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NCMHCE Exam Review
Crisis Assessment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director AllCEUs
Host: Counselor Toolbox Podcast and NCMHCE Exam Review Podcast
CEUs are available for this presentation at
~ Review crisis theory and the varying types of crises
~ Describe the stages of crisis
~ Identify the features of a general crisis assessment
~ Differentiate between a crisis and suicide assessment
~ Identify factors associated with a high risk of suicide
~ Review legal and ethical responsibilities (Tarasoff and Bellah vs. Greenson
~ Explore prevention and intervention strategies
Crisis Definition
~ Crisis involves
~ A pivotal moment in which a decision must be made which involves facing both peril and promise (Echterling, 2005)
~¬†‚ÄúPeople are in a state of crisis when they face an obstacle to important life goals‚ÄĒand obstacle that is, for a time, insurmountable by the use of customary methods of problem-solving.‚ÄĚ (Caplan, 1961)
~ Symptoms of crisis:
~ Emotional distress
~ Physical distress/stress response
~ Cognitive disruption (concentration, problem solving, memory)
~ Behavioral changes
Basic Human Needs (CHARGES)
~ When a basic human need has been impacted, it may prompt a crisis
~ Maslow:
~ Air, water, food, sleep, shelter, medical care, safety, love and belonging
~ Elliot (CHARGES)
~ Connection to something bigger than one’s self or a system of meaning to help us understand the world
~ Health and biological needs
~ Acceptance (love and belonging)
~ Relationships (intimate)
~ Goals and Purpose (Identity)
~ Efficacy/Control
~ Safety
Types of Crisis
~ Situational crises are not anticipated and usually outside a person’s control
~ Physical (accident, illness, prematurity, birth defects)
~ Interpersonal (death of a person or pet, abuse, divorce)
~ Financial/Environmental/Material (Job loss, Foreclosure, House fire, hurricane, burglary, stock market crash, not getting accepted to …)
Types of Crises
~ Cultural/Societal
~ Individuals have less control over these due to the fact that they are perpetuated by the action or inaction of others
~ Political unrest, discrimination and stigma related to gender, race, sexual orientation, violence
Types of Crisis
~ Maturational
~ Normal developmental changes produce developmental crises (see Erikson), however, when these crises overwhelm a person’s ability to cope, they may prompt a mental health crisis.
~ To successfully resolve developmental crises, people need support, energy and safety.
~ Examples: Child to adult, empty nest, retirement, child birth, marriage…
Types of Crisis
~ Normal developmental reaction or mental health issue?
~ *Determine which symptoms are expected reactions to a normal developmental transition vs. a sign of an emotional or mental health issue
~ Adjustment disorder with depressed mood, anxiety, both or behavior disturbances is conditional upon a particular situation, a life change or a stressor of some sort that precipitates the event
~ Carefully differentially diagnose between adjustment disorder, anxiety, depression, PTSD and personality disorders.
~ Normalize expected reactions to developmental transitions
Types of Crisis
~ Normal developmental reaction or mental health issue?
~ The symptoms of adjustment disorder with disturbance of conduct can include:
~ Behaviors that are outside the norms of society
~ Actions that violate the rights of others
~ Outbursts of anger
~ Attempts at revenge
~ Substance use or abuse
~ Emotionality/mood swings that are acted upon
Factors Affecting the Response
~ Demographics (DARES)
~ Age
~ Religion
~ Ethnicity
~ Situational and social supports
~¬†Perception of the event‚Äď How does it impact (BASIC)
~ Biological necessities
~ Acceptance and belonging
~ Similarity to prior traumas or crises
~ Interpretation/world view
~ Control (sense of)
~ Available coping (CRAP)
~ Crises in the past 6-12 months
~ Resources
~ Addiction
~ Psychiatric
Stages of Crisis
~ The event that disrupts the persons ability to maintain homeostasis (balance)
~ The vulnerable state in which the person tries to cope with given resources and strategies
~ The active crisis state
Crisis Assessment
~ Emergent assessment conducted when the client expresses a sense of disequilibrium
~ Identify the precipitating factor
~ Identify the client’s responses
~ Identify all the ways the event has disrupted the client’s life (BASICS (Echterling, 2005) )
~¬†Behavioral‚ÄĒwhat they do
~¬†Affective‚ÄĒHow they feel
~¬†Somatic‚ÄĒPhysiological reactions and impact
~¬†Interpersonal‚ÄĒHow they relate to others and their support system
~¬†Cognitive‚ÄĒProblem solving, memory, perceptions
~¬†Spiritual‚ÄĒSense of belonging and system for understanding the world
Crisis Assessment
~ Emergent assessment conducted when the client expresses a sense of disequilibrium
~ Explore coping strategies client has used in the past
~ Explore current resources and supports
~ Identify specific goals
~ Assess client’s mental status and sobriety
~ Assess for suicidality and homicidality
Suicide Assessment
~ Crisis assessment determines the cause of the situational disequilibrium and resources needed to help the client cope
~ Suicide assessment is
~ Designed to determine the probability of a suicide attempt in the near future
~ Ongoing since suicide risk changes over time
~ Comprised of input from collateral sources
~ Direct (asking the client) and indirect (general risk factors)
Suicide Assessment
~ Risk Factors
~ Gender:
~ Male: 75+ although age 45-60 has increased 43% since 1997
~ Female: 45-64
~ Adolescents: 15-24
~ Prior suicide attempt(s)
~ Misuse and abuse of alcohol or other drugs
~ Mental disorders, particularly depression and other mood disorders
~ History of abuse
~ Access to lethal means
~ Exposure to someone who died by suicide, particularly a family member
~ Social isolation or lack of social support
~ Chronic or major disease and disability, recent childbirth or major surgery
~ Lack of access to behavioral health care
~ Recent medication changes
~ Stressful (crisis) life events or anniversary therein
Suicide Assessment
~ Risk Factors
~ Motivation: if it is to escape it is high.  If it is to impact another person it is lower
~ Ethnicity and Culture
~ Highest rates across the life span occurring among non-Hispanic American Indian/Alaska Native and non-Hispanic White populations.
~ Veterans, military personnel and workers in certain occupational groups.
~ Sexual minority youth: Prolonged stress resulting from prejudice and discrimination
Direct Assessment
~ Communicated intent
~ Frequency, intensity and duration of suicidal thoughts
~ Prior attempts?
~ Family history?
~ What might prevent you from killing yourself?
~ Plan? Specificity? Time?
~ Means?
~ Level of lethality?
Things to listen for
~ Desire to die
~ Hopelessness
~ No reason to live
~ Feels like a burden
~ Feels trapped
~ Unbearable pain
~ Increased use of substances
~ Learning about suicide methods
~ Withdrawal/Isolation
~ Sleeping changes (esp. waking up in the middle of the night)
~ Saying goodbye
~ Tying up loose ends
~ Fatigue
~ Depression/Anxiety
~ Sudden improvement or sense of calm
American Foundation for Suicide Prevention
Legal and Ethical Responsibilities
~ Tarasoff, the California Supreme Court held that, under certain circumstances, a therapist had a duty to warn others that a patient under the therapist's care was likely to cause personal injury to a third party. where a therapist knows that his patient is likely to injure another and where the identity of the likely victim is known or readily discoverable by the therapist, he must use reasonable care to prevent his patient from causing the intended injury. Such care includes, at the least, informing the proper authorities and warning the likely victim.
Legal and Ethical Responsibilities
~ Bellah vs. Greenson
~ Outpatient client committed suicide.  The court ruled that the Tarasoff decision did NOT apply to threatened self-harm but established a legal duty for therapists to take reasonable steps
~ Breaching confidentiality in this case requires that you determine the client is an imminent threat to self AND  a breach of confidentiality will prevent the danger
Indications for Hospitalization (LIMPS)
~ Lack of available support system
~ Medical issue causing suffering or symptoms
~ Intoxication
~ Psychiatric comorbidity
~ Suicide risk high
Indications for OP Management
~ Risk is low
~ Precipitating crisis averted
~ Adequate supports
~ Client agrees to a safety contract
~ American Counseling Association Guidelines (PIECED-Med)
~ Provide emergency numbers
~ Increase frequency of counseling sessions, possible phone check-ins
~ Explore and mobilize available resources, e.g. family support, friends, support groups, community resources, crisis team etc
~ Contract (Safety)
~ Encourage voluntary commitment, but get the client hospitalized if necessary
~ Develop a plan to deal with potential weapons, medications, drugs, etc
~ Medication Assessment (decide)
~ Tell the client you don’t want them to ham themselves
~ Consult and document
~ Encourage client to wait until the crisis has passed to make a decision about suicide
~ People generally come to counseling when they are experiencing some level of crisis
~ Crisis is often caused when people cannot meet their basic needs (CHARGES)
~ There are many factors that contribute to a person’s reaction to a precipitating event (Who DARES to Perceive BASIC Coping CRAP)
~ Hospitalization may be indicated in some circumstances (LIMPS)
~ When conducting a suicide screening, remember the mnemonic PIECED-Med
Test Taking Tips
~ An answer choice may be wrong simply because it leaves no room for exception.
~ Accept the situation in the problem at face value. Don’t read too much into it.
~ Don’t be distracted by an answer choice that is factually true but doesn’t answer the question
~ Sally is a 30-year-old woman who has never been married and is estranged from her family.  She has been living in a supported living home for the past 2 years due to a diagnosis of disorganized schizophrenia.  Her intellect is normal and her daily functioning is high.  She has held a job at the local supermarket for 1 year. You are to evaluate her continued eligibility for services in the facility. There have been at least 5 episodes of decompensation in the past 3 years, but she has had no psychotic episodes in the past 22 months
~ Which of the following would you need to assess to determine if she still met the criteria for disorganized schizophrenia and continued services?
What to Assess
‚Äʬ†Current Stressors‚Äď Yes, because stressors could contribute to decompensation
‚Äʬ†Quality of Existing Family Relationships‚ÄĒNo.¬† Vignette stated she was estranged
‚Äʬ†Employment History‚ÄĒNo. Stated in the vignette.
‚Äʬ†Educational History‚ÄĒNo.¬† Irrelevant.
‚Äʬ†Current and Past Addictive Behaviors‚ÄĒNo. Irrelevant.
‚Äʬ†Family History of Psychosis‚ÄĒNo.¬† You are not deciding IF she has schizophrenia, rather if it is in remission
‚Äʬ†Past/Current Medications‚ÄĒYes.
‚Äʬ†Medication Compliance‚ÄĒYes.¬† Evaluating whether client will reliably take her medications in independent living.
‚Äʬ†Mental Status‚ÄĒNo. Vignette indicates she is currently high functioning.
‚Äʬ†Frequency and nature of psychotic episodes‚Äď Yes to determine precipitating factors for prior episodes and the 22 month remission.
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