Critical decision points in crisis support: using checklists and flow charts in psychological crises

The field of crisis intervention has grown dramatically during the last hundred years. Many new procedures and techniques have been added to the crisis intervention repertoire. Periodically, providers of crisis intervention, psychological first aid, critical incident stress management, or Peer Support overlook important elements of crisis intervention or make inadvertent mistakes as they attempt to intervene. The use of checklists and flow charts, similar to those used in aviation and medicine, may assist crisis intervention personnel in properly assessing a traumatic event and its impact on the people involved. Simple checklists and flow charts may significantly decrease the potential for mistakes in crisis intervention. This article provides background on the development of flip charts in aviation and medicine and suggests how these tools may be utilized within the field of crisis intervention. Examples of checklists and flow charts that are relevant to crisis intervention are provided. The article also provides guidelines for developing additional checklists and flow charts for use in crisis intervention services.     

Assessing the impact of community-based mobile crisis services on preventing hospitalization

OBJECTIVE: This study evaluated the impact of a community-based mobile crisis intervention program on the rate and timing of hospitalization. It also explored major consumer characteristics related to the likelihood of hospitalization. METHODS: A quasi-experimental design with an ex post matched control group was used. A community-based mobile crisis intervention cohort (N=1,696) was matched with a hospital-based intervention cohort (N=4,106) on seven variables: gender, race, age at the time of crisis service, primary diagnosis, recency of prior use of services, indication of substance abuse, and severe mental disability certification status. The matching process resulted in a treatment group and a comparison group, each consisting of 1,100 subjects. Differences in hospitalization rate and timing between the two groups were assessed with a Cox proportional hazards model. RESULTS: The community-based crisis intervention reduced the hospitalization rate by 8 percentage points. A consumer using a hospital-based intervention was 51 percent more likely than one using community-based mobile crisis services to be hospitalized within the 30 days after the crisis (p<.001). Treating a greater proportion of clients in the community rather than hospitalizing them did not increase the risk of subsequent hospitalization. Those most likely to be hospitalized were young, homeless, and experiencing acute problems; they were referred by psychiatric hospitals, the legal system, or other treatment facilities; they showed signs of substance abuse, had no income, and were severely mentally disabled. CONCLUSIONS: Results indicate that community-based mobile crisis services resulted in a lower rate of hospitalization than hospital-based interventions. Consumer characteristics were also associated with the risk of hospitalization.     

Suicide prevention: A view from the bridge

The future of suicide prevention activities is seen in terms of developments over the past decade. Seventy-four suicide prevention services have been established since the Los Angeles Suicide Prevention Center was opened in 1958. While many models have developed, principles of crisis therapy, transfer of patients rather than referral, use of the telephone in therapy, integration of the center into the community network of helping agencies, and use of nonprofessional volunteers are present as common elements in all. Predictions are offered for the differential development of independent suicide prevention centers and inserted suicide prevention services. Future emphasis is predicted for primary prevention of suicide crises, as well as continued refinements of secondary intervention procedures already developed.     

PSYCHOPHARMACOLOGY WORKSHOP

Abstract

The growing number of reported child abuse cases continues to pressure the South African social services. The present scenario demands that creative ways of helping the child survivor and family be investigated.

Substantiated by relevant statistics, this paper will advocate the crisis intervention approach as a means of dealing with child abuse cases in South Africa today. Various applications of the crisis intervention approach will be explained, which may be useful with the abused child. It is suggested that this approach, which has been implemented by the author at the Red Cross Children's Hospital in Cape Town, may facilitate both the healing and the prevention of mental illness in relation to child abuse.     

Think about it till it hurts: targeting intensive services to facilitate behaviour change - two examples from the field of substance misuse

BACKGROUND: In traditional services for people in crisis there is an expectation that those people will come forward and seek help. At a time of crisis this may not be a reasonable expectation. METHOD: Two proactive and engaging programmes have been developed for substance users in crisis. 'Option 2' is for families at risk of having their children removed. 'STIR' is for people leaving prison. In both cases, a brief but intensive person-focused intervention is offered during the critical period. While both interventions may incorporate standard clinical elements, the distinctive feature they have in common is that workers go to the prospective client and encourage him or her to shape the solution in terms of both defining the immediate practical support they need and beginning to set longer term goals. RESULTS: In-service evaluations suggest that these services are valued by the clientele, produce measurable change in function for the majority and are likely to save public money. CONCLUSIONS: Formal research evidence of effectiveness and efficiency might be accomplished by comparing outcomes for similar clients in areas with and without these service options.     

Thoughts on training guidelines in emergency mental health and crisis intervention

Given the terrorist attacks in Oklahoma City, Washington, D.C., and New York City, there has been increased interest in the provision of emergency mental health services, especially disaster mental health. Rather remarkably, however, there is a paucity of formal emergency mental health training programs. As a result, psychologists, psychiatrists, and social workers have found themselves thrust into situations where they have been expected to provide emergency mental health services in the absence of formalized training. Herein follows a discussion of what may be argued to be five core competencies in the provision of emergency mental health services. These guidelines may be of value to those interested in assessing existing training programs, or those interested in developing new training programs in emergency mental health and crisis intervention.     

Community care for patients with Alzheimer's disease and non-demented elderly people: use and satisfaction with services and unmet needs in family caregivers

OBJECTIVE: This study measures and compares use of and satisfaction with medical and social services in addition to subjectively perceived needs of family supporters of patients with probable or possible Alzheimer's disease (AD) and family supporters of non-demented elderly people. Differences in judgement of services within the subpopulation of families of AD patients are also assessed by gender and burden level.METHODS: The main family supporters of 60 community-dwelling elderly (aged over 65) with Alzheimer's disease and of 60 age- and sex-matched controls were tested with a detailed questionnaire on use and satisfaction with services, any unmet needs and kinds of intervention perceived to be helpful.RESULTS: Supporters of elderly people with AD were significantly more involved in providing care than supporters of non-demented people. Judgement on the health, social relations and financial status of their families was significantly worse in AD supporters than in supporters of non-demented elderly people. Although the former made more use of available health and social services than the control population, they did appear to make little use of such services, not only because of lack of information but also for logistic reasons or because they would prefer a service with more specifically trained operators or more tailored intervention. AD family supporters would like to receive more information and support from their general practitioner, which confirms the importance of this figure in management of this pathology. They were less satisfied with the care provided than the control population, particularly those with a moderate-high burden. Irrespective of burden level, they also expressed a need for financial and psychological support and adequate intervention schemes, especially within the home. These should be provided by specially trained personnel and be tailored to specifically manage the individual patient's problems, especially in relation to behavioural disorders. This would help alleviate caregiver burden and allow patients to continue to be managed at home.     

A crisis model revisited

The concept of crisis hospitalization in a mental health center was one that was vigorously promoted a few years ago.^1,2 Since then it has continued to be seen by its supporters as more economical of time and money and frequently as effective as more traditional hospital treatment.³ Others have raised questions about its clinical validity.^4,5 Something useful may be added to the controversy by looking at the evolution of the idea of 3 day hospitalization which was defined as a model for intensive intervention by one center.¹For the purpose of this report crisis hospitalization is defined as an inpatient stay of less than 5 days which is usually followed by intensive but time-limited out-patient treatment. The characteristic clinical approach involves the use of time-limited contracts, intervention through multiple therapist teams aimed at minimizing dependency and regression, an adaptive focus in therapy, early involvement of family members and use of medication to control incapacitating symptoms. Ventilation of feelings related to those painful situations which usually precede crisis admission occurs during individual and group sessions. It starts with the identification of problems and ends when the patient is ready to return to the precrisis level of functioning. Discussion of long standing inner psychological conflicts is avoided and actively discouraged.     

Critical Incident Stress Management (CISM): a statistical review of the literature

Crisis intervention has emerged over the last 50 years as a proven method for the provision of urgent psychological support in the wake of a critical incident or traumatic event. The history of crisis intervention is replete with singular, time-limited interventions. As crisis intervention has evolved, more sophisticated multicomponent crisis intervention systems have emerged. As they have appeared in the extant empirically-based literature, their results have proven promising. A previously published paper narratively reviewed the Critical Incident Stress Management (CISM) model of multicomponent crisis intervention. The purpose of this paper was to offer a statistical review of CISM as an integrated multicomponent crisis intervention system. Using the methodology of meta-analysis, a review of eight CISM investigations revealed a Cohen's d of 3.11. A fail-safe number of 792 was similarly obtained.     

Editorial: The future of crisis mental health services for children and young people

The future of mental health services for children and young people are at a turning point. There is increasing recognition that there is huge unmet need. In the UK only approximately 25% of children and young people with a mental health disorder receive treatment, but demand to access care is increasing. At the same time evidence is building on what treatments are effective. This has not been matched by equivalent research evidence on what service configurations are most effective. In their systematic review of ‘the impact of pediatric mental health care provided in outpatient, primary care, community and school settings on emergency department use’, Kirkland et al (2018) found only limited evidence to suggest that the provision of services in the community impact on the use of emergency departments. The absence of robust RCT evidence should not prevent us from improving the outcomes and experience of children and young people facing a mental health crisis. Much is known about the value of early intervention and effective community interventions. Action should be taken now to prioritise the use of scarce resources where they are needed most to reduce unnecessary and sometimes unhelpful attendances at emergency departments and avoid potentially harmful mental health admissions.     

Predictors of psychiatric hospitalization for adults with co-occurring substance and mental disorders as compared to adults with mental illness only

Predictors of psychiatric hospitalization, predisposing, enabling and need, of adults with co-occurring mental and substance disorders were compared to predictors for adults with a mental illness only. Research participants were 1613 users of crisis intervention services. Findings using Cox regression show that dually-diagnosed individuals were more likely to be hospitalized. Enabling and need factors were important predictors for both groups. Disruptive behavior was a predictor for dually-diagnosed clients but not for clients with mental illness only. Findings suggest that outpatient mental health services are less well equipped to address a psychiatric crisis when it was accompanied by substance use issues.     

Psychiatric crisis intervention. Oranizational and administrative services in the Governmental health service

After describing the principles and structure of the psychiatric services in Bulgaria, the author goes in more detail into the organizational and administrative conditions of psychiatric crisis intervention. It is emphasized that the main basis for psychiatric crisis intervention must be the psychiatric out-patient service which includes and coordinates all service branches and works together with the non-psychiatric services. The author stresses two channels of information about crises: 'passive', when psychiatric services receive information from the family or non-psychiatric agencies associated with crisis interventions (e.g. general medical agencies, councelling centres, administrative authorities, etc.); 'active', if the dispensary itself collects information as e.g. by regular observation of registered patients, by psychiatric or general medical field investigation as may be carried out by the Prevention Department, etc.). A few ideas are also offered concerning the organization of a subsystem for crisis intervention within the entire psychiatric service delivery system.     

Some basic considerations in crisis intervention

In an effort to add greater understanding to the concept of crisis intervention, it is proposed that emotional crises be placed on a continuum ranging from normal developmental crises to psychiatric emergencies. If emotional crises are placed on such a continuum, reasons behind crisis intervention are clarified as are the roles of direct treatment and consultation. Along with such clarification it is suggested that a variety of viewpoints of an emotional crisis should be considered in its assessment. This in turn results in a more pragmatic and comprehensive orientation for a community mental health center to effectively assist people in crisis.     

Soins intensifs à domicile : modèles internationaux et niveau de preuve

Introduction

Despite recent legislation favouring home treatment services, international literature contrasts with its development in France, where those programs stay rare. They were implemented since the deinstitutionalization movement of the 1970s, to provide care to severe mentally ill outpatients, who used to stay in long-term inpatient wards. Those home treatment programs can be divided in two groups: Assertive Community Treatment and crisis interventions teams.

Objectives

This article first aims to describe those two types of programs, and then to review their evidence level. Finally, we will discuss the actual controversy about effectiveness of home treatment.

Method

This article is a literature review of international research about home treatment programs for adults’ severe mental illness. It excluded children psychiatry, addictology and elderly psychiatry. We selected reviews and research articles taken from international publications, using a PubMed research.

Results

This article concerns home treatment programs, belonging to “mobile teams”, which is a group of psychiatric teams including varied goals: Improving continuity of care, community assessment, avoiding admissions to psychiatric hospital, improving skills in community living, and supporting families. Those programs practice assertive outreach. Some provide care and others only assess and direct people to other services. Only the first ones are concerned by this article. We distinguish two types of home treatments: Assertive Community Treatment (ACT) and Crisis Intervention teams. Assertive Community Treatment, also named Assertive Outreach teams or Intensive Case Management, is a very well described model which aims to keep people with severe mental illness in the community. It is an intensive kind of Case Management. It is specially addressed to high services users, with frequent admissions. ACT consists in visiting people at home, providing cares and social support, developing skills to cope with daily living. It is provided by a 24-hour available multidisciplinary team, in an unlimited time. The first Stein and Test study showed benefits compared to standard treatment, but more recent trials failed in improving hospital use or clinical and social outcomes. Some even show and increased hospitalization rate. This variation can be explained by an improvement of standard care with time, and international heterogeneity. A higher fidelity to the original model could decrease bed use. Fidelity scales have been developed to compare different programs. ACT seems to be useful to improve engagement in care for people with a high level of needs, and to maintain them in housing. Studies also show a dilution of the effectiveness of ACT in routine practice. Those results limit its implementation. The second group of home treatments is crisis intervention and home treatment teams, also called crisis assessment teams. Those teams aim to treat crisis at home for severe mentally ill people. Crisis is defined as a symptomatic exacerbation in severe mental illness. Treatment is provided by a 24 hours available multidisciplinary team which assesses the situation, directs the patient and programs a crisis intervention. The intervention is time limited, about six weeks. It helps people to resolve crisis in the community. It could avoid 50% of psychiatric admissions, without increasing readmission rates. A recent study shows it could reduce the suicide rate. It also improves satisfaction with care and engagement.

Conclusions

Despite the controversy, home treatment services can be useful to improve engagement in care, user's satisfaction, and to avoid psychiatric admissions. Visiting patient at home and associating social interventions with medical treatment improve bed use outcomes. Less intensive but well organized community teams can also bring benefits. In the French context, the lack of visibility of home treatment teams can be explained by several hypotheses. We can cite the lack of systematic evaluation of care programs, the persistence of more inpatient beds than in other countries, the difficulty to implement home treatment in rural areas or the cultural use of hospital.     

A pilot study of social inclusion and quality of life for parents of children with autism spectrum disorder

ABSTRACT

Background Access to both childcare and early intervention for pre-school children with autism spectrum disorder (ASD) can be difficult for parents or carers and may impact on parental social inclusion and wellbeing. There is limited research investigating how specialist centres offering both services may impact on parental outcomes.

Method Parents whose children were attending such a specialised childcare setting in two states in Australia (Tasmania and South Australia) were invited to participate in a mixed-methods study investigating quality of life (Qol), social inclusion and perceptions of the centres.

Results Parents had typically low levels of QoL but reported a range of benefits from receiving services, including increased levels of community participation and increased competence and confidence in themselves as parents.

Conclusions Childcare centres offering specialist multi-disciplinary early intervention and parental support are valued by parents and assist with social inclusion.     

Self-perceived social integration and the use of day centers of persons with severe and persistent schizophrenia living in the community: a qualitative analysis

Background The study examined how persons with severe and persistent schizophrenia perceive their social integration and how particular types of social integration are related to the use of day centers and patient clubs. Methods Problem-focused interviews on self-perceived social integration and the use of day structuring services were done with 100 persons with an ICD–9 diagnosis of schizophrenia living in Leipzig. Transcribed interviews were subjected to computer-aided qualitative content analysis. Results Results of the qualitative content analysis show that the study participants can be classified in five different groups according to their self-perceived degree of social integration. The use and the subjective meaning of existing day structuring services was found to be associated with the type of self-perceived social integration. Conclusion The heterogeneous ways persons with chronic schizophrenia organize their social lives lead to different kinds of needs for support. In order to meet the needs of the whole spectrum of patients this heterogeneity must be taken into account in the process of service planning. Accepted: 4 September 2001     

The role of pastoral crisis intervention in disasters, terrorism, violence, and other community crises

The term "pastoral crisis intervention" has been defined by Everly (2000) as the functional integration of faith-based resources with traditional crisis intervention assessment and intervention technologies. Pastoral crisis intervention has been differentiated from ministry and the provision of chaplaincy services. This paper provides a public health model for integrating pastoral crisis intervention services within the larger domain of community disaster response, crisis intervention, and emergency mental health.