Learning From The Past and Planning For The Future
MENTAL HEALTH MOMENT May 17, 2002 "A problem is a chance for you to do your best." - Duke Ellington
Short Subjects
LINKS Mental Health Moment Online CONFERENCES AND WORKSHOPS:
Suicide Prevention Strategies and Helping Those Left Behind Cope
Wednesday May 29, 2002
8:30 AM to 4:00 PM
Cheyenne, WY
Contact: William Quinn, Southeast Wyoming Mental Health Center
(307) 634-9653SUMMER EMOTIONS INSTITUTE:
August 19-22, 2002
Les Greenberg, Ph.D.
Skills training in working directly with emotion in psychotherapy
York University, Toronto
Phone: (416) 410-6699.International Biennial Conference on Self-Concept Research: Driving International Agendas August 6 - 8, 2002 Location: Sydney, AUSTRALIA Contact: Kate Johnston, SELF Research Centre
University of Western Sydney, Australia Email: k.johnston@uws.edu.auLatino Psychology 2002 Conference
October 18-20, 2002
Location: Providence
Rhode Island, USA
Contact: Maria Garrido,Chair
"Latino Psychology 2002"
Adjunct Professor of Psychology
University of Rhode Island
Email: mgarrido@etal.uri.eduSMART MARRIAGES SIXTH ANNUAL CONFERENCE: July 11-14, 2002 Washington, D.C.; 69.5 hours CE; (202) 362-3332
FIRST OF ITS KIND LAW ALLOWING PSYCHOLOGISTS TO PRESCRIBE GARNERS MIXED REACTIONS
With four similar bills pending in other states, the debate is set to heat up even more in the coming months. Brown University Child and Adolescent Psychopharmacology Update 13(4) 2002 http://www.medscape.com/viewarticle/431308?srcmp=psy-050302
U.S. SENATE SET TO CONSIDER MENTAL HEALTH 'PARITY' BILL
The U.S. Senate could take up a bill to require "parity" in insurance benefits for mental illness before Memorial Day. Reuters Health Information 2002 http://www.medscape.com/viewarticle/432923?srcmp=psy-050302
FOCUS ON SERIOUS MENTAL ILLNESS
Approximately 23% of American adults each year have a diagnosable mental disorder and as many as 5.4% of American adults have a serious mental illness. Medscape's Serious Mental Illness Resource Center gives you the latest medical news and information on the evaluation and treatment of persons with serious mental disorders. http://www.medscape.com/mp/rc/mentalillness
Kids on Psychiatric Drugs -- Is There Cause for Alarm?
Over the past decade, the number of children taking medications for depression, attention deficit hyperactivity disorder (ADHD), or other behavior problems has tripled. Learn more. http://my.webmd.com/content/article/3606.1515
Expectant Moms: Let the Sunshine In
Pregnant women battling depression may get a mental boost from bright morning light, according to researchers. http://my.webmd.com/content/article/1663.52988
Red Cross Caseworker Reunites Afghan Sisters From Across the Globe
An American Red Cross caseworker delivers an important message during the war on terrorism in Afghanistan.
House Fires: Seniors Most Vulnerable to Deadliest U.S. Disaster
Every year in the United States, one type of disaster is more deadly than all others combined — house fires. For the elderly, the fire death risk is twice as high as that of the average population.
CRISIS MANAGEMENT
Defining The Problem
An effective response to a crisis depends in part on the characteristics of the crisis and in part on the therapist's comprehensive understanding of the client. This includes both manifest clinical circumstances and problem formulation. One description of the elements that make up a workable formulation is offered by Perry, Cooper and Michels (1987):
1) A summary...that describes the patient's current problems and places them in the context of the patient's current life situation and developmental history;Among the factors to include are such issues as genetic predisposition, mental retardation, overwhelming trauma, and drugs or any physical illness affecting the brain. In assessing current life problems, the therapist should be on the lookout for changes in biological (including physical illness), psychological and social circumstances of the client's life. Chrzanowski (1977) defined several common categories of crisis:2) a description of nondynamic factors that may have contributed to the psychiatric disorder;
3) a psychodynamic explanation of the central conflicts, describing their role in the current situation and their genetic origins in the developmental history; and
4) a prediction of how these conflicts are likely to affect treatment and the therapeutic relationship.
* The emergence of an acute psychosis, which may or may not require hospitalization.Whether such circumstances lead to an emergency depends on the interactions among the severity of the stress, the strength of the client's ego and support network, and the therapist's skill. Some clients with relatively weak egos (schizophrenics; chronically depressed, narcissistic, and borderline personalities; substance abusers; and some adolescents) are especially prone to developing crises that become emergencies. In treating vulnerable people, the therapist should be vigilant for personality and behavioral changes that indicate increasing tension or problems in adjusting to routines of daily living. When problems are anticipated, especially early in the course of treatment, the therapist is well advised to meet with the family and lay the groundwork for working together if the need arises.* Self-destructive acting out often associated with alcohol or drug abuse, promiscuity, or delinquency.
* Major illness or serious accidents involving the client or people close to him/her.
* Family disturbances, including separation and divorce.
* Economic crisis.
* Severe transference distortions (i.e., psychotic transference).
* Serious countertransference distortions.
* The paradoxical upsurge of disturbed and disturbing emotion and behavior when the client is threatened by success in the therapy, including the prospect of termination, as cause of crisis.
* The response of a significant other who perceives the client's improvement as a threat.
Crisis Adaptation
The client's adaptive mechanisms function in a way to maintain overall physical and psychological equilibrium. However, in a crisis situation, the capacity of the client's (and the clinician's) coping mechanisms may be exceeded. This can result in erratic or impulsive behavior. Though there are no pathognomic signs of impending violence, precipitous assault is quite rare, if indeed it exists at all. However, warning signs may be subtle. Typically, the crisis process involves 1) a prodrome; 2) an identified "incident"; and 3) a reintegration/ restabilization period. The clinician can optimize crisis outcome through early identification and intervention (dependent on clinician sensitivity and judgment), and by adopting the therapeutic stance of collaborating with the client in working through the various stages of crisis adaptation. The clinician must participate in rather than attempt to short-circuit this process.
Aggressive behavior results from the client's experience of fear or anger. Both affects are meaningful and potentially understandable reactions (defensive and offensive, respectively) to the client's (perhaps accurate, perhaps inaccurate) perception of threat. Whereas most clinicians seem to assume that aggressive client behavior is indicative of anger, most aggressive behavior in the clinical setting may instead be a reflection of fear. A fearful client must be approached differently than an angry client. However, this crucial distinction is often overlooked. All people direct their behavior according to the channels or alternatives that they perceive. Even a gentle person may fight when feeling cornered without alternatives. In working through the crisis process with any client, the clinician must take great care not to inadvertently structure a situation so that the client's only perceived option to meet essential needs is through dysfunctional means. An acceptable alternative must be allowed to any inappropriate behavior.
Assessment/Intervention Interaction
Just as the aggressive client typically experiences either fear or anger, the clinician's actions can be conceptualized as either yielding or firm. These possibilities form the matrix shown below:
These four cells may help the clinician to conceptualize four prototypical approaches to working with the aggressive client. Assessment involves differentiating the fearful client from the angry. Intervention requires choosing between the yielding and the firm approach. Sound clinical judgment is central to both assessment and intervention.Clinician's Response Yielding Firm _____________________________________________________________Fear Reduce perceived threat Increase perceived coping capacity
_____________________________________________________________
Anger Appease Set limit
_____________________________________________________________
In response to the fearful aggressive client, the clinician may attempt to reduce the degree of threat the client perceives, verbally (e.g., "It's safe here now") or nonverbally (e.g., allowing plenty of interpersonal distance). Alternatively, the clinician may attempt to help the client feel able to cope with the perceived threat (e.g., "I am on your side, and I will help"). Just as one fearful client may respond better to yielding threat reduction, another may respond better to firm support and enhancement of perceived coping capacity. Similarly, in response to the angry client, the clinician may employ a yielding strategy in order to appease the client and so defuse aggressive potential (e.g., "I am sorry that I hurt your feelings"), or alternatively may respond firmly and inhibit aggressive expression through limit setting.
Good judgment is required for the clinician to choose between the yielding and the firm approach to the angry client. The practical test of the chosen approach lies in the resulting behavior of the client. One angry client may only attempt further to "push around" the yielding clinician. Another angry client may be "pushed over the edge" into violence by the firm clinician. Though appeasement is not synonymouswith inappropriately pacifying a bully (it is possible to defuse anger through appeasement without sacrificing the essential interests of both client and clinician), many clinicians seem loathe to react gently in the face of anger. It seems likely that the most common precipitant of unnecessary client violence is clinician counterhostility.
Setting Limits
The ultimate goal in external limit setting is for the client to develop internal controls. However, limit setting may be instrumental in the course of the client's development of autonomous self-regulation. Limit setting can be a positive therapeutic technique inasmuch as it allows the client to understand which behaviors are prescribed and which are proscribed. It also gives the client realistic expectations about the behavior of others. This allows the client to gain approval rather than disapproval. Additionally, limit setting may prevent the client from doing something humiliating or harmful. It can also convey clinician concern and competence. Some degree of client resistance to limit setting is a positive sign. Generalized, docile acceptance of the clinician's will is dysfunctional. It is important to remember that, whenever any of the client's intentions is blocked, an acceptable alternative must be allowed.
Limit setting should be presented to the client as a statement of fact. It should never be presented as a request, as a bribe, as advice, as punishment, or as a challenge or threat. Reality-based, natural consequences of behavior are a more productive focus than are consequences contrived and maintained by the clinician. Fairness and consistency in limit setting are absolutely essential. Expected and prohibited behaviors must be described concretely in terms of actions that can be performed immediately. The clinician must know the actual enforceable limit, and must never describe either positive or negative consequences that he/she is unable or unwilling to deliver. Generally, limit setting is often utilized too late rather than too early by well-meaning but inexperienced clinicians. Timely implementation can prevent undue deterioration of the client and the therapeutic milieu. Once the need for a behavioral limit has been established, the clinician may briefly explain the limit and its rationale but must avoid being drawn into superfluous discussion or argument.
There are two major methods of limit setting: direct and indirect. The former involves presenting the client with one specific directive. The latter involves presenting the client with choices among acceptable alternatives.
Direct Technique
The direct technique of limit setting consists of stating clearly and specifically the required or prohibited behavior. Though the clinician may additionally describe consequences of violating the limit, such a statement is not a defining aspect of this method. Whenever possible, a directive should be expressed in a positive format ("do this", which describes the behavior), rather than in the negative ("do not do that", which does not describe acceptable behavior). The direct method is often preferable for the confused or emotionally overwhelmed client.
Indirect Technique
The indirect method of limit setting consists of keeping the client in a state of choosing among acceptable behaviors. This divides the client's will to resist. Though it may be easy for the client to oppose a single directive, attention cannot be focused simultaneously on two or more alternatives and therefore the resistance to any particular one is diminished. The clinician subtly maintains control by limiting the choices while giving the client the opportunity to choose among them ("You can sit down and we can talk about how you are feeling, or you can leave"). Should the client refuse to make any choice, the clinician can then make a time-bound conditional choice on behalf of the client ("If you do not choose to sit down in 10 seconds, I will take that to mean that you choose to leave and I will have the security guards escort you out"). Even when the situation develops in this way, any resistance demonstrated is typically far less than had the client not been given a choice.
The clinician must exercise sound judgment in deciding which limit-setting technique to employ. Some clients will be angered by and vigorously resist directives. Others will be confused or disorganized by choices. At an appropriate time after such an intervention, the meaning of the limit setting within the context of the therapeutic relationship must be addressed with the client. Ultimately, clinician actions with the client's best interests at heart are likely to be understood and appreciated.
Exercising Judgment
In situations which require emergency action, the clinician has substantial authority and responsibility to take necessary steps (such as physical intervention, medication, seclusion, and restraint) to protect the client, the self, and others (Roth, 1987; Tardiff, 1984). Behavior that is destructive to the client, to others, or to the therapeutic environment legally warrants immediate intervention even without the consent of the client. Similarly, preventive intervention when such destructive behavior appears to be imminent but has not actually occurred (even in the absence of a specific threat or act) may be considered appropriate legally. In an emergency, the clinician is given a great deal of legal flexibility to exercise judgment in determining the necessity of and particular methods for immediate intervention. The clinician's judgment in such emergency situations is typically presumed to be valid. The clinician is typically held liable only if the intervention performed is such a substantial departure from the usual standard of care that it calls into question whether judgment was in fact exercised (Roth, 1987; Tardiff, 1984). As a legal protection and (more important) as a clinical validation, the clinician is well advised to consult with colleagues whenever possible in important matters requiring judgment, and to document the consultation appropriately.
Summary
Aggression against the mental health clinician is simply a fact of professional life. Far from being a phenomenon limited to the public sector emergency or forensic facility, such violence is known in almost every applied setting and with nearly every client population (Lion & Reid, 1983; Roth, 1987; Thackrey, 1987; Turner, 1983). Although incidence is difficult to estimate with precision, and the percentage of clients who actually threaten or enact violence against the therapist may be quite low, the more clients one sees, the greater are one's chances of eventually being the object of an assault. Such an eventuality has been characterized as an "inevitable phenomenon that may occur at some time to every therapist" (Whitman, Armao, & Dent, 1976, p. 428). It therefore behooves each mental health professional to understand the fundamental clinical and legal principles relevant to psychological/physical intervention. ***********************************************************************************************
REFERENCES Chrzanowski, G. (1977). The occurrence of emergencies and crisis in psychoanalytic therapy. Contemporary Psychoanalysis, 13, 85-93.
Perry, S., Cooper, A. & Michels, R. (1987). The psychdynamic formulation: Its purpose, structure, and clinical application. American Journal of Psychiatry, 144, 543-550.
Roth, L.H. (Ed.). (1987). Clinical treatment of the violent person. New York: Guilford Press.
Tardiff, K. (Ed.). (1984). The psychiatric uses of seclusion and restraint. Washington, DC: American Psychiatric Press.
Thackrey, M. (1987). Therapeutics for aggression: Psychological/physical crisis intervention. New York: Human Sciences Press.
Turner, J.T. (Ed.). (1983). Violence in the medical care setting: A survival guide. Rockville, MD: Aspen.
Whitman, R.M., Armao, B.B. & Dent, O.B. (1976). Assault on the therapist. American Journal of Psychiatry, 133, 426-429. To search for books on disasters and disaster mental health topics, leaders, leadership, orgainizations, crisis intervention, leaders and crises, and related topics and purchase them online, go to the following url: https://www.angelfire.com/biz/odochartaigh/searchbooks.html ********************************************************************** ********************************************************************** Contact your local Mental Health Center or check the yellow pages for counselors, psychologists, therapists, and other Mental health Professionals in your area for further information. ********************************************************************** George W. Doherty O'Dochartaigh Associates Box 786 Laramie, WY 82073-0786 MENTAL HEALTH MOMENT Online: https://www.angelfire.com/biz3/news
