Crisis Intervention - 2nd Edition

Educational Objectives

Upon completing this educational activity, participants will be able to:
1. Utilize knowledge of recent developments in genetics and neuroscience to more effectively diagnose and manage psychiatric disorders.
2. Discuss optimal diagnosis, treatment, and clinical understanding of bipolar disorder.
3. Identify and overcome barriers to the effective management of personality disorders.
4. Identify and manage key factors that may affect a patient's risk for violent behavior.
5. Recognize common causes of treatment failures in patients suffering with anxiety and depression.
6. Implement therapy techniques for managing patients with somatic disorders.

Summary

Crisis Intervention

Nancy Swerdlow Downs, MD, Clinical Professor of Psychiatry, and Senior Psychiatrist at Counseling Psychological Services, University of California, San Diego, School of Medicine, La Jolla, California

Introduction: excerpt from resource guide of Substance Abuse and Mental Health Services Administration (SAMHSA) underscores value of effective crisis intervention; psychiatrists uniquely trained to respond to crises, deliver effective interventions

Overview: sparse evidence-based research to guide interventions; review key competencies of American Board of Psychiatry and Neurology; deliver crisis intervention effectively and expertly; definitions in academic literature; 7-stage crisis intervention model (Roberts et al.); principles of safe intervention (SAMSHA) to improve effectiveness of intervention

Case vignette: demonstrate theme effective crisis interventions; clinician ability to safely, calmly provide assessment, treatment; skill to stabilize patient, staff, family affected by patient behavior during crisis

Key competencies: patient care, medical knowledge, interpersonal communication, practice-based learning/improvement; professionalism, systems-based practice; how to assess, deliver crisis intervention services (emergency psychiatric evaluations, risk assessments, biopsychosocial evaluations, multidisciplinary treatment plans); best practices reviews; maximize clinical effectiveness; evaluate, document patient potential for self-harm or harm to others comprehensively

Crisis and crisis intervention in academic literature: crisis is perception of event or situation as unbearable, exceeding resources and coping skills; components — hazardous, traumatic event, vulnerable or unbalanced state, precipitating factor, active crisis state based on person’s perception; emergency psychological care aimed at assisting individuals in crisis; priority to increase stabilization; trauma arises instantaneously; refer to Assessment, Crisis Intervention, and Trauma Treatment or ACT intervention model; assessment and triage integrated with 7-stage crisis intervention; 10-step acute traumatic stress management protocol; facilitates planning for effective, brief treatment in outpatient clinic, community mental health center, or counseling center; rapid assessment of problem and resources; collaboration on goal selection and attainment, finding alternative coping methods, developing working alliance, building on strengths; develop protocols for patients in urgent care situations (attempted suicide, withdrawal from alcohol, benzodiazepines, opiates)

7-stage model: conduct thorough biopsychosocial imminent danger assessment; establish therapeutic relationship; identify major problems and crisis precipitant; explore feelings using active listening and validation; generate, explore alternatives including untapped resources and coping skills; develop action plan; follow-up plan agreement; steps 1 and 2 intertwined; creates firm foundation; review sociocultural factors (ethnicity, language, assimilation, acculturation, spiritual beliefs, community support, economic conditions, educational background); detailed review of topics; Topic #9 Psychiatric Interview and Mental Status Examination; Topic #59 Motivational Interview; Topic #60 Suicidality; Topic #61 Dangerousness, Seclusion, and Restraint; Topic #62 Risk Management; Topic #63 Child Sexual and Domestic Violence; judicious use of medications review Audio Digest for specific disorders; Topic #41 General Principles of Psychopharmacology; Topic #42 Drug Interactions; Topic #44 Antidepressants; Topic #45 Mood Stabilizers; Topic #46 Anti-anxiety Agents; Topic #47 Antipsychotics; Topic #48 Psychostimulants; Topic #49 Hypnotics and Sedatives more thorough review of psychotropics; psychopharmacology less is more; chronically suicidal patients consider lithium augment or clozapine; evidence-based strategies to decrease suicidal acts; acutely manic, psychotic consider neuroleptics; Topic #16, Topic #20 (recommendations related to detoxification protocols for alcohol and opiates, respectively); evaluate postcrisis patient status; consider need for referral or modification of treatment plan

Case vignette: demanding, belligerent patient; demonstrate clinician must remain calm (key); take own pulse; feel safe in workspace; exit plan if escalation; assess safety at work (waiting room, office staff) regularly; work space design for quick exit

SAMSHA Core Elements in Responding to Mental Health Crises goals: ensure consistent standards with recovery and resilience; work toward reducing likelihood of future emergencies; 7-stage crisis intervention model fulfills principles; timely access to support, services; provide services in least restrictive manner; spend adequate time with patient; strengths-based help plans; emergency interventions consider context of individual’s overall plan of services; services provided by individuals with appropriate training; individuals not turned away; comprehensive understanding of crisis; help individual regain sense of control (priority); services congruent with culture, gender, race, age, sexual orientation, health literacy, communication needs; respect patient rights; provide trauma-informed services; recurring crises signal problems in assessment

Summary: review key competencies; psychiatrists deliver expert and effective crisis intervention; crisis and crisis interventions as described in academic literature; 7-stage crisis intervention model; review principles of safe interventions (SAMHSA)

Questions and Answers

Obstacles when providing crisis intervention: redirection of previously acquired automatic reactions to stressful situations (biggest obstacle); feelings of anxiety, anger, hopelessness, helplessness; learned behaviors of passivity, passive aggression, or aggression; work to create safe environment for self and staff

Benzodiazepines not discussed: limited role in crisis intervention; contraindicated for panic attacks; nonpharmacologic strategies produce lasting improvements; risk that patient may take more than recommended dose; leads to disinhibition; may result in poor decision making that escalates crisis

Suggestions for future research efforts in psychiatric crisis intervention: focus on reviews of critical incidents; develop best practices protocols; establish meaningful evidence-based outcomes measures for services and programs

Readings

Disclosures

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PSBR160156

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation