Training
& Continuing Education: By: Michael G. Conner, Psy.D, Clinical, Medical & Family Psychologist E-mail: Conner@OregonCounseling.Org
Presenting Problems
Service Continuum
Service Delivery (& Context)
Service Delivery Interface
Risk Assessment
Risk Management Issues
Risk Management Guidelines
Primary Differentials
Evaluation/Examination Clusters Bio-psycho-social-cultural-spiritual "Triage" Identifying information Ethnicity/Culture Appearance LOC Motor function Behavior Cooperation/Attitude Problem statement Orientation x4 Collateral Vitals Observations
NKDA Physical complaints Known medical problems Current medical Tx & Rx's Speech Affect "Mental Status" Hx current problem Symptoms Insight Memory
Thought content Thought process Perception Tasks
Intelligence Judgment/Impulse control Reliability/Honesty
Self care & basic needs
"History" Marital Children Recent loss or trauma Religious/Spiritual beliefs Employment Relationships Education Family of origin Medical Hosp Psychiatric Hosp Family psychiatric Past medication trials Financial Legal problems Criminal D/A
Suicide/Homicide Epidemiology Suicide attempts average 1 per minute in the U.S. Successful suicides average 1 per 17 minutes Oregon has the 7th highest rate of suicide 2x’s as many people die from suicide as homicide 10% of first time suicide "attempters" try again Women attempt suicide 3x’s more often than men Males succeed at suicide 4x’s more often than women 70% of all suicides are by male Caucasians Blacks are 8x’s more likely to be murdered 30% of all suicides involve alcohol or other drugs (40% of all homicides) 65% of all suicides involve a depression Suicide is the leading cause of death in adolescents
Immediate Risk Behavior Visual Verbal Progressions Social/group Triggering Influences Chemical Surrounding influences Medical/Mental health History Recent Past Social Mental health Motivations Mental and Emotional Status
Short Term Risk Factors Age Sex Race Religious beliefs Insight Motivation/purpose Mental & emotional status Dx/Dx Impression D/A Ideation Statements Behavior Hx of violence Hx of suicidal behavior Hx of loss, trauma or abuse Self-sufficiency Personal/social support Ability to solve their problems Resources to solve their problem Health status Self-care Honesty/Reliability Collateral opinions
Self-Harming & Suicidal Behavior (3 C’s & 3 P’s) Motivations Change Choice Control Punish self Punish others Psychotic proc
Aggressive & Violent Behavior Motivations Justice, Revenge, Victim rage Freedom (threats to or loss of) Control (fear of loosing or anger at loosing) Carry-over (ongoing aggression or violence) Contempt; Sadism (expression of) Blaming, Acting out (taking it out on others) Image, Status, Role, Reputation (defending, altering, establishing) Protection, Survival reaction (self, property, family, or friends) Threat reduction, Aggressive precaution Self-punishment; Guilt relief Civil or rationalized disobedience Exposure to violence and diffusion of individual responsibility (wilding) Psychotic process
Factors Contributing to Crisis Resolution Chemical detoxification Positive transference Emotional "detoxification" Time within a safe "container" or "structure" Support instituted or renewed Change in relationships Change in perspective Change in behavior Restored health and well-being Biochemical gate keeping
Crisis Intervention Goals Information/Knowledge Symptom relief/elimination
Insight & understanding Normalized perspective Adaptive response/behavior Can conceptualize a reasonable plan to recover Restoring necessary self and other reliance Can apply contingencies to "what if’s" Reduced
Medication Interventions Potential Benefits Restore reality contact Improve judgment Reduced lability Greater cooperation Reduce resistance Relieve symptoms Persuasive/Instill hope Behavioral restraint Problems Exacerbation and ASEs Negative impact single trial learning Medical crisis Increased liability Medication ASE's Major to minor ASEs Prophylactic treatment Expectancy & contingency
Dispositions Discharge/Release Degree of collaboration in establishing plan History and presentation of disorder Availability of resources to support the discharge plan Adequate contingencies Response to intervention Ability of others to support Risk that others will undermine
Transfer/Admission Medical vs Psychiatric Full mental health evaluation Medical clearance Impression Diagnosis Goals for treatment
Referral to ED’s Transport
Collaboration with Primary Medical Care & Psychiatry Medical Screenings & Baselines Therapeutic levels CBC, WBC, … LFTs Thyroid Ftn, Blood chemistry Fasting glucose, Lytes RFTs, Urinalysis, ECG Urine drug tox screen, EKG Rx’s Antidepressants Anxiolytics Antimanics Antipsychotics
Defusing Immediate Risk Strategies Mere presence Establishing a relationship and using it Use reason and rationality Redirecting emotions and motivations Manage, control or eliminate triggers Give directive and set limits Physical restraint, control and direction Chemical restraint Verbal Techniques Calming Persuasion "Clarifiers" & rapport builders Distraction Questioning Confrontation
Holds, Commitments & Investigations Emergency transport 12 hour hold Community mental health hold Judicial/Magistrate Two physician hold
Use of 911 & Police Give only that information necessary Answer questions Provide useful information to 911 that is compelling Anticipate possibility of over/under response Get 911 incident number Request/Insist to speak with the responding officer Speak with officer and provide information that is compelling Taking notes Get last name and the BPSST number of the officer you speak with Consider going to the hospital
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