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Crisis Intervention with Potentially Dangerous Individuals. Working with clients who pose a danger to either themselves or other people. Suicide: Facts & Figures. 25,000-50,000 Americans commit suicide every year. Suicide may be more common than homicide.
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Crisis Intervention with Potentially Dangerous Individuals Working with clients who pose a danger to either themselves or other people.
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 suicides).
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 attempts. • 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.
Direct verbal warnings. Suicidal Ideation or Plans. Family History. Prior hx. of self-destructive behavior. Prior psychiatric hospitalization. Chronic physical illness. Depression: especially hopelessness & insomnia. Personality Disorder. Recent loss (divorce, unemployment). Alcohol & drug problems. Finalizing one’s affairs. Lack of social support. Poor impulse control. Tunnel vision. Poor problem-solving skills. Risk Factors & Warning Signs
Psychological Intent for Suicide • Hopeless Suicide: pessimistic view that life is unbearable & will not get any better; view suicide as the only solution. • Psychotic Suicide: tired of battling a chronic, psychotic disorder; person may also experience command hallucinations & delusions. • Rational Suicide: view suicide as a reasonable solution to a terminal illness; desire relief from current or future suffering. • Impulsive/Histrionic Suicide: driven by a desire for attention, revenge, or stimulation; they hope attempt will change other people’s behavior toward them.
Assessing Suicide: Funneling • Complete thorough assessment: focus on risk factors, mood, psychiatric history, A & D use, support system, & outlook on the future. • Inquire specifically about past and present suicidal ideation, plans, or attempts.
If suicide is a concern, obtain additional information: • 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 yourself?” • “Have you made any plans to hurt or kill yourself?” • “What would prevent you from killing yourself?
Overdosing 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 home. • Consider hospitalization, psychiatric consultation, or intensifying treatment. • Closely monitor care.
. . . . • Work with client’s strengths & reasons for living. • 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: • Emergency contact numbers. • Steps to follow in the event of an emergency (e.g., call crisis line, go to ER). • Prevention Plan, include practical coping skills. • 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? • Tension reduction. • Coping with negative emotions (e.g., turn emotional pain into physical pain). • Interpersonal communication (e.g., manipulation). • Atonement for perceived sins. • Hatred toward one’s body or sexuality. • Self-stimulation (“to feel something”). • Feel more powerful & in control of one’s life. • Psychosis.
Coping Strategies to Reduce Self-Mutilation: • 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 impairment. • Examples: psychotic disorders, Alzheimer’s disease, dementia, or other organic brain disorders.
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 situation?