1. Chapter Five

2. Principles Comparison
Long-Term Therapy Crisis Intervention
 Diagnosis: Complete  Diagnosis: Rapid triage
evaluation  Treatment: Focus on
 Treatment: Focus on immediate trauma
underlying issues  Plan: Focus on immediate
 Plan: Focus on long-term needs
needs  Methods: Use brief therapy
 Methods: Systematically effect to gain immediate control
short-term, intermediate, and  Evaluation: Validation is
long-term gains
based on the return of pre-
 Evaluation: Validation is crisis level of equilibrium
based on client’s total
functioning

3. Objectives Comparison
Long-Term Therapy Crisis Intervention
(order is irrelevant) (order is relevant)
 Prevent problems  Ensure client safety
 Correct etiological factors  Predisposition
 Provide systematic support  Define problem
 Facilitate growth  Provide support
 Re-educate  Examine alternatives
 Express emotional attitudes  Develop a plan
 Resolve conflict  Obtain commitment
 Accept reality  Follow-up
 Reorganize attitudes
 Maximize intellectual resources

4. Assessment Comparison
Long-Term Therapy Crisis Intervention
 Intake data: Client is stable  Intake data: Client may not be
and provides comprehensive stable and crisis worker relies
on verbal/visual cues
details
 Safety: Client and other’s
 Safety: Typically not the safety is the first concern
primary focus unless indicated  Time: No time for formal
 Time: Ample time for formal assessments
and informal assessments  Reality testing: Always
 Reality testing: Typically not
assessed via verbal/non-verbal
cues
needed unless indicated
 Referrals: Used to attain safety
 Referrals: Used to achieve and stability
long-term goals

5. Assessment Comparison Cont.
Long-Term Therapy Crisis Intervention
 Consultation: Available as  Consultation: Sometimes
needed available via specifically
trained police officers or
 Drug use: Assessed via
mobile crisis teams
intake data and throughout
 Drug use: Immediately
the course of therapy assessed via verbal and non-
 Disposition: Begin and end verbal cues
therapy with the same  Disposition: Begin and end
counselor. Therapy is usually intervention with the same
voluntary worker within hours to days.
Initial intervention is often
involuntary

6. Walk-In Crisis Facilities
 Types of Presenting Crises
 Chronic Crisis
 Community Mental Health Centers Act of 1963
 Increased drug abuse and rates of crime
 Mental health centers shift focus to “developmental” issues
 Understaffed and underfunded mental health clinics
 Acute social/environmental crises
 Survivors of violent crimes or natural disasters, terminally ill,
runaways, addicts, unemployed, etc.
 Precipitating events may be unexpected and may leave entire
systems in disequilibrium.
 Combination types
 Types overlap
 The rule rather than the exception

7. Community Mental Health Clinic
 Entry
 Clients may admit themselves voluntarily or be admitted by
their family, social service agency, or by the police.
 Commitment
 Clients may remain if they are stable or be hospitalized if they
are a danger to themselves or others.
 Under no circumstances should a crisis worker transport a
client.
 Intake interview
 Assess for client safety (degree of client lethality) and drug use
 Begin to define the presenting problem
 Apprise the client of their rights

8. Community Mental Health Clinic Cont.
 Disposition
 Proposed diagnosis and treatment
recommendations are constructed
 Client has the right to accept or reject services
 Full clinical team meeting is held to adjust and
confirm the treatment plan
 Anchoring
 The client is not left alone
 Therapist gives the client a verbal orientation
 Short-term disposition
 Short-term provisions are made for necessities
such as food, clothing, shelter, and medication

9. Community Mental Health Clinic Cont.
 Long-term disposition
 Interdisciplinary team (psychiatrist, pharmacist, psychologist,
counselor, and social worker) meet on a regular basis to
review the client’s progress
 Twenty-four-hour service
 Crisis hotline
 Police Department Crisis Intervention Team
 Mobile crisis teams
 Operate to serve clients who are physically unable to transport
themselves to receive services (i.e., elderly, physically
disabled, or extreme cases of immobile clients)
 Typically equipped with sophisticated communication and
information retrieval systems
 Often only available in urban areas

10. Police and Crisis Intervention
 Changing role of the police
 Instrumental vs. expressive crimes
 Police and the mentally ill
 Community Mental Health Act of 1963
 Memphis Model
 Crisis Intervention Team (CIT) Program
 Concept
 CIT training
 De-escalation and defusing techniques
 Fishbowls with clients
 Success of CIT
 Suicide by police officer

11. Crisis Intervention Team (CIT) Program
 Concept
 Strong working alliance between the local police
department and mental health community.
 Alliance is collaborative, systematic, and democratic.
 CIT training
 Trainees ride with an experienced CIT officer on a
weekend evening prior to their formal 40 hours of
training.
 Formal training

12. Formal CIT Training
 Cultural awareness of the mentally ill
 Substance abuse and co-occurring disorders
 Developmental disabilities
 Treatment strategies and mental health resources
 Patient rights, civil commitment, and legal aspects of crisis
intervention
 Suicide intervention
 Using the mobile crisis team and community resources
 Psychotropic medications and their side effects
 Verbal defusing and de-escalating techniques
 Borderline and other personality disorders
 Family and consumer perspectives
 Fishbowl discussion

13. CIT Program Cont.
 De-escalation and defusing techniques
 Basic introductory techniques taught
 Basic exploratory skills
 Incorporate the conceptual with the experiential
 Role play scenarios with difficult clients (e.g. suicidal or
severely psychotic)
 Fishbowls with clients
 Mental health professional sits in a circle with a client
surrounded by CIT trainees and conducts a role play
scenario.

14. CIT Program Cont.
 Success of CIT
 Increased volume of calls (more awareness of the program)
 Reduction in the time spent on each call
 Increased diversion from jail to hospitals
 Reduction in the use of force
 Hostage negotiation team is no longer needed
 In Memphis, only two fatalities have occurred since the
development of the CIT program
 Suicide by police officer
 People who engage a police officer in a threatening manner
and succeed in forcing the police officer to fire their weapon

15. Transcrisis Handling in Long-term Therapy
 Anxiety reactions
 Successful at achieving difficult goals, but struggles with a seemingly
minor goal
 Regression
 When a client is overwhelmed and reverts in their cognition or
behavior
 Problems of termination
 When a client suddenly discloses new problems just before
termination
 Often a sign of dependency
 Successive approximation technique
 Crisis in the therapy session
 When a client gains insight from a deeply traumatic experience and
then unexpectedly looses control
 Psychotic breaks
 Therapist’s priority is to remain calm and try to establish control of
the situation

16. Transcrisis Handling Cont.
 People with Borderline Personality Disorder
 Presenting problems
 Chronic suicide ideation
 Dual diagnosis
 Self-destructive behavior
 Impulsive behavior
 Intense emotional reactions
 Extreme approach/avoidance relationships
 Therapeutic relationship
 Frequent misinterpretations of the therapist’s statements
 Constant attempts to cross boundaries
 Strong resistance to termination of therapy
 Often emotionally draining for the therapist

17. Counseling Difficult Clients
 Ground Rules
 Attend all sessions on time
 No physical violence
 Respect the person who is speaking
 Focus on the “here and now”
 Everyone participates
 The crisis worker will not take sides
 No retribution, retaliation, or grudges
 Client intoxication is not accepted
 Conflicts will be resolved in a constructive manner

18. Counseling Difficult Clients Cont.
 Confronting difficult clients
 Confrontation should be direct
 Use “I” statements
 Set limits and adhere to them
 In extreme circumstances termination may be
necessary
 Consultation is suggested

19. Confidentiality in Case Handling
 Principles Bearing on Confidentiality
 Legal -> privileged communication (state laws may
vary)
 Ethical -> general standards of conduct governed by
one’s own profession.
 Moral -> personal principles
 Intent to harm and duty to warn
 Tarasoff
 Virginia Tech