Crisis Intervention with Suicidal Individuals by yurtgc548


									Crisis Intervention with Potentially
             Dangerous Individuals

    Working with clients who pose a
   danger to either themselves or other
              Suicide: Facts & Figures
• 25,000-50,000 Americans commit suicide every year.
  Suicide may be more common than homicide.
• 300,00-600,000 suicide attempts annually; 15% of
  those who attempt suicide will eventually succeed.
• Attempt to complete ratio is approximately 10:1.
• 1/3 of Americans will experience suicidal ideation
  during their lifetimes.
• Most common methods of attempting suicide:
  overdosing (80%) followed by cutting wrists (10%).
• Most lethal method: firearms (60% of completed
• Males are 4-5x’s more likely than females to
  complete suicide; females are more likely than males
  to make non-lethal attempts.
• Highest Demographic Risk: White males over age 65.
• 80% of those who complete suicide had previously
  communicated this intention to another person.
• As many as 15% of clients with chronic depression or
  alcohol dependence will eventually commit suicide;
  10% rate for those with BPD or schizophrenia.
• Alcohol is involved in 15-50% of suicide
• Most people who commit suicide were
  experiencing a mental disorder at the time.
• 20-50% of mental health professionals will
  lose a client to suicide.
      Risk Factors & Warning Signs

•   Direct verbal warnings.       • Recent loss (divorce,
•   Suicidal Ideation or Plans.     unemployment).
•   Family History.               • Alcohol & drug problems.
•   Prior hx. of self-            • Finalizing one’s affairs.
    destructive behavior.
                                  • Lack of social support.
•   Prior psychiatric
    hospitalization.              • Poor impulse control.
•   Chronic physical illness.     • Tunnel vision.
•   Depression: especially        • Poor problem-solving
    hopelessness & insomnia.        skills.
•   Personality Disorder.
             Psychological Intent for Suicide

1.   Hopeless Suicide: pessimistic view that life is
     unbearable & will not get any better; view suicide as
     the only solution.
2.   Psychotic Suicide: tired of battling a chronic, psychotic
     disorder; person may also experience command
     hallucinations & delusions.
3.   Rational Suicide: view suicide as a reasonable solution
     to a terminal illness; desire relief from current or future
4.   Impulsive/Histrionic Suicide: driven by a desire for
     attention, revenge, or stimulation; they hope attempt
     will change other people’s behavior toward them.
Level of Dangerousness

       No Danger

Depression or Recent Loss


Passive Suicidal Ideation

 Active Suicidal Ideation

     Current Attempt
     Assessing Suicide: Funneling

1. Complete thorough assessment: focus on
   risk factors, mood, psychiatric history, A
   & D use, support system, & outlook on the
2. Inquire specifically about past and present
   suicidal ideation, plans, or attempts.
3. If suicide is a concern, obtain additional
• Frequency/intensity of thoughts.
• Specificity & lethality of plan.
• Availability of means.
• Probability of rescue.
• Expectation of attempt.
• Identify barriers (reasons to live) or resources
   that might prevent suicide. “What has stopped
   you from committing suicide?”
                     Example Questions
                     (Zuckerman, 1995)

• “Has it crossed your mind that death would relieve
  you or end your pain?”
• “Have you felt ‘my life is a failure’ or ‘my
  situation is hopeless’?”
• “Have you thought about how you might kill
• “Have you made any plans to hurt or kill
• “What would prevent you from killing yourself?

                 Frequently Used Drugs

•   Anxiolytics & Sleeping Pills.
•   Tricyclic Antidepressants (e.g., Elavil).
•   Aspirin.
•   Acetaminophen (i.e., Tylenol).

• As a very general rule of thumb, 10x’s a normal
  dose of a dangerous drug is lethal.
   Special Issues with Adolescents

• Suicide rate among adolescents has
  increased in recent years, but continues to
  be lower than adult rates.
• Reluctance to confide in adults; collateral
  information can be very valuable.
• Younger adolescents may not fully
  understand the irreversibility of death.
• “Personal Fable” Mentality.
                   Intervention Strategies

 Develop a crisis management plan,
  including emergency procedures.
 Remove dangerous objects (guns, pills).
 Develop a Care Team to monitor client at
 Consider hospitalization, psychiatric
  consultation, or intensifying treatment.
 Closely monitor care.

 Work with client’s strengths & reasons for
 Help client identify specific alternatives to
  ending his or her life.
 Improve problem solving & coping skills.
                      No-Harm Contracts:

•    Objective: client makes a commitment to not
     harm himself for a specific period of time.
•    Components:
1.   Emergency contact numbers.
2.   Steps to follow in the event of an emergency
     (e.g., call crisis line, go to ER).
3.   Prevention Plan, include practical coping skills.
4.   Identify who can provide social support.
                Self-Mutilation & Other
                 Parasuicidal Behaviors

• Definition: inflicting harm on one’s body without
  any intention of death or serious injury.
• Typical sufferer: young female (15-25) with a
  history of childhood abuse or neglect.
• Manifestation: (1) scratching, cutting or burning
  one’s arms, wrists, face, legs, genitals, etc.; or (2)
  preventing wounds from healing.
• Co-Morbid Problems: eating disorders, mood
  disorders, BPD, & chemical dependency.
• Duration: chronic & compulsive course
  lasting 10-15 years.
• Ironically, sufferers typically feel little pain
  while engaging in self-mutilation.
      Why do people self-mutilate?

1. Tension reduction.
2. Coping with negative emotions (e.g., turn
   emotional pain into physical pain).
3. Interpersonal communication (e.g., manipulation).
4. Atonement for perceived sins.
5. Hatred toward one’s body or sexuality.
6. Self-stimulation (“to feel something”).
7. Feel more powerful & in control of one’s life.
8. Psychosis.
        Coping Strategies to Reduce
• Engage in non-harmful sensation-seeking (e.g.,
  submerge arm in ice water).
• Destroy something non-living & invaluable.
• Use a red marker rather than a knife.
• Response Prevention.
• Direct verbal expression of feelings.
• Distraction.
• Social Engagement.
• Physical movement or Exercise.
• Relaxation Techniques
    Potentially Violent Clients: Risk Factors

•    History of violent or impulsive behavior.
•    Family conflict.
•    Low frustration tolerance.
•    Former or current legal issues.
•    A & D Use.
•    Plan for committing violence.
•    Means for carrying out violence.
           Gravely Disabled Clients

• Responsibility to protect people who cannot
  care for themselves because of cognitive
• Examples: psychotic disorders, Alzheimer’s
  disease, dementia, or other organic brain
                           Legal Issues:

• Legal duty to provide ordinary and
  reasonable care.
• Negligence: unreasonable failure to adhere
  to professional standards.
• Objective Test: What would the average and
  reasonable helper of similar training and
  experience have done in the same or similar

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