenol).Acetaminophen (i.e., Tylenol).

• As a As a veryvery general rule of thumb, 10x’s a normal general rule of thumb, 10x’s a normal dose of a dangerous drug is lethal. dose of a dangerous drug is lethal.

Special Issues with AdolescentsSpecial Issues with Adolescents

• Suicide rate among adolescents has Suicide rate among adolescents has increased in recent years, but continues to increased in recent years, but continues to be lower than adult rates.be lower than adult rates.

• Reluctance to confide in adults; collateral Reluctance to confide in adults; collateral information can be very valuable.information can be very valuable.

• Younger adolescents may not fully Younger adolescents may not fully understand the irreversibility of death.understand the irreversibility of death.

• ““Personal Fable” Mentality.Personal Fable” Mentality.

Intervention StrategiesIntervention Strategies

Develop a crisis management plan, Develop a crisis management plan, including emergency procedures.including emergency procedures.

Remove dangerous objects (guns, pills).Remove dangerous objects (guns, pills). Develop a Develop a Care TeamCare Team to monitor client at to monitor client at

home. home. Consider hospitalization, psychiatric Consider hospitalization, psychiatric

consultation, or intensifying treatment.consultation, or intensifying treatment. Closely monitor care.Closely monitor care.

. . . .. . . .

Work with client’s strengths & reasons for Work with client’s strengths & reasons for living.living.

Help client identify specific alternatives to Help client identify specific alternatives to ending his or her life.ending his or her life.

Improve problem solving & coping skills.Improve problem solving & coping skills.

No-Harm Contracts:No-Harm Contracts:

• ObjectiveObjective: client makes a commitment to not : client makes a commitment to not harm himself for a specific period of time.harm himself for a specific period of time.

• ComponentsComponents::

1.1. Emergency contact numbers.Emergency contact numbers.

2.2. Steps to follow in the event of an emergency Steps to follow in the event of an emergency (e.g., call crisis line, go to ER).(e.g., call crisis line, go to ER).

3.3. Prevention Plan, include practical coping skills.Prevention Plan, include practical coping skills.

4.4. Identify who can provide social support. Identify who can provide social support.

Self-Mutilation & Other Self-Mutilation & Other Parasuicidal BehaviorsParasuicidal Behaviors

• Definition: inflicting harm on one’s body without Definition: inflicting harm on one’s body without any intention of death or serious injury.any intention of death or serious injury.

• Typical sufferer: young female (15-25) with a Typical sufferer: young female (15-25) with a history of childhood abuse or neglect.history of childhood abuse or neglect.

• Manifestation: (1) scratching, cutting or burning Manifestation: (1) scratching, cutting or burning one’s arms, wrists, face, legs, genitals, etc.; or (2) one’s arms, wrists, face, legs, genitals, etc.; or (2) preventing wounds from healing.preventing wounds from healing.

• Co-Morbid Problems: eating disorders, mood Co-Morbid Problems: eating disorders, mood disorders, BPD, & chemical dependency.disorders, BPD, & chemical dependency.

• Duration: chronic & compulsive course Duration: chronic & compulsive course lasting 10-15 years.lasting 10-15 years.

• Ironically, sufferers typically feel little pain Ironically, sufferers typically feel little pain while engaging in self-mutilation.while engaging in self-mutilation.

Why do people self-mutilate?Why do people self-mutilate?

1.1. Tension reduction.Tension reduction.2.2. Coping with negative emotions (e.g., turn Coping with negative emotions (e.g., turn

emotional pain into physical pain).emotional pain into physical pain).3.3. Interpersonal communication (e.g., manipulation).Interpersonal communication (e.g., manipulation).4.4. Atonement for perceived sins.Atonement for perceived sins.5.5. Hatred toward one’s body or sexuality.Hatred toward one’s body or sexuality.6.6. Self-stimulation (“to feel something”).Self-stimulation (“to feel something”).7.7. Feel more powerful & in control of one’s life. Feel more powerful & in control of one’s life. 8.8. Psychosis.Psychosis.

Coping Strategies to Reduce Coping Strategies to Reduce Self-Mutilation:Self-Mutilation:

• Engage in non-harmful sensation-seeking (e.g., Engage in non-harmful sensation-seeking (e.g., submerge arm in ice water).submerge arm in ice water).

• Destroy something non-living & invaluable.Destroy something non-living & invaluable.• Use a red marker rather than a knife.Use a red marker rather than a knife.• Response Prevention.Response Prevention.• Direct verbal expression of feelings.Direct verbal expression of feelings.• Distraction.Distraction.• Social Engagement.Social Engagement.• Physical movement or Exercise.Physical movement or Exercise.• Relaxation TechniquesRelaxation Techniques

Potentially Violent Clients: Risk FactorsPotentially Violent Clients: Risk Factors

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

Gravely Disabled ClientsGravely Disabled Clients

• Responsibility to protect people who cannot Responsibility to protect people who cannot care for themselves because of cognitive care for themselves because of cognitive impairment.impairment.

• Examples: psychotic disorders, Alzheimer’s Examples: psychotic disorders, Alzheimer’s disease, dementia, or other organic brain disease, dementia, or other organic brain disorders.disorders.

Legal Issues:Legal Issues:

• Legal duty to provide ordinary and Legal duty to provide ordinary and reasonable care.reasonable care.

• NegligenceNegligence: unreasonable failure to adhere : unreasonable failure to adhere to professional standards. to professional standards.

• Objective TestObjective Test: What would the average : What would the average and reasonable helper of similar training and reasonable helper of similar training and experience have done in the same or and experience have done in the same or similar situation? similar situation?