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