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Crisis Assessment
CPSE Preparation
| Question | Answer |
|---|---|
| Crisis Characteristics: Defining features | (Roberts, 2000) A crisis is a time-limited event It lasts six to eight weeks It may result in lasting dysfunction, particularly if not addressed. |
| Components of a crisis | (Golan, 1978)It is a hazardous event Involves a person in a vulnerable state Involves a precipitating factor Involves an active crisis state Eventually involves reintegration from disequilibrium |
| Crisis Characteristics: Stages of an active crisis state | Physical and psychological agitation Preoccupation with the events leading to the crisis Gradual return to equilibrium |
| Crisis Characteristics: Crisis origins | 1) Situational crises: Triggered by sudden, uncontrollable, & unanticipated event. 2) Maturational (developmental) crises: Embedded in developmental processes, occurs when person struggling w/ transition from 1 life stage to another. |
| Reactions to a crisis: Phases | Impact phase; recoil phase, posttraumatic recovery phase |
| Reactions to a crisis: Symptoms | Affective symptoms; cognitive symptoms; behavioral symptoms; and physical symptoms |
| Reactions to a crisis: Risk factors | Pre-event factors; peri-event factors; post-event factors |
| Reactions to a crisis: Anniversary Reaction | Re-experiencing; affective reactions; guilt/helplessness; physical symptoms |
| Reactions to a crisis: Impact of culture | Reactions to unwed pregnancy, expressions of feelings, interpretation of psychological symptoms, and responses to offers of help |
| Three Types of Crisis Assessment | (Roberts,2005) Triage, crisis instruments, biopsychosocial assessment |
| Crisis Assessment instruments and interviews | Rapid assessment instruments (RAI) Semi-structured interviews (Myer’s triage assessment model, 2001) |
| Crisis intervention: Primary goal #1 (applies to all crisis interventions) | Relieve client’s current symptoms |
| Crisis intervention: Primary goal #2 (applies to all crisis interventions) | Help client identify and gain understanding of factors leading to the crisis |
| Crisis intervention: Primary goal #3 (applies to all crisis interventions) | Use remedial measures and resources to restore client to (or above) pre-crisis functioning |
| Crisis intervention: Primary goal #4 (conditional to some crisis situations) | Help client develop adaptive strategies for current or future situations |
| Crisis intervention: Primary goal #5 (conditional to some crisis situations) | Help client connect current stress with past experiences |
| Crisis intervention model #1 | Stress-Crisis Continuum (Burgess and Roberts, 2005) |
| Crisis intervention model #2 | Seven-Stage Crisis Intervention Model (Roberts & Ottens, 2005) |
| Levels of the Stress-Crisis Continuum | Level 1-Somatic Distress Level 2-Transitional Crisis Level 3 –Traumatic Stress Crisis Level 4 – Family Crisis Level 5- Serious Mental Illness Level 6- Psychiatric Emergencies Level 7-Catastrophic Crisis |
| The Seven-Stage Crisis Intervention Model | 1) Crisis Assessment 2) Establish Rapport 3) Identify Major Problems 4) Explore Feelings and Emotions 5) Generate and Explore Alternatives 6) Develop and Implement an Action Plan 7) Follow-Up |
| Crisis Intervention Methods: Three approaches (Gilliland and James, 1997) | Nondirective approach Collaborative approach Directive approach |
| Crisis Intervention Alternatives (Methods) | Psychological first aid (PFA) Group interventions Individual interventions Family interventions Referrals |
| Suicide Risk Factors | Suicidal thoughts/behaviors Psychiatric diagnosis and symptoms Physical illness Psychosocial factors Demographic characteristics |
| Suicide: Treatment alternatives | 1) Hospitalization 2) Outpatient crisis intervention 3) Outpatient psychotherapy |
| Danger to others: Risk factors | Demographic characteristics Psychiatric diagnosis and symptoms Situational factors |
| Danger to others: Treatment alternatives | Hospitalization Outpatient management, including: Cognitive-behavioral Therapy Couple and Family therapy Group therapy |
| Three types of grief | Anticipatory grief Normal (uncomplicated) grief Complicated grief |
| Grief: Two general types of treatment alternatives | Treatments for normal grief Treatments for complicated grief |
| Grave disability: Adult legal definition | Adults: Inability to provide for basic personal needs as a result of mental condition or alcoholism Mental retardation does not meet this requirement, is not a grave disability in and of itself |
| Grave disability: Hospitalization requirements | 1) When disability is a result of mental disorder or chronic alcoholism 2) When individual refuses or unable to comply with voluntary hospitalization 3) Cannot stay in less restrictive environment |
| Grave disability: Legal code requirements for hospitalization | Regulated by Lanterman-Petris-Short Act Begins with 72-hour hold ("5150") May extend to 14-day hold ("5250") May re-extend to another 14-day hold ("5260") |
| Grave disability: Legal determination for hospitalization | 1) Necessary to first consider if reliable caregivers are available to help, per Welfare and Institutions Code 5350(e) 1 and 2 2) Next must R/O existence of responsible persons who indicate willingness & ability to help provide for basic personal needs |
| Grave disability: Minor legal definition | Minors: Inability to use elements of life essential to health, safety, and development, even when provided by others. Mental retardation, epilepsy, alcoholism, antisocial behavior, developmental disabilities are not grave disabilities by themselves. |
| Grief: Treatments for normal grief | Intervention may not be necessary In some cases brief interventions based on crisis theory are useful Interventions for particular types of loss (death of a child, etc.) may be useful Supportive counseling Support/self-help group Medication |
| Grief: Treatments for complicated grief | Grief-focused therapy (Worden, 2009), such as: Interpersonal Psychotherapy Cognitive-Behavioral Intervention Group Counseling Family Focused Grief Therapy |
| Types of grief: Anticipatory grief | Occurs prior to an expected loss Vacillation between acceptance and denial May provide acceptance of the reality of loss, prepare for life without the deceased |
| Types of grief: Uncomplicated grief | Symptoms subside within 6 to 12 months May involve Kubler-Ross stages: denial, anger, bargaining, depression, and acceptance |
| Types of grief: Complicated grief | Unresolved or pathologic Involves four types: Masked, delayed, distorted/exaggerated, and chronic May eventually meet criteria for mental disorder (Adjustment, PTSD, MDD, etc.) |
| Danger to others: Hospitalization due to imminent danger | 1) Imminent danger to others due to mental disorder or alcoholism, 2) Clinician needs to follow up with hospitalized client until resolved 3) Proceed with treatment, refer for program enrollment, or to criminal justice after hospitalization |
| Danger to others: Outpatient management | 1) Indicated when sincere desire to change is present and risk is low 2) Develop a safety plan 3) Useful approaches: Cognitive-Behavioral Therapy, Couple and Family Therapy, Group Therapy |
| Crisis intervention: 7 Core Principles | 1) Proximity 2) Immediacy 3) Expectancy 4) Brevity 5) Simplicity 6) Innovation 7) Practicality |
| Four crisis intervention tasks (Slaikeu, 1984) | Physical survival task; Expression of feelings task; Cognitive mastery task; Behavioral and interpersonal adjustments task |
| Crisis intervention: Ending intervention | Before ending a crisis intervention, answer "yes": Equilibrium restored? Coping capabilities regained? Event has been integrated into life as a whole? Success in working through unresolved personality issues? |
| Crisis intervention method: Psychological first aid | 1) Often the 1st phase in intervention 2) Involves 6 steps: a) Immediate intervention b) Establish rapport c) Assessment d) Take action e) Utilize referral sources f) Provide aftercare |
| Suicide assessment: Timing of assessments following initial evaluation | Each session following release from hospital Each session during a suicide intervention At onset of new, painful, disabling medical condition Onset of new/intensified co-existing psych disorder Onset of signs of relapse Major stressor Other risks |
| Risk factors for suicide: General | Suicidal thoughts/behaviors Psychiatric diagnosis Psychiatric symptoms Physical illness: Cancer, HIV+, neuro disorder Psychosocial factors: Lack of social support Demographic characteristics: Older, male, White, LGBT |
| Risk factors for suicide: Adolescent | 1) Aggression and hostility 2) Depression, but not bipolar disorders 3) Impulsivity 4) Interpersonal conflict or loss 5) Substance abuse 6) History of being abused |
| Risk factors for suicide: Older adults | physical illness Depression Loss of relationships, resource, abilities Access to firearms or poisons |
| Risk factors for suicide: Gender, age, and race | Male gender Older Whites have hihghest overall rates of suicide Highest risk for ages 75 and older for most Highest risk for women is at ages 45 to 54 Completed suicide highest for men American Indian aged 15-34 is double nat'l ave. for ages 15-34 |
| Risk factors for suicide: Making predictions | A concrete, detailed, and lethal suicide plan, and the means to carry it out suggest a high risk of suicide, even when no other risk factors are present (depression, other stressors, etc.) |
| Suicide screening questions | Ask about feelings about living Questions addressing thoughts about death, suicide, and self-harm. When thoughts are present, follow up with specific questions about them Those who have attempted in past, follow-up with specifics Address harm to other |
| Suicide treatment primary goals | Ensure the client's safety Eliminate or reduce access to means of suicide Establish therapeutic alliance Develop trust Alleviate acute risk symptoms (panic symptoms, agitation, insomnia, substance abuse) |
| Suicide treatment secondary goals | Reduce future suicide risk Address mania, depression, other conditions and risk factors. |
| Danger to others: Definition | Danger (risk) to others is a number of harmful acts: Emotional, sexual, physical violence Intimidation and threats Neglect or abuse of dependents Stalking/harassment Property damage Reckless behavior |
| Danger to others: Assessment goals for clinician | 1) Determine probability client will be violent in near future. 2) Identify factors contributing to client's dangerousness Obtain added info needed to ID treatment goals & develop a treatment plan |
| Danger to others: Assessment methods | 1) Uses comprehensive approach. 2) Obtain info on multiple factors from multiple sources. Factors to address: History of violent behavior Access to weapons and victims Mental status/overall level of functioning Current stressors Client's cooperation |
| Danger to others: Assessment and sources of info | Sources of information include: The client Family members Friends Others familiar with client Medical & mental health records Police & court records |
| Danger to others: Assessment w/ psych tests & tools | Psychopathy Check List-Revised (Hare, 1991) MMPI-2 or MMPI-A Millon Clinical Multiaxial Inventory - III |
| Danger to others: determining risk Sue and Sue (2008) | 1) Low risk when few risk factors, no history or plan 2) Moderate risk when multiple risk factors 3) High risk when concrete plans, access to lethals |
| Danger to others: treatment goals | Initial goals are: Build rapport Reduce risk for future violence by: Have client adhere to medication regimen Have a safety plan or no-violence contract Address issues such as substance use or impulsiveness |
| Grief: Definitions | Bereavement: state or condition caused by a loss, including grief and mourning Grief: pscyhological, behavioral, physical experience of loss Mourning: Outward expression of grief, affected by gender, culture, religion, cause of bereavement |
| Grief: treatment primary goal | Help the client successfully complete the grieving process |
| Grave disability: primary goal of assessment | Determine extent client's mental disorder or chronic alcoholism interferes with ability to effectively deal with everyday functioning. Examples: signs of malnutrition/dehydration Inability to maintain hygiene to prevent illness Unable to get shelter |
| Grave disability: assessment instruments | Mental status exam Global assesssment of functioning or WHODAS GAF score of 0-30 = association w/ grave disability MMPI-2/MMPI-A MCMI-III |
| Golan's crisis characteristics components: The hazardous event | 1) A specific stressor disrupting person's equilibrium, initiates series of reactions leading to crisis. 2) May be anticipated (marriage) or unanticipated (death of family member) |
| Golan's crisis characteristics components: The vulnerable state | 1) Refers to a person's phys, emotional, cognitive, behavioral responses to an event. 2) Marked by increased tension, sense of ineffectiveness relieved by use of customary coping strategies. 3) Tension increased if unsuccessful, leading to dysfunction |
| Golan's crisis characteristics components: The precipitating factor | 1) The final stress event in a series, moves person from vulnerability to disequilibrium/disorganization. 2) Precipitating factor may coincide with a hazardous event, may be minor event assuming huge proportion along w/ other events & ineffectiveness |
| Golan's crisis characteristics components: The active crisis state | 1) this occurs when person's coping skills break down, tension at a maximum. 2) Characterized by disequilibrium & involves three stages: agitation, preoccupation, & return to equilibrium. 3) Person may recognize inadequate coping & be motivated for help |
| Golan's crisis characteristics components: The reintegration state | Restoration of equilibrium after crisis depends on factors including person's ability to evaluate crisis & develop/use adaptive coping strategies. |
| Reactions to a crisis: Impact phase | 1) This occurs immediately after an event, lasts a few minutes to hours. 2) Person exhibits shock, fear, agitation, confusion, other signs of distress, may deny event occurred |
| Reactions to a crisis: recoil phase | 1) Acknowledgement of reality of situation, attempt to make sense of what happened. 2) Characterized by intensification of emotional & physical symptoms |
| Reactions to a crisis: posttraumatic recovery phase | 1) May include alternating periods of adjustment & relapse, person becoming aware of implications of incident, attempts re-establishment of equilibrium. 2) Severity of crisis = amount of time spent on this phase, person's characteristics, & good/bad Tx |
| Reactions to a crisis: Affective symptoms | Includes shock, disbelief, numbness, fear, anger, etc. |
| Reactions to a crisis: Cognitive symptoms | Includes flashbacks, intrusive thoughts & images, nightmares, disorientation, confusion, & impaired memory, concentration, & decision-making |
| Reactions to a crisis: Behavioral symptoms | Includes difficulties accomplishing activities of daily living, social withdrawal, change in sexual activity, inability to work, inappropriate behaviors, impulsive/dangerous actions, & substance abuse |
| Reactions to a crisis: Physical symptoms | Sleep disturbances, appetite changes, muscle tension & ahces, nausea & diarrhea or constipation, sweating, hyperventilation, agitation, palpitations, dizziness, & heightened startle response. |
| Reactions to a crisis: Pre-event risk factors | Include previous unresolved trauma or loss, previous psychiatric history, substance abuse, concurrent life stressors socioeconomic disadvantage, & female gender. |
| Reactions to a crisis: Peri-event risk factors | Include sudden & unexpected events, man-made disasters, prolonged exposure to events, perceived or actual threat to life, self, others, exposure to horrific scenes or sensory exp, substantial personal loss. |
| Reactions to a crisis: Post-event risk factors | Include survivor or performance guilt, adverse reactions by others, & lack of social support. |
| Types of Crisis Assessment: Triage (Roberts, 2005) | This type of assessment occurs following disaster or trauma and is conducted by frontline workers. |
| Triage care first responder tasks | Obtain crucial demographics & info on person's perceptions of event, coping skills, sources of support, safety & lethality, MSE, current Sx, pre-existing psych conditions, environmental stressors, & ability to benefit from Tx. |
| Purpose of triage care | 1) The purpose is to determine if intervention is necessary; 2) I.D. needed interventions (emergency hospitalization, outpatient Tx, referral to support group or agency) |
| Types of Crisis Assessment: Crisis Assessment vs. Triage Assessment goals (Roberts, 2005) | Goals of crisis assessment include 1) systematic organization of client info related to personal characteristics, parameters of the crisis episode, & intensity, duration of crisis, 2) Utilize this data to develop an effective Tx plan |
| Crisis Assessment: Distinguishing reactions (Roberts, 2005) | 1) An important aspect of crisis assessment. 2) Distinguishes between normal and excessive reactions to a crisis, or those reflecting a preexisting condition. |
| Crisis assessment: Rapid Assessment Instruments (RAIs) | 1) Brief standardized self-reports, 2) Easy to admin & score 3) Can be in initial assessment 4) Used to monitor progress of Tx, 5) Includes BDI-II; Brief Sx Inventory; Impact of Events Scale - R; Crisis State Assessment Scale |
| Crisis assessment: Semi-Structured Interviews & components of Myer's triage assessment | 1) Affective domain component measures (Mx) anger/hostility, anxiety/fear, & sadness/melancholy; 2) Cognitive domain Mx client perceptions of crisis as transgression, threat, loss; 3) Behavioral domain Mx reactions: avoidance, approach, immobility |
| Types of crisis assessment: Biopsychosocial | 1) Used to obtain info on client's bio, psych, & sociocultural experiential functioning helpful to forming Tx goals & plan. 2) Amount of info collected depends on factors including severity of crisis, urgency & nature of services required. |
| Crisis assessment and intervention vs. long-term therapy: Comparing differences | The differ in the following ways: 1) Diagnosis, 2) Tx focus, 3) Tx plan, 4) Tx strategies, 5) Eval of results |
| Crisis intervention vs. long-term therapy: Diagnostic differences | Crisis intervention: Uses focused crisis assessment. Long-term therapy: Uses comprehensive diagnostic evaluation |
| Crisis intervention vs. long-term therapy: Treatment focus differences | Crisis intervention: Immediate traumatized aspects of the person. Long-term therapy: Underlying causes and whole person |
| Crisis intervention vs. long-term therapy: Treatment plan differences | Crisis intervention: Problem-specific plan to alleviate crisis symptoms. Long-term therapy: Personalized comprehensive plan that addresses long-term needs |
| Crisis intervention vs. long-term therapy: Treatment strategies differences | Crisis intervention: Time-limited techniques for immediate resolution of the crisis. Long-term therapy: Various techniques that address short-term, intermediate, and long-term goals |
| Crisis intervention vs. long-term therapy: Evaluation of results differences | Crisis intervention: Behavioral evaluation of person's return to pre-crisis state of equilibrium. Long-term therapy: Behavioral evaluation of therapeutic outcome in terms of person's overall functioning |
| Crisis Intervention Methods: Non-directive approach (Gilliland and James, 1997) | 1) Approach is indicated when client can initiate, perform action steps to resolve a crisis. 2) The less severe a crisis, the less directive the clinician must be. 3) Clinician facilitates client's ability to make decisions by providing support, encourage |
| Crisis Intervention Methods: Collaborative approach (Gilliland and James, 1997) | 1) Most effective for client who cannot function with nondirective approach. 2) Client has mobility to work collaboratively to resolve crisis. 3) Clinician serves as catalyst, facilitator, consultant, provider of support |
| Crisis Intervention Methods: Directive approach (Gilliland and James, 1997) | 1) Indicated when client immobilized by depression/anxiety, psychosis, etc. 2) Clinician assumes temporary responsibility for client, defines problems & solutions, facilitates client's actions by providing instruction & guidance |
| Crisis intervention method: Group intervention Types | 1) Group cognitive processing therapy; 2) CBT group; 3) Bereavement support groups; 4) Critical Incident Stress Management (CISM); 5) Debriefing |
| Crisis intervention group: Two Components of Critical Incident Stress Management (CISM) | Component 1: Defusing, in which structured discussions occur within a few hours of trauma allowing members to vent & reflect; 2: Group debriefing in which meetings held at intervals over days to weeks after trauma provide info to victims, families |
| Crisis Intervention Methods: Individual (brief) interventions | 1) Behavior therapy 2) Trauma-focused CBT 3) Solution-focused therapy |
| Crisis Family Intervention Methods: Used for Tx of who? | A preferred Tx for children & adolescents in crisis |
| Crisis Family Intervention Methods: Five-step systemic model (Harris, 1991) | 1) Make psychological (therapeutic) contact w/ family by building rapport, encouraging expression of feeling, tell stories; 2) explore the family problem; 3) explore solutions; 4) assist family to take action; 5) follow-up, referrals, check on progress |
| Crisis referral intervention types, facilities, & locations | 1) Ambulance for immediate problems 2) County evaluation facility 3) ER 4) Police, sheriff 5) Physician 6) Neurological or drug eval 7) Hotlines 8) Shelters 9) Protective services 10) Crisis groups |
| Suicide assessment primary goals | 1) Determine client's imminent & future risk for suicide 2) Obtain info to develop Tx plan 3) Monitor effectiveness of Tx plan |
| Suicide assessment timing | 1) Assessment of suicide is an ongoing process. 2) Conduct suicide assessment at initial eval of everyone |
| Suicide assessment methods | 1) Integrate info from a variety of sources 2) Include clinical interview, MSE, family, physician, psych tests. 3) Make note of risk factors for suicide |
| Suicide assessment and protective factors | 1) Good coping, problem-solving skills 2) Intact reality testing 3) Sense of responsibility to family 4) Ability to get social support 5) Culture, moral/religious values discouraging suicide 6) Fear of suicide 7) Motivation for help 8) + therapy alliance |
| Suicide screening psychological tests | 1) Beck Scale for Suicide Ideation (BSS), 2) BDI-II, 3) Beck Hopelessness Scale (BHS), 4) Reasons for Living Inventory, 5) MMPI-2/MMPI-A, 6) Rorschach Suicide Constellation (S- CON) of Rorschach Inkblot Test |
| Suicide treatment clinical choices & clinical considerations | 1) Consider client's preferences 2) Potential risks & benefits of each approach 3) No-suicide contracts don't guarantee safety, to be used only as a component of comprehensive interventions |
| Suicide Tx: Triggers to use of hospitalization treatment alternative | 1) Following suicide attempt 2) When imminent suicide risk is indicated by specific plan 3) When access to lethal means is accompanied by impaired judgment, impulsivity, severe depression, or chem dependence |
| Suicide Tx: Voluntary vs. involuntary hospitalization | 1) Encourage voluntary hospitalization 2) Initiate involuntary hold if client refuses |
| Suicide Tx: Outpatient crisis intervention | 1) Appropriate when client at moderate risk for suicide 2) Evidenced by intent w/ lack of access to lethal means, fair judgment, social support, willingness to comply w/ Tx. 3) Involves application of 7-Stage crisis intervention model |
| Suicide Tx: The Hoff et al. (2009) outpatient intervention | 1) Reduce social isolation (move in w/ a friend); 2) remove lethal means; 3) encourage expression of anger in alternative ways; 4) relieve anxiety & sleep loss; 5) Persuade to postpone deciding on suicide until after current crisis ends |
| Suicide Tx: Outpatient psychotherapy intervention | 1) Useful as follow-up to hospital & as Tx for clients low in risk for suicide; 2) useful when evidence of no specific plan, presence of social support, willingness to talk Re: problems, & comply w/ Tx; 3) use CBT, IPT, DBT, & problem-solving Tx |
| Danger to others: Taking action for protection from violent clients (Sue & Sue, 2008) | Remain calm, encourage communication, determine intensity of client feeling and lethality of intent |
| Danger to others: Methods for reducing agitation in violent clients (Sue & Sue, 2008) | 1) Less intrusive method is speaking softly, moving slowly, maintaining physical distance, leaving door open, sympathy, setting limits, suggesting alternatives to violence. 2) More intrusive is leaving room, calling 9-1-1, use of weapon. |
| Danger to others: Use of 9-1-1 with violent clients (Sue & Sue, 2008) | 1) Acceptable only if client's condition permits a violation of confidentiality, or 2) if client gives permission to call police |
| Danger to others: Timing assessment | Assessment of danger is an ongoing process starting w/ 1st contact w/ client & when change in mental or legal state, when major change in life (divorce), or modification in care (discharge from hospital, referral to new clinical provider) |
| Danger to others: Assessment of risk factors predicting violence | 1) Look at demographic, personality, & situational factors indicating risk for danger to others. 2) Research confirms the single-best predictor is past history, particularly of violence at early age, & commitment of multiple acts. |
| Assessment of danger to others: demographic characteristics as risk factors predicting violence | Past violence, male gender, younger age, lower SES, low intelligence, history of child abuse, witnessing spousal abuse, father w/ criminal arrest history |
| Assessment of danger to others: psychiatric diagnosis as risk factors predicting violence | Substance use disorder, antisocial personality disorder, BPD, schizophrenia, manic phase of bipolar disorder |
| Assessment of danger to others:psychiatric symptoms as risk factors predicting violence | Neurological impairment, hostility, aggressive attributional & interpersonal style, violent thoughts & fantasies, anger & impulsivity, command hallucinations, threat/control override Sx (feeling threatened combined w/ belief in external control locus) |
| Assessment of danger to others: situational factors as risks predicting violence | Lack of social support, access to weapons, high level of perceived stress, victim specificity & availability, non-compliance w/ Tx, & poor therapeutic alliance |
| Assessment of danger to others: The two-stage method approach to screening questions (Borum et al., 1996) | 1) Initial screening questions asked of all clients (general & less sensitive); 2) More detailed questions asked if elevated risk for violence is suggested by initial questions or history of violence |
| Assessment of danger to others: psychological tests & assessment tools | 1) Tests aren't needed when intent to harm is expressed, when in acute crisis state & in need of immediate help. 2) May be helpful to detect portential in those not overtly aggressive/assaultive, assessing contributing conditions such as psychosis, A & D |
| Assessment of danger to others: Psychopathy Check List - Revised | 1) Designed as a measure of psychopathy, used to predict violent recidivism. 2) Twenty items measure for psychopathy (lying, poor control, grandiosity). 3) Scored on 3-pt. scale and total ranges from 0-40, w/ >30 = psychopathy. |
| Assessment of danger to others: MMPI-2 & MMPI-A scales useful for checking anger & aggression | 1) Very high score on Scale 4 (Pd). 2) Highs cores on Scales 4 & 9 = underlying anger, alienation, impulsiveness, & antisocial + high energy. 3) High Scale 6 (Pa) & 4 & 9 = very dangerous & poor judgment, acting out is violent & feels justified to client |
| Assessment of danger to others: Millon Clinical Multiaxial Inventory - III | 1) Assesses DSM-IV PDs & clinical syndromes. 2) High score on Antisocial (6A) scale = impulsive acting out. 3) High on Aggressive (6B) = aggressive outbursts w/ no shame or guilt. 4) Both 6A & 6B together = direct, abusive expressions. |
| Assessment of danger to others: Millon Clinical Multiaxial Inventory - III elevations on 6A, 6B, & P (paranoid) scales | Elevations on these three scales suggests the person is paranoid, may express this in a controlling, intimidating, & belligerent way, may brood about perceived injustices & develop plans of revenge. |
| Danger to others: initial treatment goals | 1) build rapport w/ client, 2) reduce client's risk for future violence, 3) bring violent, aggressive behavior under control. |
| Danger to others: initial treatment methods for reducing risk | 1) These methods depend on nature, lethality, & immediacy of violence threatened by client. 2) May include having client agree to adhere to medication, safety plan, no-violence contract. 3) May depend on factors such as setting for Tx, client's character |
| Danger to others: choosing the best treatment environment | When choosing a treatment alternative, the primary guiding principle is to keep the client in the least restrictive environment. |
| Danger to others: Hospitalization when mental disorder is the cause | 1) If mental disorder is cause, then voluntary psych hospital is best, but if no mental disorder, then substance abuse, etc 2) If refusal then involuntary hospitalization. 3) Follow-up with client until crisis stabilizes 4) Tx after release from hospital |
| Danger to others: Outpatient management using CBT | 1) For violent & aggressive behaviors when these are embedded in thought patterns that can be controlled/replaced w/ pro-social thinking. 2) Strategies: Training in cognitive self-control, anger management, social perspective-taking, relapse prevention |
| Danger to others: Outpatient management using couple and family therapy | 1) Useful since violence often occurs in families. 2) Includes educating family members Re: family dynamics leading to violence & early warning signs, training in interventions for high-risk situations, communication, problem-solving, & support groups |
| Danger to others: Outpatient management using group therapy | 1) Often less threatening to clients than individual therapy. 2) Provides members opportunities to see others also struggle w/ violence & aggression. 3) See how others dealt w/ situations triggering violence. 4) Learn to resolve conflicts w/ other members |
| Danger to others: Consultation with other professionals | 1) An important adjunct when choosing appropriate management strategy for dangerous client. 2) Increases predictive accuracy. 3) Facilitates I.D. of useful interventions. 4) Reduces clinician's legal liability |
| Six risk factors associated with complicated grief | 1) A very close, dependent, or conflicted relationships w/ the deceased. 2) Sudden or unanticipated death. 3) Multiple losses. 4) Lack of social support. 5) Past history of mental illness, substance abuse. 6) Concurrent circumstances interfering w/ grief |
| Three risk factors associated with complicated grief | 1) Physical illness or the presence of other stressors that interfere w/ grieving 2) Lack of cultural traditions 3) Lack of spiritual beliefs |
| Assessment goals for grief | 1) Determine how to client is coping w/ loss 2) Distinguish between grief & other conditions or disorders 3) I.D. effective interventions |
| Assessment methods for grief: The clinical interview | 1) Is the main source of info 2) Determines nature of loss, 3) client's current symptoms, 4) mental status & level of functioning, 5) psych history, 6) coping style, 7) concurrent stressors, 8) & support network. |
| Assessment methods for grief: Instruments for initial assessment & monitoring | 1) Brief Symptoms Inventory-II 2) BDI-II 3) Acute Stress Disorder Scale, 4) Impact of Events Scale -Revised, 5) DSM's Global Assessment of Functioning Scale. |
| Grief treatment alternatives: Grief therapy (Worden, 2009) | 1) A time-limited therapy for complicated grief. 2) Primary goal is to resolve conflicts related to separating from deceased that interfere w/ the four tasks of mourning. 3) Therapy = determining which of the 4 tasks are not complete and addressing them |
| Grief therapy (Worden 2009): Four tasks of mourning | 1) Accepting the reality of the loss, 2) working through the pain & emotional aspects of the loss, 3) Adapting to an environment w/o the presence of the deceased, and 4) Establishing a new relationship w/ the deceased person & reengaging in life. |
| Grief treatment alternatives: Interpersonal psychotherapy (IPT) | Useful approach for those whose depression is related to abnormal (complicated) grief Strategies used to achieve therapy goals include |
| Grief treatment and primary goals of interpersonal psychotherapy (IPT) | 1) Facilitate client's grieving process, 2) help client re-esetablish interests & interpersonal relationships |
| Grief treatment strategies to achieve goals of interpersonal psychotherapy (IPT) | 1) Linking the onset of depressive symptoms to the loss 2) reconstructing the client's relationship w/ the deceased person, 3) exploring feelings associated w/ the loss, and 4) I.D. ways to connect w/ others |
| Grief treatment alternatives: CBT interventions | 1) There are several CBT interventions developed for complicated grief 2) Shear et al (2005) developed "targeted treatment" |
| Grief treatment CBT interventions and targeted complicated grief treatment (Shear et al., 2005) | 1) Combines education Re: grief w/ imaginal exposure thru listening to recorded retelling of the death, 2) In vivo exposure to avoided situations 3) Guided conversations w/ the deceased, 4) recalling + memories of the deceased, 5) I.D. of personal goals |
| Grief treatment alternatives: Group counseling | 1) Provides benefits for grief Tx, 2) Reduces social isolation 3) provides chance for catharsis, 4) builds coping skills, 5) most commonly use psychodynamic, interpersonal, & cognitive-behavioral orientations |
| Grief treatment alternatives: Family Focused Grief Therapy (FFGT, Kissane & Lichtenthal, 2008) | 1) A time-limited approach, 2) emphasizes prevention, provides Tx to families including terminally-ill member who are at risk for complicated grief, 3) Focuses on improved family functioning by enhanced cohesion, conflict resolution, communication |
| Assessing grave disability with the Mental Status Exam | 1) MSE is a systematic method for obtaining info on client's appearance, behavior, communication processes, thought content & processes, cognition, emotional functioning, & orientation. 2) Mini-MSE is brief version for assessing cognitive functioning |
| Assessing grave disability with the MMPI-2/MMPI-A | 1) Generally elevated scales on the MMPI may indicate functional impairment. 2) Functional impairment is especially associated w/ socre elevations on Scales 6 (paranoia), 8 (Schizophrenia), and/or 9 (Hypomania) |
| Assessing grave disability with the MCMI-III | 1) Generally elevated scales on the MCMI-III indicate a high level of functional impairment 2) If elevations occur on Severe Personality Pathology scales (Schizotypal, Borderline, Paranoid) or Severe Syndrome scales (Thought, Depression, Delusional) |
| Grave disability: 5260 legal code requirements | 1) Must have threatened suicide prior to and/or during a 72-hour hold or subsequent 14-day extension hold 2) Is deemed still an imminent risk for suicide at end of 14-day extension 3) Refuses voluntary Tx 4) Is accepted by a county facility that offers Tx |
| Assessing risk from danger to others: Factors associated with risk for women | 1) Under 24 years age 2) Low-income/below poverty 3) Race/ethnicity, non-White or Asian 4) Chronic physiological troubles 5) Wife more educated than husband 6) A & D abuse 7) Saw or experienced violence as a child |
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