Monday, January 29, 2007

Crisis Intervention and Suicide Assessment: Part 2 - Intervention and Crisis Assessment

[Episode 4] This is part two of a two-part series on Crisis Intervention. In this lecture, I discuss individual crisis intervention within the context of Roberts's Seven-Stage Model of Crisis Intervention, and the most popular group crisis intervention model currently in use, Critical Incident Stress Debriefing. The podcast ends with a detailed review of suicide assessment.

Please visit: for the first part of Crisis Intervention and Suicide Assessment.

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Now that you’ve assessed the affective, behavioral and cognitive domains of your client, we're going to move to the intervention model for today’s lecture. And although there are a variety of intervention models, including James and Gilliland (they have a 6-stage intervention model) and Hillman (has a 14-stage model of intervention), I'm going to talk today about Roberts’ 7-stage model for crisis intervention. And I'm going to talk about it because it provides a useful framework for crisis intervention, but it's not prescriptive to the point where it can't be modified to be used in either a single session or over multiple sessions. And Congress in 2000 (the author Congress, not the governmental body, but Elaine Congress) noted that it is, its flexibility enables it to be used in a culturally competent manner.

On the first stage is the assessment of safety and lethality and when we talk about suicide and risk assessment later, you'll get a better idea of specifically how to do that. But suffice it to say that in Stage One, you want to make sure that you are safe, that the client is safe, that the surroundings are safe. So you want to identify whether the client is at risk for harm to self or others or whether someone or something is putting the client at risk.

In Stage Two, that’s the rapport building stage and Roberts notes that that often happens concurrently with Stage One. As you're establishing safety, you're building a rapport and rapport, as I mentioned in the beginning of lecture, is the foundation for any clinical intervention (crisis intervention included). The Third Stage is problem identification. This is where you really identify what the precipitating event was and what problem the crisis intervention will focus on.

In Stage Four, you address feelings and emotions and this is where your assessment of affective, behavioral and cognitive domains is useful. You can implement Myer’s Triage Assessment at this stage or you can use it throughout. In Stage Five, you generate and explore alternatives. Now, similar to the problem solving method, generating and exploring alternatives is an area where the crisis worker can be more active in the crisis intervention model without necessarily being directive.

Being directive in Stage Five would look like presenting the client with a list of possible actions that they could do or solutions to the problem. Active would be collaborating with the client to identify things that they could use. One technique in particular that’s very congruent with social work perspective is using a very solution-focused approach in Stage Five. For example, when you're generating and exploring alternatives, you can review exceptions or use the miracle question or use other techniques that enable the client to think about times when they have actually been successful in resolving issues and thereby drawing on those successful opportunities as a way of reminding them of things that they can do in the current situation.

In Stage Six, you develop an action plan and again the action plan is very specific. It's concrete. It's measurable and it usually has a very short time frame. When I was doing crisis intervention in Austin, Texas, our crisis plans often lasted no longer than 24 hours without meeting again. And so they would include things like: When I leave here I will drive my child home. We will do this, this and this and this and this. It was very prescriptive. It provided structure and it was organized and it enabled me to review with the parents and the children the plan to find out exactly where it worked and where it didn’t, both as a way of helping me gather information, but also as a way of letting the family know exactly what it was that they were and were not doing to resolve whatever crisis was at hand.

And the Final Stage is follow up, and this looks like the referral stage for most traditional treatments because crisis intervention is short term and does not address long term intrapsychic or interpersonal or social problems (social environmental problems). [00:05:00] The need for a referral is great and it is expected that in fact you will be referring your clients out once the crisis has been resolved. So for that reason, follow up is a significant part of crisis intervention.

In different cultures, follow up can look like different things. If you have a family from the dominant culture that does not demonstrate underlying psychopathology and once they’ve reestablished prior coping skills, they're fairly easily able to address their activities of daily living. Then referrals can be fairly traditionally professional and say: “Here’s a phone number. We’d like you to follow up with them.” They agree to it and then you check up and you say: “Did you call?” It's great.

In families that might not be from the dominant culture, for example let's say you have a Latino family that has recently immigrated to the United States: follow up might be more personal. For example, making personal introductions, (assuming that consents have been signed) and really being more active in the follow up to make sure that both the information has been transferred to the new clinician, but also that there's that sense of trust that the family can have in the new provider.

Those were the Seven Stages of Roberts’ crisis intervention model. And again, it's a very flexible and very useful framework to have in mind when doing crisis intervention. And Roberts discusses this model in numerous articles and publications and books most recently in the third edition of the Crisis Intervention Handbook and also in an article that he wrote for the journal Brief Treatment in Crisis Intervention.

A second approach to crisis intervention that’s commonly used with groups is Critical Incident Stress Debriefing (CISD) or Critical Incident Stress Management. Everly and Mitchell are the main authors and proponents of this model. Critical Incident Stress Debriefing is typically used with first responders, for example: firefighters, EMS workers, police officers and it follows a group format. The CISD occurs no later than one week after the critical incident and the debriefing is run by a first responder who’s trained in the model.

And so again, if we think back to Hillman’s critique of the current research on crisis intervention, the question is: Is a peer who has been trained actually better than a licensed professional doing crisis intervention? If you have a police officer that has been trained in Critical Incident Stress Debriefing and they run a group with other police officers who have been involved in a critical incident, then it is possible that they would be more effective in this particular type of crisis intervention.

The CISD centers on the workers and is sensory-based and it encourages the participants to report on what each of them saw during the critical incident, what they heard and what sort of physical and emotional feelings they had, as well as what they smelled and tasted.  After a critical incident such as a multi-car pile-up with fatalities on a highway or a shooting or some other critical incident that first responders are involved in, this type of debriefing can have the effect of reducing anxiety, letting people know they're not “crazy.”

Also important in these debriefings is that information about the event is shared. Crisis situations are fast-paced and people are not always sure that what they're experiencing is actually true. And so if during a fire, a floor collapses and a firefighter falls three or four storeys and the other firefighters are called in for Critical Incident Stress Debriefing, some information can be shared about the nature of the fire, how it developed, what other people were doing at that time. And in this way, it can actually provide concrete information that can be useful for individuals in reducing anxiety and addressing this critical incident.

In the protocol for Critical Incident Stress Debriefing is that the trained mental health professional is a silent observer of the proceedings and his or her purpose is to identify first responders who might benefit from individualized crisis intervention and/or ongoing psychotherapy. So, again, Roberts’ model is typically used with individuals or families and if you're in a group situation, the most commonly used approach is the Critical Incident Stress Debriefing Model by Everly and Mitchell.

The final area we're going to cover today in our discussion of crisis intervention is suicide assessment and this is a special instance of crisis intervention, so don’t go anywhere.  We'll be back after this [00:10:00] brief pause for the cause.




Now, the purpose of suicide assessment is to determine the lethality and severity of suicidal behaviors. It's also to predict risk of imminent harm to self. Empirical evidence does not support that we know how to predict future suicidal behaviors. However, the courts and the public expect mental health professionals to be able to predict future behaviors.

The third purpose of suicide assessment is to gather information used for crisis planning and intervention and treatment and management of suicidal behaviors. Now, this is of course is only if suicidal behaviors are present and you won't know that if you do not do a crisis – rather if you do not do a suicide assessment. Because suicidal attempts are higher with people who have psychiatric disorders than in the general population, anytime you're working in a psychiatric setting, either outpatient or inpatient, and you're working with people with a diagnosis, it is important to do suicide assessments so that you can determine whether past suicidal behaviors have been present. If so, what those triggers were and/or if there is current suicidal ideation.

So, the basic suicide assessment covers three areas. It covers ideation (and those were thoughts), intent (which is how serious the thoughts are and how serious the person is about dying by suicide). And the third area is the plan (how, with what, when, access to the means, etc. etc.). During the suicide assessment, it's important to use the words kill and die and specific words like that, so that your client knows you're not afraid of the topic and they’ll be more likely to confide in you and also that you can gather more accurate information.

The father of suicidology, Edwin Shneidman, suggested that people choose suicide because it's a means to end intolerable psychic pain. And if you ask people if they want to hurt themselves, which is the more mild way of addressing suicide assessment that people who were not trained sometimes do, if you say – if you ask people if they want to hurt themselves, somebody who’s actively suicidal might honestly say no because in fact they do not want to inflict more pain on themselves. They do not want to hurt more. In fact, they want to end their pain. They want to end the hurt and that is why they're suicidal.

So, that’s just one example of – or one reason why it's important to be specific when talking with clients about suicidal ideation and why it's important to use the words such as: “Do you want to kill yourself? Have you thought of dying?”

Ideation: “Do you have thoughts of killing yourself? If so, how frequent do you think of killing yourself? Every hour, a couple of times a day, weekly or never? How long are your suicidal thoughts? What is the longest time period in which you’ve consistently thought of killing yourself and what is the shortest? And answers can range from you know: “It just flashed into my mind and then it was gone” to you know, “I was thinking about it constantly for eight hours. I just couldn’t get it out of my head.”

In intensity: “How strong or weak are these thoughts? Do they interfere with your activities of daily living?” For example: “Are you afraid to go into the kitchen because your suicidal thoughts are so intense that you're afraid you're going to do something like grab a knife from the kitchen and cut yourself?”

The intent areas, how serious and one way of using scaling questions for this area is to say: “On a scale of 1 to 3, how badly do you want to die?” When you're talking with someone who’s actively suicidal, it's not necessary to give a 1 to 10 scale, which can be difficult to interpret and also it can be a little overwhelming. But a 1 to 3 scale is not cognitively complex and also if somebody says that on a scale of 1 to 3, 1 being “I'm not serious at all” and 3 being “I'm totally serious,” if they give you 1, 2 or 3 then you pretty much know what they're talking about and you can ask more detailed questions at that point.

The third area is the plan: “Do you have a plan? Is your plan general or is it detailed?  How will you do it? Do you have access to the means?” And that could be to the materials or the specific weapons. [00:15:00] “And when are you planning on killing yourself?” I've worked with a number of children who in response to that question would say: “Well, there's a party this weekend and so I'm not planning on killing myself until Monday.” Well, that was important and significant information for me to have because even though they might have had a detailed plan and they might have frequent thoughts, it provided information about how serious they were imminently ending their life.

After you talk about ideation, intent and plan, it's useful to talk about prior attempts, because prior attempts have been reported to be the single best indicator of a future death by suicide. So, you want to ask: “How recent was your prior attempt?” and because there's usually a limited time to discuss suicidal ideation with a client either because you're in a crisis situation or because that’s not the primary focus of your work with the client. Shawn Shea, who wrote a wonderful book on The Practical Art of Suicide Assessment, he suggests that the most valuable thing for a clinician is to find out what the most serious prior attempt was, as opposed to getting an exhaustive history of all the prior attempts.

And by getting details on the most important prior attempt, then you gather information on triggers, on what kept the person alive, how long it lasted, things like that. So, other questions to ask are: “Do you know somebody who has recently died by suicide? Do you have friends or family members who have died by suicide? Have you told anyone about your ideation, intent or plan?” Finally, you can ask the client who do they talk to when they're really down, when they're having thoughts of killing themselves, and this can give a lot of information about their social support or lack thereof.

It also provides information about resources for the clinician about who they can contact in the event of a suicidal emergency that would enable them to breach the limits of confidentiality and go outside of the client-therapist relationship.

At the end of the suicide assessment, you should be able to establish a severity rating.  Rudd and his colleagues in 2001 recommended a five-level severity rating ranging from 1 (which is nonexistent) to 5 (which is extremely severe). The least and most severe ratings are relatively easy to establish and have clear plans of action.

Number one: nonexistent, there's no identifiable suicidal ideation. Number five is: there is extremely severe suicidal risk. And this looks like frequent, intense and enduring suicidal ideation, specific plans, clear subjective and objective intent, evidence of impaired self-control, severe dysphoria and symptomology and many risk factors and almost no protective factors.

The middle ratings are: mild, moderate and severe. Mild risk would look like: suicidal ideation of limited frequency, intensity and duration, no identifiable plans or intent, mild dysphoria and symptomology, good self-control, few risk factors and identifiable protective factors. Moderate suicidal risk looks like: frequent suicidal ideation with limited intensity and moderation. So, again, the distinction between mild and moderate is you have limited intensity and duration, but you have frequent ideation for the moderate, but for the mild it is limited ideation, frequency and intensity and duration. For the moderate, you also have good self-control, limited dysphoria and symptomology, some risk factors and identifiable protective factors.

Severe suicidal risk looks like: frequent, intense and enduring suicidal ideation, specific plans, no subjective intent, but some objective markers of intent for example: they talk about specific lethal methods, they know that the method is available and there are some limited behaviors in preparation for death by suicide. There's evidence of impaired self-control, severe dysphoria and symptomology and multiple risk factors present and few if any protective factors.

In summary, the big three areas to cover in a suicide assessment are suicidal ideation (that is thoughts of suicide), suicidal intent (that would be motivation to die by suicide) and plan (which looks at how and when somebody is going to try to kill themselves).  Another area that’s also useful is prior attempts and prior attempts are useful because the best predictor for a future attempt is a past attempt.

Ultimately, the purpose of gathering information [00:20:00] about intent, ideation and plan is to be able to determine the client’s risk for imminent harm to self. Once you have a severity rating, such as the one developed by Rudd, Joiner and colleagues, you're able to quickly and easily identify what the next step is in terms of a treatment plan. This has the obvious benefit of providing safety for the client and has the less obvious, but no less important benefit of providing the clinician with solid clinical evidence to support their decision.

Well, that’s it. Congratulations. You’ve made it through Crisis Intervention. Today, we've talked about crisis intervention, crisis assessment and suicide assessment and all of these are invaluable skills for social workers. In fact, they're some of the few skills that you really want to memorize because well, during a crisis you don’t really have time to look things up.

[End of Audio]

Transcription generously donated by Kelsi Macklin.

Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care (2nd ed.). Washington, D.C.: American Psychological Association.

Greenstone, J.L., & Leviton, S.C. (2002). Elements of crisis intervention: Crises and how to respond to them (2nd ed.). Pacific Grove, CA: Brooks/Cole

Hillman, J. L. (2002). Crisis intervention and trauma: New approaches to evidence-based practice. New York: Kluwer Academic/Plenum Publishers

James, R.K., & Gilliland, B.E. (2005). Crisis intervention strategies. (5th ed.). Pacific Grove, CA: Brooks/Cole

Lukas, S. (1993). Where to start and what to ask: An assessment handbook. New York: W. W. Norton & Company.

Myer, R. A. (2000). Assessment for crisis intervention: A triage assessment model. Belmont, CA: Wadsworth Publishing.

Roberts, A.R. (Ed.). (2005). Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). New York: Oxford University Press

Rudd, D. M, Joiner, T., and Rajab, M. H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: The Guilford Press.

Shea, S. C. (2002). The practical art of suicide assessment. Hoboken, NJ: John Wiley & Sons.

Simpson, S., and Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicidal risk assessment. Journal of Psychiatric Practice, 10(3), 185-189.

Singer, J. B. (2006). Making stone soup: Evidence-based practice for a suicidal youth with comorbid ADHD and MDD. Brief Treatment and Crisis Intervention, 6(3), 234-247.

Stone, G. (2001). Suicide and attempted suicide: Methods and consequences. New York: Carroll & Graf.

Weller, E. B., Young, K. M., Rohrbaugh, A. H., & Weller, R. A. (2001). Overview and assessment of the suicidal child. Depression and Anxiety 14,157-163.

APA (6th ed) citation for this podcast:

Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 2 - intervention and crisis assessment [Episode 4]. Social Work Podcast. Podcast retrieved Month Day, Year, from

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