Download Crisis Oriented Risk Assessments

Crisis Intervention: Addressing
Suicidal Thoughts and Behaviors
Presented by:
Amanda Myatt, LCSW
Director of Emergency Psychiatric Services
Mental Health Cooperative, In.
Crisis Defined
 A crisis represents both danger and opportunity
 Danger—threatens to overwhelm the person and/or
their support system. May result in suicide,
homicide, and/or psychotic break.
 Opportunity—during time of crisis, the individual
may be more receptive to therapeutic influence and
intervention.
 Intervention may lead to new and/or improved
coping skills
Facts about Suicide
 In 2006, suicide was the 11th leading
cause of death in the U.S., claiming
33,300 lives per year. Suicide rates
among youth (ages 15-24) have
increased more than 200% in the last 50
years.
Facts and Stats Continued
 Four times more men than women kill
themselves; but three times more women
attempt than men attempt.
 Suicide occurs across ethnic, economic,
social and age boundaries.
Facts and Stats Continued
 Suicide Methods
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Firearm
50.2%
Suffocation
Poisoning
Drowning
What do you do when a
client is in crisis???
 DON’T panic
 Stay calm and gather information
 Seek assistance from others
Elements of Crisis
Assessments
 Determine nature of the crisis situation and it’s
impact on the individual.
 What factors precipitated the crisis?
 Adaptive capacities of the individual (How do
they usually cope with stress?)
 Resources that can be tapped to alleviate the
crisis situation
 Extent to which the individual is receptive to
intervention
Goal of suicide risk
assessment
 The goal of a suicide risk assessment is
to identify factors that may increase or
decrease the person’s level of risk, to
estimate an overall level of suicide risk,
and to develop a treatment plan that
addresses patient safety.
Beck Suicide Intent Scale
 Aaron Beck has developed and validated
several scales that are used in both
research and clinical settings.
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Beck Anxiety Inventory (BAI)
Beck Depression Inventory (BDI-II)
Beck Cognitive Insight Scale (BCIS)
Beck Hopelessness Scale (BHS)
Beck Suicide Scales
 Beck Scale for Suicide Ideation (BSI)
 The BSI is a 21-item self report
questionnaire that may be used to identify
the presence and severity of suicidal
ideation. Items on this measure assess the
respondent’s suicidal plans, deterrents to
suicide, and the level of openness to
discussing suicidal ideations and openness
to interventions.
Beck Scale for Suicide
Ideation (SSI)
 The SSI measures characteristics of an
individual’s plans and wishes to commit
suicide. The 19 item clinician
administered scale is based on a semistructured interview with the client.
Common Elements of all
Crisis Risk Assessments
 Suicidality
 Current suicidal ideations
 Current plan?
 Access to means to act on plan?
 Does the individual understand risk involved and
lethality of their plan?
 Time/place to execute plan?
 Has the individual recently given away any of
their possessions? Recently made a will?
Crisis Risk Assessment
Continued
 History of gestures/attempts (seriousness
of prior attempts; outcome of attempt;
and treatment received)?
 Suicide modeling (attempts/gestures by
significant others—when and whom?)
All these questions need to be explored fully.
Crisis Risk Assessments
Continued
 Current Impulse Control Ability
 History of impulsive actions?
 Current Stressors
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Recent relapse
Financial
Residential
Domestic Violence
Legal
Grief Issues
Separation from significant other
Recent loss of a partner
Extreme community violence/trauma
Crisis Risk Assessment
Continued
 History of Physical and/or Sexual Abuse
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Are they the victim or perpetrator?
How recent?
Police involvement?
Mandatory reporting?
Crisis Risk Assessment
Continued
 Medical issues
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Chronic medical condition?
New diagnosis?
History of head injury?
History of seizures?
Complicated withdrawal issues?
Crisis Risk Assessment
Continued
 Mental Health Diagnosis?
 The presence of a psychiatric disorder is
probably the most significant risk factor for
suicide. Psychological autopsy studies have
consistently shown that more than 90% of
person who die from suicide satisfy the
criteria for one or more psychiatric disorders.
Crisis Oriented Risk
Assessment Continued
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Mood Disorders (Depression; Bi-polar;)
Schizophrenia
Anxiety Disorders
Eating Disorders
Crisis Risk Assessment
and Substance Use
 Use of alcohol and/or illegal drug abuse
increases risk with period of intoxication
being one of the highest risk times for
individuals.
Crisis Risk Assessment
Continued
 Current Consumer Resources
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Perceived resources
Actual resources
Involvement of patient’s family/social support
Current family/social support concern
regarding dangerous thoughts or behaviors?
 Is support system sufficient?
Gender Specific Issues
 In virtually all countries that report suicide
statistics to the World Health
Organization, suicide risk increases with
age in both sexes, and rates for men in
older adulthood are generally higher than
those for women.
Gender Specific Continued
 Suicide rates in males is approximately 4
times higher than rates for women in the
US.
 A number of factors may contribute to
these gender differences in suicide risk.
Men who are depressed are more likely
to have comorbid alcohol and/or
substance abuse problems than women,
which places the men at higher risk.
Gender specific issues
continued
 Men are also less likely to seek and accept
help or treatment.
 Women, meanwhile, have factors that protect
them against suicide. In addition to lower rates
of alcohol and substance abuse, women are
less impulsive, more socially embedded, and
more willing to seek help.
 ***However these differences are changing.
Gender specific issues
continued
 Women have higher rates of depression
and respond to unemployment with
greater and long-lasting increases in
suicide rates than do men.
 Other gender specific issues to consider
 Pregnant women
 Post partum complications
 Women with children in the home
Services to assist
individuals in crisis
 When do you call 911 and request an
ambulance or law enforcement vs when
do you call a mobile crisis team?
 If the person is trying to leave or is
aggressive, call law enforcement.
 If the person has attempted or you suspect
an attempt (ie—overdose) call 911 and
request an ambulance.
Services to assist
Consumer’s in crisis
 If the person is highly intoxicated,
medical clearance will be required.
 If the person is not threatening to leave
or has no means to leave---call your local
mobile crisis team. Be prepared to give
demographic information and explain
what is going on at this time.
Crisis Continuum Services
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24/7 Mobile Crisis Response Services
Police walk-in centers
Crisis Resolution Centers
Crisis Respite Programs
Crisis Stabilization Units
Crisis Resolution Center
(CRC)
 24/7 Crisis assessment and Resolution
 Staffed by nurses and Bachelor Level
Mental Health Professionals
 Daily rounds and evaluations performed
by Psychiatrist and/or psychiatric nurse
practitioner
 Offers quick, solution focused assistance
for individuals in crisis
Crisis Resolution Center
Continued
 Length of Stay—Up to 12 hours
(sometimes this stay may be extended
but cannot exceed 23 hours)
Crisis Respite
 Can be helpful in de-escalating a
situational crisis, providing stabilization in
a mental health emergency, and giving
he person time to make positive
decisions that they may not be able to
make during the initial crisis phase.
 Staffed with 24/7 awake staff; nurse
makes visits 5 days a week; access to
psychiatric consult daily.
Crisis Respite Continued
 Length of stay up to 3 days
 While in respite, individuals are
encouraged to attend house groups and
work with staff on development of
comprehensive discharge plan.
 Crisis respite is for individuals who do not
require hospitalization but need 24 hour
monitoring in a community based setting.
Crisis Respite Admission
Criteria
 An individual is appropriate for Crisis
Respite if they:
 Are experiencing a mental health crisis,
 Have insight into their need for intervention
 Agreeable to the placement
Crisis Stabilization Unit
 Intensive level of care
 24/7 staff that includes RN; LPN;
Bachelor’s level mental health staff; Peer
support specialist
 Daily rounds by psychiatric provider
 24/7 on-call psychiatric provider
 Unit must maintain a 1:5 ratio at all times
Crisis Stabilization Unit
 15 bed capacity
 Groups conducted daily (at least 5
groups offered throughout a typical day)
 Individual sessions as needed
 Highest level of care that an individual
can receive in a “community based
setting.”
Crisis Stabilization Unit
Continued
 Length of stay is up to maximum of 96
hours with average length of stay
approximately 2.5 days.
 CSU is a voluntary unit
 Individuals appropriate for CSU are
experiencing an “acute crisis episode”
but have insight and agree to
intervention.
Crisis Stabilization Unit
Continued
 Individuals may be actively suicidal
and/or psychotic but have enough insight
to know that they need treatment.
 Once on the CSU unit, if a higher level of
care is needed to maintain the
individual’s safety, then the staff will
facilitate transfer to an inpatient
psychiatric hospital.
Involuntary
Hospitalization Criteria
 Involuntary Commitment Process State of
Tennessee
 Title 33, Chapter 6, Part 4, Tennessee Code
Annotated (commonly known as 6-404)
 Latest revision of the mental health law of
Tennessee became effective July 1, 2002 (last
major revision was over 20 years ago)
Involuntary Commitment
Criteria in TN
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Criteria:
To Detain for Examination (TCA Section 33-6-401)
1. A person has a mental illness or serious emotional disturbance (SED),
AND
2. Poses an immediate substantial likelihood of serious harm because of
the mental illness or serious emotional disturbance.
Admission to Hospital (TCA Section 33-6-403)
1. A person has a mental illness or serious emotional disturbance, AND
2. Poses an immediate substantial likelihood of serious harm because of
the mental illness or serious emotional disturbance.
3. Needs care, training, or treatment because of the mental illness or
serious emotional disturbance, AND
4. All available less drastic alternatives to placement in a hospital or
treatment resource are unsuitable to meet the needs of the person
Substantial Likelihood of
Serious Harm
 TCA Section 33-6-501
If and Only If:
(1)(A) A person has threatened or attempted suicide or to inflict serious bodily
harm on himself, OR
(B) The person has threatened or attempted homicide or other violent
behavior, OR
(C) The person has placed others in reasonable fear of violent behavior
and serious physical hart to them, OR
(D) The person is unable to avoid severe impairment or injury from
specific risks, AND
(2) There is a substantial likelihood that such harm will occur unless the
person is placed under involuntary treatment.
Then
(3) The person poses a “substantial likelihood of serious harm” for purposes
of Title 33.
Examples of Key Indicators for
Certificate of Need Completion
1. Is mentally ill as shown by the following facts and
reasoning:
- active symptoms of psychiatric disorder
- previous psychiatric diagnosis
- previous psychiatric hospitalizations
- previous prescription of psychotropic medications
- reported or clinically suspected substance
dependence
- reported history of behaviors clinically indicative of a
psychiatric disorder
Examples of Key Indicators for
Certificate of Need Completion
Cont.
2.
Poses an immediate substantial likelihood of serious harm
because of the mental illness as shown by the following facts
and reasoning:
- clinical depression with suicidal attempt by overdose
- threatening to kill wife due to paranoid delusions that she was
poisoning food
- entered neighborhood grocery threatening revenge on former
co-workers
- walking in interstate traffic; drinking toxic substances; etc.
Plus, clinical opinion/indicators that such harm will occur or reoccur unless the individual is placed under involuntary
treatment.
Examples of Key Indicators for
Certificate of Need Completion
Cont.
3. Needs care, training or treatment because of
the mental illness:
- treatment likely to prove beneficial in
symptom reduction
- medication likely to prove beneficial in
behavior control
- condition is likely to further deteriorate
without treatment
Examples of Key Indicators for
Certificate of Need Completion Cont
4.
All available less drastic alternatives to hospital or
treatment resources are unsuitable due to:
- adequate evaluation requires secure setting
- inability to contract for safety
- unable to resist impulses or control behavior
- will not agree to respite; suitable respite not
available; failed respite, etc.
- unable to provide safe environment; no support
persons to provide or assist with supervision
- present condition places self/others at too high a
risk for injury
Involuntary Commitment
Process State of Tennessee
Continued
 Role of Mandatory Pre-screening Agent
(MPA)
 Intersecting Roads…The Law and
TennCare
“Contracting for Safety”
 Don’t rely on the suicidal client to tell you
that they will not harm themselves.
 Decision about intervention strategies
should be based on thorough clinical
evaluation.
Taking Care of yourself
and your Staff
 Critical Incident De-briefing
 De-briefing needs to occur quickly and in an
environment that the individual feels safe to
express their emotion.
Presentation Sources
 Aguilera, D., 1998. Crisis Intervention Theory and Methodology,
Eighth Edition
 American Psychiatric Association, 1994. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition
 Bureau of Justice Statistics – Special Report. Washington, DC:
U.S. Department of Justice, Office of Justice Programs
 Harris, R., Vanderbilt School of Nursing, 9/01. Diagnostic
Interview: Assessment of Thought Disorders
 Hersen, M. & Turner, S., 1994. Diagnostic Interviewing, Second
Edition
 Hoff, L., 1995. People in Crisis: Understanding and Helping,
Fourth Edition
 American Psychiatric Assoction, 2009, Practice Guidelines for the
Assessment and Treatment of Patients with Suicidal Behaviors
 American Association of Suicidology, May 2010
Questions/Comments
For more information
 Contact
Amanda Myatt, LCSW
Director of Emergency Psychiatric
Services
Mental Health Cooperative
Direct office number 744-7442
E-mail: [email protected]
24/7 crisis line: 726-0125