Chapter 4 - Intervening with Crises related with danger to self, others or being gravely
disabled.
Suicidal Ideation: Results when a client is totally overwhelmed because of perception of
variety of events.
● Risk Factors: Unemployment, illness, impulsivity, rigid thinking (all or nothing),
stressful events, hospitalizations.
● Some statistics:
○ 12.9/100k suicides in the US.
○ 10th most leading cause of death.
○ 3.5X more often than women.
○ 7/10 suicides were white males 2014
○ Whites highest in suicide. 2nd highest american indian.
● Symptoms and clues: Usually preceded by a warning. Clients do not always tell
crisis workers directly.
○ Giving things away, withdrawal from usual activities, feeling hopeless or
worthless
● Most suicidal clients feel relieved with counselors ask client about thoughts of
self harm.
Suicidal Assessment: Purpose is to assess for signs of suicide to determine risk level.
● Not a single way to conduct a suicide assessment. Counselors must use discretion.
● Risk level leads to appropriate intervention.
● (SIS-MAP) developed by Shrivastava and Nelson: Scale Impact of Suicidality -
Management Assessment Planning.
○ Balance risk and resilience factors. Fairly new scale.
○ Multiple domains that contribute:
■ Demographics, ideations, coping methods, current mental state, future
plans, comorbidities (drugs/alcohol), family history, biological (medical),
protective factors, economic/environmental problems (finances, support
groups, access to healthcare), and Psychiatric disorders.
● Table 4.1 Short and Simple Suicide Risk Assessment: Classification Tree approach.
Each next question is contingent on the previous answer.
○ Factor → Client Response → Risk Level → Intervention.
○ Answers to previous questions determine which question follows based on risk.
○ Ideation(yes,no) → Plan (yes,no) low risk [if yes go to means] → Means
(yes,no) med risk [if yes ask for possible prevention] → Self Prevention (yes,no)
[if yes: med risk, if no: high risk]
■ Low: Maintain regular contact, no-suicide contract plan.
■ Med: (low+) Family watch, support groups, give weapons to counselors,
encourage prevention, reason, reframe, and support.
● Caplan’s characteristics of coping behavior to instill hope and
optimism.
■ High: Involuntary hospitalization. Voluntary preference. Medication.
Risk Levels and Interventions
● Low-Risk suicidal clients: Never tried, has adequate support, fear act.
○ “I thought about it. Scared to have feelings like this. Need someone to talk to.”
○ Encouraged to make an appointment with an outpatient therapist.
○ Educational interventions/ books.
○ Reframing: “The part of you that sought help is strong.”
○ Elderly people often consider suicide after the death of a spouse (require
medication, senior centers, out patient therapy.)
● Med Risk Suicidal: Often difficult to evaluate. They can still function but believe there is
no way out.
○ Families may ignore or not take client threats seriously. Clients may carry out
threats of reaction.
○ No-suicide contract, monitor with dail phone calls, enlist family help,
hospitalization as last resort.
○ Ask client to bring the Means or suicidal weapons to counselor.
○ Address ambivalence of clients and focus on the part that wants to live and future
plans.
● High Risk: “I am going to kill myself and you cannot stop me.”
○ Very depressed and angry. Tried suicide before.
○ Lack of support.
○ Viable plans with the means.
○ If possible, convince the client to admit himself voluntarily. This empowers
clients and reduces conflict.
■ Involuntary hospitalization may be necessary (local police or PET
Psychiatric Emergency Team.
● Sometimes state law.
● Mental illness might also require hospitalization and medication.
Phenomenoligical Understanding of Suicide: Subjective and unique view of clients suicidal
thoughts and behaviors past and present.
● B section of ABC model of intervention.
● While gathering objective information explore subjective perceptions of the client.
● Suicide might seem to be a more viable alternative at times during stressors.
○ Chronic family fighting, tough economy, confused social roles.
Non-Suicidal Self Injury (NSSI): Deliberatley damaging ones own body tissue without suicidal
intent.
● Six Criteria:
○ Five or more days in the past year with intentional self inflicted damage with
absence of suicidal intent.
○ Engage in self-injurious behavior for relief from negative feeling or cognitive
state, resolve interpersonal difficulty or induce a positive feeling state.
○ Self-injury associated with negative thoughts or feelings.
○ Behavior is not socially sanctioned.
○ Behavior causes significant distress and interferes with areas of functioning.
○ Behavior not better explained by another syndrome related to psychosis.
● Interventions: Cognitive Behavioral components creating a safe and nonthreatening
structured environment,
○ Also psychodynamic and psychotherapy.
○ Group therapy.
○ SAFE self abuse finally ends support groups.
Client Who Is a Danger to Others
● Homicidal Client: Crisis worker must warn the intended victim and contact the police.
○ May be a threat to the public because of psychosis.
○ Homicidal ideation: psychiatric term for thoughts about homicide which range
from value ideas of revenge to detailed plans about the act.
○ 10-17% of patient presentations to psychiatric facilities.
○ Results from psychosis, delirium, personality disorders, substance-induced
psychosis.
● Risk Factors:
○ History of violence.
○ Thoughts of committing harm.
○ Poor impulse control
○ Delusions/hallucinations.
○ Perception of rejection.
○ Influence of substances.
○ Antisocial personality disorder.
Psychotic Breakdowns and Gravely Disabled
Gravely Disabled: Client suffering from psychotic decompensation. State of active
delusions and hallucinations. Out of touch with reality.
● Extreme personality disorganization and heightened states of anxiety. Cannot function in
any way.
● Sometimes a client's psychotic thoughts can leave them both disabled and catatonic.
● Suicide by psychosis is possible.
● Crisis worker may need to be the client's ego strength until the client returns to a realistic
state of function.
● Cannot look after their basic needs: food, water or keep themselves clean.
● May be grounds for involuntary hospitalization and stabilization with medication.
● Stabilization period depends on severity of psychosocial stressor, client premorbid
function, and other support systems.
● The Mental Status Exam:
○ Formal assessment tool aid to determine if someone is psychotic, gravely
disabled, danger to self or others
○ Describes a person's state of mind under domains of: appearance, attitude,
behavior, speech, mood, thought process, thought content, perception, cognition,
insight, and judgment.
