Dealing With Mental Health Emergencies

(1-17-13)

Violence

• Toward self (suicide, deliberate self harm/self-injurious behavior)
• Toward others (threats of violence, threats of harassment, threats of murder, plans for homicide)
• Toward therapist (agitated behavior/shouting, physical threats, assault)

Preparation

1. be aware of your agency’s policies and procedures
   • a) who should you notify in event of threaten/actual violence, threats, confused/disorganized behavior, medical emergency, need for hospitalization?
   • b) what actions are you to take beyond administrative notification?
   • c) what are the emergency numbers/pages/codes for your agency? What are the telephone numbers for local police, ambulance, crisis?
2. stay familiar with the current professional literature on “psychiatric emergencies”
   • a) internet sites, new groups, professional group newsletters, journals
   • b) consider occasionally selecting a CE workshop on this or related topics
   • c) recognize that our accuracy at prediction of violence is quite limited
     • 1. most valid predictors are nomothetic (group averages) that have limited utility in ideographic (individual) predictions (high rates of false positives & false negatives)
     • 2. most reliable predictor of future behavior has consistently been shown to be past behavior
3. think about your office, your routine, your behavior in terms of personal safety
   • a) lay out of your office, communication with secretary/staff
   • b) entry and exit from agency, parking
   • c) never, ever disregard your own feelings regarding what is or may be going on

Response

in the event of violence:

1. protect yourself
   • Rule Number One: Keep Yourself Safe
   • Rule Number Two: there is no rule number two, do what you need to–to Keep Yourself Safe
   • While this is couched in terms of violence toward the therapist, I believe the same general principle applies in the other cases: In cases of self-directed violence–our first duty is to prevent harm to our client;
   • in cases of violence/potential violence toward others, our duty is to warn and try and prevent harm.
2. Take appropriate action to communicate with your agency, the police, or other necessary contacts
3. After things calm down, write down a relatively complete account of the incident, including times, actions, decisions, feelings/thoughts; date and note the time you write this account

if you have an opportunity to prevent violence:

1. assess thoroughly the situation
   • a) try to get a complete understanding of the client’s concerns, fears, frustrations, irritations, stress, etc. as possible
   • b) try to gain as empathetic an understanding as possible of how the situation/world looks to them, what they see as the available options, short and long term consequences
   • c) assess reality testing, chemical impairment, fatigue, level of pain, fear for life, etc: the status variables that may be influencing them
   • d) assess access to weapons, means of self-injury, places of refuge, support persons and services immediately available to them
   • e) monitor your own level of stress
   • f) direct, descriptive, honest communication; emotionally neutral and nonthreatening manner; and expressed concern and empathy are usually helpful
2. come up with a plan
   • a) develop a short term plan to keep everyone safe
     • 1. work at engaging their active participation in the process
     • 2. be realistic and honest, don’t promise things you can’t guarantee or deliver
     • 3. develop a back-up, “plan B” for all significant steps
   • b) begin developing a longer term plan to address the basic problems
3. fully document all the actions you have taken
   • a) document any actions/interventions made in the session
   • b) document any actions/plans you are to take after the session: notify supervision, consult with peer, communicate with family
   • c) document any follow-up plans/steps client is to take: call you to report in midway before next session, contact physician about medication, etc.

Aftermath

1. remember that you are human, no more or less prone to all the struggles everyone else faces
2. try not to over or under pathologize your reactions
   • a) remember that most posttraumatic responses fade naturally
   • b) attention to physical care for yourself may facilitate regrouping (exercise, sleep, minimize alcohol/drug use, daily routines)
     • 1. sleep may be a difficulty following a trauma
       • a. review your “good sleep hygiene” advice to clients
       • b. mindfulness, “gentle exposure” (let the elephants lose), journaling are probably much more helpful that attempting thought suppression of ruminations
       • c. you might consider discussing very time-limited use of “sleep agent” or anxyolitic medication with your physician
   • c) emotional support is usually beneficial in helping you regroup
     • 1. friends, peers, family
     • 2. professional consultation
     • 3. counseling

Agitation, Disorganization, Psychosis

• clients can become nonviolently upset and agitated in many ways and for many reasons
• it is difficult/unlikely to be productive to try an focus on your therapeutic agenda is client is too confused and agitated

Preparation

1. review periodically your own experiences with clients in various states of stress, turmoil, and decompensation
2. stay alert to professional communications (journal article, newsletter pieces, web postings, e-mail new groups threads) on these topics; consider participating in in-service or CE workshops touching

Evaluation

1. is there any evidence of chemical and/or medical factors contributing?
2. is there evidence of active psychosis?
3. can you interrupt and/or redirect the client?
4. can the client focus/attend to what you are saying?
5. can the client stay on topic?
6. what is the client’s level of emotional arousal?
7. what is the client’s mood?

Response

1. What is the immediate need?
   • a) Client safety, e.g., drunk client drove self to session–do you want them driving themself home?; client with possible acute confusional state may need hospitalization for detoxification
   • b) Client stabilization, e.g., manic client may need hospitalization to prevent self-destructive behavior; client experiencing panic episode may need to remain in waiting area until acute symptoms subside;
     • planned therapeutic work for session may need to be put aside for crisis management
     • caution: clients with Borderline Personality Disorder or “borderline traits” tend to be in crisis every week or every other week; making any real progress difficult; this would need to be addressed
2. Should the session be continued?

Post session

1. again, documentation
2. follow-up with the client prior to the next scheduled session may be useful, both for assessment/planning and therapeutic relationship maintenance