Crisis Assessment & Intervention

Question 1

A gay client tells his psychologist that he is afraid to disclose to sexual orientation to his family. How should the psychologist proceed?

A. help the client evaluate the consequences of continuing to hide his homosexuality
B. discuss the benefits of telling his family
C. initially support secrecy to build trust
D. find out about the client’s family and then offer her opinion about whether or not the client should come out to them

Answer 1

Help the client evaluate the consequences of continuing to hide his homosexuality

Question 2

When a new therapy client’s symptoms meet the diagnostic criteria for major depressive disorder, severe, you are MOST likely to involuntarily hospitalize the client for risk of harm to self if he/she:

A. expresses suicidal intent, exhibits poor judgment, and lacks social support
B. has access to a gun, has an alcohol-abuse problem, and lacks social support
C. expresses hopelessness, has an external locus of control, and has access to a gun
D. expresses hopelessness, exhibits poor judgment, and has a history of migraine headaches

Answer 2

Expresses suicidal intent, exhibits poor judgment, and lacks social support

NOTE:

• Expression of suicidal intent is the first consideration in determining whether a client is at risk for harm to self
• Need for hospitalization is suggested when expression of intent is combined with a specific plan, access to legal means, impaired judgment, comorbid psychotic disorder or chemical dependency, and/or an absence of social support

Question 3

A client becomes agitated and begins pacing around your office. He says he is angry about the state of his life. Which of the following actions would NOT be appropriate at this time?

A. faciltating the client’s expression of his feelings and providing supportive feedback
B. encouraging voluntary commitment to a psychiatric facility
C. providing structure and setting firm limits on the client’s behavior during the session
D. letting the client know you are going to leave your office for several minutes in order to allow him the chance to regain control of himself

Answer 3

Encouraging voluntary commitment to a psychiatric facility

Question 4

During the initial 72 hour involuntary commitment, it is determined that Luis L. is still at high risk for suicide. According to the California Welfare and Institutions Code, Luis may be detained for an additional 14 days for treatment under certain conditions. One of these conditions is that Luis will be informed that he is entitled to a certification review hearing within the first _____ of the 14-day hold.

A. 24 hours
B. 48 hours
C. four days
D. six days

Answer 4

Four days

NOTE:

• After a 72 hour hold an individual may be held for an additional 14 days if it is determined that he/she is still a danger to self or others or is gravely disabled
• However, Section 5254 also requires that the individual be notified that he/she is “entitled to a certification hearing review hearing to be held within four days of the date on which the person is certified for a period of intensive treatment.”

Question 5

Parents who physically and/or emotionally abuse their children are LEAST likely to do which of the following?

A. describe their children in negative ways (e.g., as worthless or “evil”)
B. offer inconsistent explanations for their children’s injuries
C. exhibit overconcern or overprotectiveness towards their children
D. have unrealistically high expectations about their children’s abilities

Answer 5

Exhibit overconcern or overprotectiveness towards their children

NOTE:

• Parents who physically or emotionally abuse their children are likely to show a lack of concern about their children
• Overprotectiveness is a characteristic of parents who sexually abuse their children

Question 6

A client who was recently divorced and has been feeling lonely says she sometimes feels as though she can’t go on. She says that dying has “crossed her mind” a few times. You perform a thorough suicide assessment and determine that the level of risk is low at this time. What are your interventions to address this?

A. talk over the problem with the client and offer emotional support; notify members of the client’s immediate support system about the client’s suicidal thoughts; and arrange to see the client more often for the time being
B. find out what event caused the client to contemplate suicide and formulate an action plan to dea with it; elicit the client’s ambivalent feelings about suicide; and have the client sign a no-suicide contract before she leaves your office
C. find out what event caused the client to contemplate suicide and formulate an action plan to deal with it; be very directive in developing the action plan; and arrange to see the client more often for the time being
D. talk over the problem with the client and offer emotional support; elicit the client’s ambivalent feelings about suicide; and obtain an agreement from the client to contact you should be there any change in her situation

Answer 6

Talk over the problem with the client and offer emotional support; elicit the client’s ambivalent feelings about suicide; and obtain an agreement from the client to contact you should be there any change in her situation

Question 7

A 32 year old man has been hospitalized for transient psychosis and violent behavior. He is at highest risk for future violence if he:

A. has average intelligence and a history of deliberate self-harm and depressive illness
B. has low intelligence and flat affect and a history of depressive illness
C. has average intelligence and a history of alcohol abuse and is socially isolated
D. has low intelligence and a history of alcohol abuse and exhibits poor impulse control

Answer 7

Has low intelligence and a history of alcohol abuse and exhibits poor impulse control

NOTE:

• The best predictor of future violent behavior:
  
  • previous violence against persons or property
  • male gender
  • drug & alcohol abuse
  • low intelligence
  • specific threats
  • having a weapon available
  • poor impulse control
  • extreme or labile affects
  • anger
  • irritability
  • absence of depressive illness

Question 8

In the context of crisis intervention, the “hazardous event” is:

A. an extreme stressor or event that is outside the range of normal human experience
B. the initial stressful event that poses a threat and disrupts the person’s equilibrium
C. a minor event that becomes catastrophic because it occurs during a highly stressful time in the person’s life
D. the final stressful event in a series of events that moves from a person from a state of vulnerability into a state of crisis

Answer 8

The initial stressful event that poses a threat and disrupts the person’s equilibrium

NOTE:
The components of crisis include the following:

1. the “hazardous event” which is the initial shock that disrupts a person’s equilibrium and initiates a series of reactions culminating in a crisis
2. the “vulnerable state” which is the person’s subjective rseponse to the stressful events
3. the “precipitating factor” which is the final stressful event in a series of events that moves a person from a state of acute vulnerability into crisis
4. the active crisis state
5. restoration of equilibrium

Question 9

A key component of crisis is the “precipitating factor,” which is defined as:

A. a minor event that assumes catastrophic proportions in the context of other stressful events and the person’s inability to use his/her customary problem-solving strategies
B. an initial shock that disrupts a person’s equilibrium
C. the final stressful event that moves a person from a state of acute vulnerability into crisis.
D. a person’s subjective response to stressful events in his/her life

Answer 9

The final stressful event that moves a person from a state of acute vulnerability into crisis

NOTE:
The components of crisis include the following:

1. the “hazardous event” which is the initial shock that disrupts a person’s equilibrium and initiates a series of reactions culminating in a crisis
2. the “vulnerable state” which is the person’s subjective response to the stressful events
3. the “precipitating factor” which is the final stressful event in a series of events that moves a person from a state of acute vulnerability into crisis
4. the active crisis state
5. restoration of equilibrium

Question 10

Your new client, Mrs. Acton is a 72-year-old widow who lives with her son, daughter-in-law, and their three children. During her first session with you, she exhibits signs suggestive of suicidal intent, but when you ask her if she has been thinking about killing herself, she adamantly denies that she has any intention of doing so. The best course of action would be to:

A. obtain permission to talk to her family members and then check with them to determine if she has exhibited any signs of suicide at home
B. obtain permission to talk to her family members and then determine if they are willing to set up at 24-hour suicide watch
C. have Mrs. Acton sign a no-harm contract and continue to monitor her for signs of suicide risk
D. contact Mrs. Acton’s family and have her hospitalized for observation.

Answer 10

Obtain permission to talk to her family members and then check with them to determine if she has exhibited any signs of suicide at home

NOTE:

• In this situation, you would want to verify Mrs. Acton’s risk for suicide before taking any other actions.
• Of the answers given, obtaining permission to check with her family to see if they have noticed any warning signs
  
  • EX: giving away property or making a will (would be the best course of action)

Question 11

Indirect self-destructive behaviors (ISDB) among the elderly include noncompliance with treatment, food refusal, and extreme self-neglect and are BEST interpreted as signs of:

A. delirium
B. suicidal intent
C. elder abuse
D. chronic pain

Answer 11

Suicidal intent

NOTE:

• Indirect self-destructive behaviors (ISBD) are slow, covert self-destrusive behaviors that are not due to a cognitive impairment and that reflect a conscious or unconcious intent to die
• Indirect self-destructive behaviors (ISBD) originally used by Nelson & Faberow (1980) who described ISBD as alternative form of suicide that is especially common in elderly residents of nursing homes where access to other means of suicide is limited

Question 12

The stress-crisis continuum model (Burgess and Roberts, 1995) predicts that which of the following interventions are likely to be MOST effective for an individual who is experiencing transitional stress (maturational) crisis?

A. education, support, and a self-help group
B. strategic solution focused therapy and pharmacotherapy
C. problem solving therapy, stress reduction interventions, and group therapy
D. medication and other symptom-reduction interventions

Answer 12

Education, support, and a self-help group

• Level 2 transitional (maturational) crisis on stress-continuum model
• the above interventions aimed at providing anticipatory guidance to help prepare for transition

NOTE:

strategic solution focused therapy and pharmacotherapy:

• Level 3 Traumatic stress (situational crisis):
  
  • precipitated by external stressor
  • ordinarily unpredictable, sudden, life-threatening
• interventions:
  
  • CBT
  • CPT
  • Strategic solution focused therapy
  • pharmacotherapy

medication and other symptom-reduction interventions:

• Level 1 Somatic distress:
  
  • biomedical disease
• interventions:
  
  • patient psychoeducation
  • medically oriented interventions focused on symptom reduction

problem solving therapy, stress reduction interventions, and group therapy:

• Level 5 SMI: SMI (dementia, psychosis, bipolar)
  
  • increases likelihood that pre-existing or new problem precipitates a crisis state
• symptom reduction through problem solving skills
  
  • environmental manipulaton
  • hospitalization
  • long-term individual
  • group treatment

Question 13

Burgess & Roberts: Stress-crisis continuum model (7 levels)

Answer 13

STRESS-CRISIS CONTINUUM MODEL (7 levels):

1. Level 1 Somatic distress: biomedical disease and/or psychiatric disorder, patient often seeks help from PCP
   * Level 1 intervention: patient education about illness, medically oriented interventions focused on symptom reduction
   
   2. L_evel 2 Transitional (Maturational crisis):_

generally anticipated stressful events/crisis reflecting life transitions over which ind may not have control

• Level 2 intervention: education, self-help groups and individual therapy
  
  3. Level 3 Traumatic stress (situational crisis): precipitated by external stressor ordinarily unpredictable, sudden, life-threatening
• Level 3 intervention: CBT, CPT, Strategic solution focused therapy, pharmacotherapy
  
  4. Level 4 Family crisis: precipitated by family or other primary interpersonal relationship, may be related to developmental (level 2) issue.
• Level 4 interventions: psychoeducation, individual, group interventions to restablize, strengthen interpersonal relationships, deter symptomatology
  
  5. Level 5 SMI: SMI (dementia, psychosis, bipolar) increases likelihood that pre-existing or new problem precipitates a crisis state
• Level 5 intervention: symptom reduction through problem solving skills, environmental manipulaton, hospitalization, long-term individual and group treatment
  
  6. Level 6 Psychiatric emergencies: severe impairment in fcning with threat or actual harm to self/others
• Level 6 interventions: rapid assessment, mobilization of appropriate resources, emergency care provision
  
  7. Level 7 Catastrophic Crisis: combines two or more level 3 crisses and a level 4, 5, or 6 crisis.
• Level 7 intervention: sometimes temporary and quickly resolved; other times life-threatening and extremely difficult

Question 14

For an Asian American client with traditional worldview and values, which of the following crisis intervention techniques is likely to be LEAST appropriate?

A. mobilizing (helping the client obtain needed resources)
B. clarifying (helping the client understanding the meaning of the crisis)
C. ordering (using techniques that promote rational thinking about the crisis)
D. catharsis (using techniques that help the client express feelings about the crisis)

Answer 14

Catharsis (using techniques that help the client express feelings about the crisis)

Question 15

Which of the following are the best predictors of future violent or aggressive behavior?

A. previous history of violent behavior, substance-related disorder, and access to a lethal weapon
B. previous history of violent behavior, depression, and suicide threats
C. history of animal abuse, substance-related disorder, and external locus of control
D. history of animal abuse, depression, and poor coping skills

Answer 15

Previous history of violent behavior, substance-related disorder, and access to a lethal weapon

Question 16

On the MMPI-2, generally elevated scales may indicate functional impairment. In addition, functional impairment is especially associated with elevations on which of the following scales?

A. Paranoid (6, Pa), Schizophrenia (8, Sc), and/or Hypomania (9, Ma)
B. Paranoid (6, Pa), Schizophrenia (8, Sc), and or Psychasthenia (7, Pt)
C.Schizophrenia (8, Sc), Hypomania (9, Ma) and/or Depression (2, D)
D. Psychopathic Deviation (4, Pd), Psychasthenia (7, Pt), and Schizophrenia (8, Sc)

Answer 16

Paranoid (6, Pa), Schizophrenia (8, Sc), and/or Hypomania (9, Ma)

NOTE:

According to Groth-Marnat (2003), functional impairment is highly associated with elevations in these three scales

Question 17

Global Assessment Functioning (GAF) scale:
Grave disability Codes

Answer 17

• 0 - 10:
  
  • persistent danger of severely hurting self or others (e.g., recurrent violence)
  • OR persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death
• 11 - 20:
  
  • some danger of severely hurting self/others (e.g., suicide attempts without clear expecation of death)
  • frequently violent, manic excitement
  • OR occasionally fails to maintain miinimal personal hygiene (e.g., smears feces)
  • OR gross impairment in communication (e.g., largely incoherent/mute)
• 21 - 30
  
  • delusions/hallucinations
  • OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation)
  • OR inability to fcn in almost ALL areas (e.g., stays in bed all day, no job, home or friends)

Question 18

MCMI-III: Grave disability/Functional Impairment scale elevations

Answer 18

Elevations:

• Severe PERSONALITY Pathology scales:
  
  • Schizotypal
  • Borderline
  • Paranoid
• Severe SYNDROME scales:
  
  • Thought Disorder
  • Major Depression
  • Delusional Disorder

Question 19

MMPI-2: Anger & Aggression scales

• Scale 4 (Pd)
• Scale 4 (Pd), Scale 9 (Hyp)
• **Scale 6 (Pa), Scale 4 (Pd), Scale 9 (Hyp)
• Scale 4 (Pd) and Scale 2 (D)

Answer 19

Scale 4 (Pd) very high:

• aggressive or assaultive

**Scale 4 (Pd), Scale 9 (Hyp):

• underlying sense of anger
• alienation
• impulsiveness
• antisocial tendencies with energy to act on these feelings

**Scale 6 (Pa), Scale 4 (Pd), Scale 9 (Hyp):

• VERY DANGEROUS
• poor judgment
• acting out likely to be violent, seems justified because of strong feelings of resentment towards others

Scale 4 (Pd) and Scale 2 (D):

• associated with personality disorders (passive-aggressive, antisocial traits)
• hostility expressed directly or indirectly

Question 20

A person experiences a traumatic event. Which of the following actors is LEAST likely to play a role in determining whether this event will activate a crisis?

A. the person’s problem-solving ability
B. the person’s cultural values regarding the event
C. the person’s current levels of social, material, and other support
D. the specific nature of the traumatic event

Answer 20

The specific nature of the traumatic event

Question 21

When assessing a crisis client, you would be LEAST concerned with which of the following?

A. psychiatric history
B. personality dynamics contributing to the crisis
C. the client’s perception of the situation
D. precrisis functioning

Answer 21

Personality dynamics contributing to the crisis

• objective of crisis assessment is to rapidly evaluate the degree of client disequilibrium and immobility (inability to take autonomous action)
• usually don’t have time to collect the type of historical material that might be relevant (like personality dynamics) in a crisis situation
• after crisis abated, should determine whether client requires further treatment to address personality dynamics

NOTE:

• While most people in crisis do not have a diagnosable mental D/O, some people in crisis have a pre-existing mental or emotional disturbance, assessment of medical and/or psychiatric histories may play a role in triggering or exacerbating crisis state
• If possible, should assess client’s pre-fcning to determine degree of change from typical functioning (cog, affective, bxal domains)

Question 22

The legal determination of “grave disability” requires the presence of all of the following conditions EXCEPT:

A. the individual is able to provide for his/her basic needs (food, clothing, and shelter) as the result of a mental disorder
B. the individual’s ability to provide for his/her basic needs may cause physical danger or harm to him/her
C. there is no willing, responsible third party to assist in the care of the individual
D. the individual refuses to receive or participate in treatment for a severe mental disorder

Answer 22

The individual refuses to receive or participate in treatment for a severe mental disorder

Question 23

The initial assessment of a client reveals that he has signs of psychic anxiety (feelings of anxiety, fearfulness, or apprehension), has experienced several panic attacks in the past few moonths, and has severe insomnia. Based on this information, the best conclusion is that this client:

A. has an increased risk for violence against another person
B. has an increased risk for suicide
C. witnessed domestic violence during childhood
D. is at high risk for (or already has) PTSD

Answer 23

Has an increased risk for suicide

NOTE:

• Research has liked severe or global insomnia and anxiety (especially psychic anxiety and panic attacks) to an increased risk for suicide

Question 24

In the context of crisis intervention, the “hazardous event” is:

A. an extreme stressor or event that is outside the range of normal human experience
B. the initial stressful event that poses a threat and disrupts the person’s equilibrium
C. a minor event that becomes catastrophic because it occurs during a highly stressful time in the person’s life
D. the final stressful event in a series of events that moves a person from a state of vulnerability to a state of crisis

Answer 24

The initial stressful event that poses a threat and disrupts the person’s equilibrium

• The “Hazard” is the first of the “Five crisis components” (Golan, 1978)

NOTE:
Precipitating factor:

• the final stressful event in a series of events that moves a person from a state of vulnerability to a state of crisis

Question 25

Golan, 1978: Five Crisis Components

Answer 25

FIVE CRISIS COMPONENTS (Golan, 1978)

1. Hazardous event
   * initial specific stressor, disrupts equilibirum
   * may be anticipated or not
2. Vulnerability state
   * physical, emotional, cognitive, behavioral responses, increased tension
   * Sense of ineffectiveness so person attempts to relieve using usual coping
   Tension increases if coping unsuccessful
3. Precipitating factor
   * FINAL stressful event in a series of events
   * moves a person from a state of vulnerability to a state of crisis
   4. Active crisis state
   5. Reintegration

Question 26

Which of the following includes four risk factors associated with a high risk for violence?

A. previous acts of violence; isolation; unstable vocational history; labile afect
B. previous acts of violence, unwillingness to use available outside resources, high IQ; alcohol or drug use
C. previous acts of violence; male; labile affect; age 30-45
D. previous acts of violence; male; chronic depressed mood; poor impulse control

Answer 26

Previous acts of violence; isolation; unstable vocational history; labile afect

NOTE:

• Low (not high) IQ is associated with high risk of violence
• Young age (begining around age 15-18 and continuing up to age 30-35) is associated with a high risk of violence
• Psychiatric diagnoses asscociated with high risk for violence:
  
  • Alcohol Intoxication or withdrawal
  • Delirium
  • Paranoid or catatonic schizophrenia
  • Delusional disorder
  • Mania
  • Temporal lobe epilepsy
  • Antisocial or paranoid personality disorder
  • Dissociative disorder
  • Impulse control disorder

Question 27

A 32 year old man has been hospitalized for transient psychosis and violent behavior. He is at highest risk for future violence if he:

A. has average intelligence and a history of deliberate self-harm and depressive illness
B. has low intelligence and flat affect and a history of depressive illness
C. has average intelligence and a history of alcohol abuse and is socially isolated
D. has low intelligence and a history of alcohol abuse and exhibits poor impulse control

Answer 27

Has low intelligence and a history of alcohol abuse and exhibits poor impulse control

Question 28

For adolescent males, which of the following are MOST associated with an increased risk for suicide?

A. depression, substance abuse, and schizophrenia
B. depression, substance abuse, and disruptive behavior
C. bipolar disorder, substance use, schizophrenia
D. bipolar disorder, social inhibition, and generalized anxiety

Answer 28

Depression, substance abuse, and disruptive behavior

• Research found that in terms of psychiatric disorders, depression, substance use, and disruptive behaviors INCREASE the risk among adolescent boys
• Suicide risk I_NCREASES DRAMATICALLY_ when depression CO-OCCURS with substance use and/or disruptive behavior

Question 29

Which of the following is considered feasible with only some clients in crisis, rather than a goal of all crisis interventions?

A. clarifying the precipitating event
B. restoring the client to the prior level of functioning
C. helping the client develping coping skills for future problems
D. identifying remedial measures

Answer 29

Helping the client develping coping skills for future problems

MUST BE ADDRESSED in all CRISIS INTERVENTION:

1. alleviate symptoms
2. clarifying the precipitating event
3. identifying remedial measures
4. restoring the client to the prior level of functioning

IF FEASIBLE, NECESSARY in SOME SITUATIONS

5. helping the client develping coping skills for future problems
6. help client connect current stresses with post-life experiences

Question 30

When is it appropriate to be highly directive with a crisis client?

A. when the client is unable to use his/her usual coping strategies
B. when the client has a crisis-oriented life history
C. when the client is too immobile to cope with the crisis
D. it is always approrpriate to be highly directive with a crisis client

Answer 30

When the client is too immobile to cope with the crisis

Question 31

Which of the following is NOT considered a necessary component of a crisis?

A. a precipitating event occurs
B. the individual’s perception of the event leads to subjective distress
C. the consequences of the event are life-threatening
D. the individual’s usual coping mechanisms are ineffective for dealing with the event

Answer 31

The consequences of the event are life-threatening

NOTE:

• A crisis is not necessarily life threatening
• Some experts distinguish between emergencies and crises
• Emergencies refer to events that are life-threatening
• Crises bring events that cause a state of disequilibrium

DEFINITION OF A CRISIS:

• involving a precipitating event
• the perception of the precipitating event leads to subjective distress (i.e. the ind perceives it as threatening or intolerable)
• Coping mechanims are ineffective for dealing with the event

Question 32

During the initial 72 hour involuntary commitment, it is determined that Luis L is still at high risk for suicide. According to the California Welfare and Institutions Code, Luis may be detained for an additional 14 days for treatment under certain conditions. One of these conditions is that Luis be informed that he is entitled to a certification review hearing within the first _____ of the 14 day hold.

A. 24 hours
B. 48 hours
C. four days
D. six days

Answer 32

Four days

• After a 72 hour hold, an individual may be held an additional 14 days if is determined that he/she is still a danger to self or others or is gravely disabled
• However, it is also required that the individual be notified that he/she is entitled to a certification review hearing to be held within four days of the date on which the person is certified for a period of intensive treatment

Question 33

Which of the following is true about the advantages or disadvantages of using a structured diagnostic interview?

A. structured diagnostic interviews tend to improve diagnostic reliability
B. clinicians using structured diagnostic interviews often fail to address comorbidity
C. when using structured diagnostic interviews, clinicians are more able to tailor the interview to the client’s needs
D. clinicians using structured diagnostic interviews are less likely to overlook important observations concerning the client’s nonverbal behavior

Answer 33

Structured diagnostic interviews tend to improve diagnostic reliability

NOTE:

UNSTRUCTURED DIAGNOSTIC INTERVIEW:

• low diagnostic reliability
• clinicians using unstructured diagnostic interviews often fail to address comorbidity by focusing too closely on the presenting problem and associated sx’s
• allows you to tailor an interview to a client’s individual needs

STRUCTURED DIAGNOSTIC INTERVIEW

• does NOT allow you to tailor an interview to a client’s individual needs
• tends to improve diagnostic reliability
• may cause you to focus closely on the decision rules and wording of questions, causing you to overlook important observations of the client

Question 34

For adolescent males, which of the following are MOST associated with an increased risk for suicide?

A depression, substance abuse, and schizophrenia
B. depression, substance abuse, and disruptive behavior
C. bipolar disorder, substance abuse, and schizophrenia
D. bipolar disorder, social inhibition, and generalized anxiety

Answer 34

Depression, substance abuse, and disruptive behavior

NOTE:

• In terms of psychiatric disorders, depression, substance, and disruptive behavior disorders increase the risk for suicide among adolescent boys
• The _risk increase_s dramatically when depression co-occurs with substance abuse and/or disruptive behavior

Question 35

Inez I., is 35 years old, an American Indian, is employed as a receptionist in a real estate office. She says she has come to therapy because of “problems” she’s having in her marriage, but she seems reluctant to provide you with details. Inez and her husband have been married for eight years and have two children, ages 2 and 4. She says that she didn’t go to college but that her husband did and that he has a “good job” at the bank. Inez tells you that she’s “tired a lot” and has chronic health problems, including irritable bowel syndrome and headaches. You noticed that Inez has several bruises and scratches on her arm, and when asked, she says she got them falling off a ladder. In addition to her injuries, what information suggests that Inez is a risk for intimate partner violence?

A. her age and her chronic health problems
B. her age and the disparity in her and her husband’s education level
C. her ethnicity and her chronic health problems
D. her ethnicity and being employed outside the home

Answer 35

Her ethnicity and her chronic health problems

FEMALE FACTORS ASSOCIATED WITH RISK OF INTIMATE PARTNER VIOLENCE

• younger age (under 24)
• low income (below poverty level)
• race/ethnicity (American Indian, Alaskan Native, Hispanic)
• chronic physical health problems
• discrepancy in education with the wife’s education greater than the husband’s
• heavy alcohol or drug use
• witnessing or experiencing violence as a child

Question 36

People who physically and/or emotionally abuse their children are LEAST likely to do which fo the following?

A. describe their children in negative ways (e.g., as worthless or “evil”)
B. offer inconsistent explanations for their children’s injuries
C. exhibit overconcern or overprotectiveness towards their children
D. have unrealistically high expectations about their children’s abilities

Answer 36

Exhibit overconcern or overprotectiveness towards their children

NOTE:

• Parents who physically or emotionally abuse their children are likely to show a lack of concern aout their children
• Overprotectiveness or excessive concern is characteristic of parents who sexually abuse their children

CHARACTERISTICS OF PARENTS WHO PHYSICALLY/EMOTIONALLY ABUSE THEIR CHILDREN

• describe their children in negative ways (e.g., as worthless or “evil”)
• offer inconsistent explanations for their children’s injuries
• have unrealistically high expectations about their children’s abilities

Question 37

During his third therapy session, a client tells you that he got into an argument with another customer at a local bar two evenings ago and end ended up giving the man “a good beating.” The client is an amateur boxer, and he feels very guilty about his behavior and knows what he did was wrong. Your initation action in this situation should be to:

A. make a report to the appropriate authorities
B. involuntarily hospitalize the client
C. assess the client’s risk for future violent behavior
D. discuss alternative ways for dealing with conflict with the client

Answer 37

Assess the client’s risk for future violent behavior

NOTE:

• You are not required to report this incident to the police
• hospitalization does not seem necessary since the young man is currently acting rationally
• while discussing alternative methods for dealingn with conflict might be appropriate, it would be MORE important to assess the client’s risk for future violence before deciding on a course of action

Question 38

A client becomes agitated and begins pacing around your office. He says he is angry about the state of his life. Which of the following actions would NOT be appropriate at this time?

A. facilitating the client’s expressions of his feeling and providing supportive feedback
B. encouraging voluntary commitmnt to a psychiatric facility
C. providing structure and setting firm limits on the client’s behavior during the session
D. letting the client know you are going to leave your ofice for several minutes in order to allow him the chance to regain control over himself

Answer 38

Encouraging voluntary commitmnt to a psychiatric facility

• The ciient is upset, but there is no indication that he needs to enter a psychiatric facility at this time.
• Hospitalization is an appropriate intervention when a client poses a serious danger to himself or others, or is gravely disabled, due to a mental disorder

POTENTIAL EFFECTIVE WAYS OF HELPING A DISTRESSED CLIENT REGAIN CONTROL:

• facilitating the client’s expressions of his feeling and providing supportive feedback
  
  • Briefly secluding the client is an alterative method for helping a client regain control
  • the purpose of seclusion must be explained. For example, you might say, “I am going to leave you alone for about 10 minutes in order to give you a chance to calm down”
• providing structure and setting firm limits on the client’s behavior during the session

Question 39

The central issue in the assessment of grave disability is determining:

A. the extent to which the client’s mental disorder results in suicidal ideation or an intent to harm others
B. the extent to which the client’s mental disorder prevents him/her from providing a reliable report to the psychologist and/or participating in a meaningful way in the psychotherapy process
C. the extent to which the client’s mental disorder interferes with his ability to effectively deal with everyday social, occupational, and interpersonal requirements
D. the extent to which the client’s mental disorder interferes with his/her ability to make sound decisions and safe judgments

Answer 39

The extent to which the client’s mental disorder interferes with his ability to effectively deal with everyday social, occupational, and interpersonal requirements

NOTE:

• Adults are considered to be “gravely disabled” when they are unable to take care of their basic needs, such as those for food, shelter, or clothing
• The gravely disabled adult is one who is unable to perform basic need meeting activities associated with independent living, such as, for example, food preparation, eating, maintaining a level of personal hygiene needed to prevent infection and illness or recognizing and responding appropriately to life-threatening situations

Question 40

Luiz L., is a 36 year old, Hispanic, recently divorced, an employed as a social worker. He has had epilepsy since his late 20s and received a diagnosis of diabetes mellitus threee years ago. During the initial therapy session with a psychologist, Luiz seems hositle and very agitated, and he says he’s been feeling very nervous lately. What information suggests that Luiz might be at high risk for completed suicide?

A. age (36), gender (male), physical ilness (diabetes mellitus)
B. occupation (social worker), marital status (divorced), and physical illnes (epilepsy)
C. race/ethnicity (Hispanic), marital status (divorced), and physical illness (epilepsy)
D. race/ethniciity (Hispanic), age (36), and personality characteristics (agitation and hostility)

Answer 40

Occupation (social worker), marital status (divorced), and physical illnes (epilepsy)

NOTE:

An increased risk for suicide has been linked to:

• marital status (a higher risk for those who are divorced, widowed, or separated)

certain occupations:

• social worker
• nurse
• physician
• dentist

certain physical disorders:

• epilepsy
• Hungtingtons disease
• Malignancies
• Multiple sclerosis

Suicide rates are highest among adolescents, young adults, and older adults

• At most ages, including age 36, the suicide age is higher for whites than for members of race/ethnic groups
• Although agitation, impulsivity, and hostility are associated with an increased risk for suicide, the client’s age and ethnicity are not

Question 41

Which of the following is a major assumption of crisis theory?

A. internal conflicts preclude problem-solving
B. people can learn to cope with stress
C. overwhelming emotions are the prime motivators for change
D insight must precede cahnge

Answer 41

People can learn to cope with stress

NOTE:

• According to crisis theory, people in crisis generally follow a predictable sequence of response and this response can be altered through appropriate education and assistance with developing more adaptive coping behaviors
• A key goal of crisis intervention is to help individuals in crisis learn more effective coping so that they respond more adaptively to future crises (i.e., client are helped to attain a better understanding of the current problem and its impact are taught new and more effective behaviors that they can use to cope when having similar experiences in the future)

Question 42

Which of the following is true regarding suicide among older adults?

A. Older adults are usually ambivalent about killing themselves, and, for these individuals, completed suicides are most often accidental
B. Older adults are more likely than younger adults to directly communicate their intent to kill themselves
C. The self-destructive acts of older adults tend to be more lethal than those of younger adults
D. The health status of older adults is unrelated to their risk of suicide

Answer 42

The self-destructive acts of older adults tend to be more lethal than those of younger adults

NOTE:

• The self-destructive acts of older adults are MORE LETHAL because these individuals often use highly lethal means, have less physical resilience due to health problems, and are socially isolated, and therefore, unlikely to be rescued following an attempt
• Older adults not only use MORE LETHAL methods with greater planning and resolve
• Older adults tend to be LESS AMBIVALENT about killing themselves than young adults are
• Older adults are LESS LIKELY than younger adults to directly communicate suicidal intent, although they may do so indirectly
  
  • EX: “I have nothing to look forward to anymore”
• Among older adults, physical health problms are associated with depression and an increased risk for suicide

Question 43

A psychologist has been providing couples therapy to a 34-year old man and his wife, age 36. After several months of therapy, the man arrives alone for a session and tells the psychologist that he feels himself beginning to lose control. He worries that he may “lose it completely” one of these days. How should the psychologist proceed?

A. call the police
B. have the client involuntarily admitted for inpatient mental health care
C. make an agreement with the client that if he feels out of control, he will notify her (the psychologist) immediately
D. role-play the situation that has made the client lose control in the past

Answer 43

Make an agreement with the client that if he feels out of control, he will notify her (the psychologist) immediately

NOTE:

• Because this appears to be an emergency, the psychologist must deal with the man’s concerns even though her contract with the clients is for couple’s therapy
• They key to selecting the best intervention is noticing that the man’s statement is vague (e.g., it does not include a specific threat of harm to others or self)
• Of the four choices, the psychologist making an agreement with the client that he will contact her if he feels out of control is the best course of action because it provides the clt with support and structure
• An even better choice would be to assess the situation further before determining the best intervention, but we are not offered that choice among the answers

Question 44

As part of crisis intervention, it is usually best to discuss the termination of treatment:

A. during an initial session
B. once the treatment goals and objectives have been achieved
C. when the client has re-established a state of equilibrium
D. when the client seems ready to discuss termination

Answer 44

During an initial session

Question 45

In the context of crisis intervention, the “hazardous event” is:

A. an extreme stressor or event that is outside the range of normal human experience
B. the initial stressful event that poses a threat and disrupts the person’s equilibrium
C. a minor event that becomes catastrophic because it occurs during a highly stressful time in the person’s life
D. the final stressful event in a series of event that moves a person from a state of vulnerability into a state of crisis

Answer 45

The initial stressful event that poses a threat and disrupts the person’s equilibrium

NOTE:

• Golan (1978) and others distinguish between hazardous events and precipitating factors.
• HAZARDOUS EVENT:
  
  • event that initially disrupts the individual’s normal state of equilibrium
• PRECIPITATING FACTOR:
  
  • the “final straw” that precipitates the crisis state

Question 46

A key component of crisis is the “precipitating factor,” which is defined as:

A. a minor event that assumes catastrophic proportions in the context of other stressful events and the person’s inability to use his/her customary problem-solving strategies.
B. an initial shock that disrupts a person’s equilibirum
C. the final stressful event in a series of events that moves a person from the state of acute vulnerability into crisis
D. a minor event that assumes catastrophic proportions in the context of other stressful events and the person’s inability to use his/her customary problem-solving strategies
D. a person’s subjective response to stressful events in his/her life

Answer 46

The final stressful event in a series of events that moves a person from the state of acute vulnerability into crisis

NOTE:
The components of a crisis include the following:

(1) HAZARDOUS EVENT:

• initial shock disrupts a person’s equilibrium and initiates a series of reactions culminating in a crisis

(2) VULNERABLE STATE:

• the person’s subjective response to stressful events

(3) PRECIPITATING FACTOR:

• the final stressful event in a series of events that moves a person from a state of acute vulnerability into crisis
• Often, but not always a minor event, no matter its magnitude, however, it can assume catastrophic proportions in the context of other stressful events and the person’s inability to use his/her usual problem-solving strategies
• *(4) ACTIVE CRISIS STATE:
  (5) RESTORATION OF EQUILIBRIUM**

Question 47

A psychologist is referred a client who mutilates animals, has flat affect, and appears to be very uneasy in the session. What should be the immediate short-term objective(s) of therapy with this client?

A. get information releases, do a substance abuse evaluation, assess for suicide risk
B. do a substance abuse evaluation, assess for suicide risk, refer to a group
C. inform the client about the limits of confidentiality and have him voluntarily hospitalized
D. try to establish rapport with the client so that he will speak more freely

Answer 47

Get information releases, do a substance abuse evaluation, assess for suicide risk

• The information in the question suggests that the man poses a potential danger to himself and/or to others. Therefore, only 1 of the 4 choices is appropriate as the first step
• When dealing with a client who appears dangerous, a psychologist’s first order of business is to assess the level of danger
• Contacting the other health professionals that this man has been (after obtaining the necessary information releases), doing a substance abuse evaluation, and assessing for suicide risk are all methods of assessing a client’s level of danger to self or others

DO A SUBSTANCE ABUSE EVALUATION, ASSESS FOR SUICIDE, REFER TO A GROUP:

• eliminate this answer right away because a referral to a group seems inappropriate at this time
• Such a referral would not address the issues of potential danger to self or others
• Also, if this man is uneasy with the psychologist, he is likely to be uneasy in a group setting as well

INFORM OF LIMITS OF CONFIDENTIALITY, THEN VOLUNTARY HOSPITALIZED:

• Having the man involuntarily hospitalized could be appropriate if he presented a clear and immediate danger, rather than a potential danger
• After further assessment, the psychologist may determine that this course of action is necessary

ESTABLISH RAPPORT SO HE WILL SPEAK MORE FREELY:

• Establishing rapport would be helpful in the long run but unlike response “A” it doesn’t address the emergency issue of potential danger to self or others

Question 48

A client expresses suicidal ideation. When performing a suicide assessment, which of the following additional factors would most concern the psychologist?

A. the client is an unmarried white female who has threatened to cut her wrists
B. the client is a unemployed, divorced 67-year old male who has decided to overdose on aspirin
C. the client is a middle-aged man who is currently very depressed and has access to tranquilizers.
D. the client is a married 30-year old female who expressed a sense of hopelessness and says that she has thought about buying a gun

Answer 48

The client is a unemployed, divorced 67-year old male who has decided to overdose on aspirin

NOTE:
The rates for completed suicide are highest for individuals:

• 65 years or older
• White (for all age groups)
  
  • EXCEPT in adolescence where rates for Native American tribes are at higher risk than Whites
• divorced, separated, widowed, followed by single (singleis less risk than those previous)
• Unemployed
• Hopelessness
  
  • Found to be more predictive of suicide than intensity of depressive sx’s
• Male
  
  • Females: attempt suicide more but males 4-5x complete suicide bc of more lethal methods (e.g., gun)
• Means present to carry out plan
• Suicide method
  
  • the client’s suicide method (overdose on aspirin) is associated with high lethality
  • Wrist cutting & overdose of tranquilizers is associated with low lethality

Question 49

During a crisis assessment of a client who has just lost his job, a psychologist would be likely to do all of the following except:

A. explore how and to what extent social and cultural factors have influenced the client’s response to this event
B. ask only close-ended questions so that she can rapidly elicit information about the client’s level of distress
C. assess actual or potential threats to life
D. explore the client’s problem-solving history and how well or poorly he has dealt with past stressful events in his life

Answer 49

Ask only close-ended questions so that she can rapidly elicit information about the client’s level of distress

Question 50

Your patient tells you that he is mad at his neighbor. He says that he plans to slash the tires of his neighbor’s car as soon as possible. You should:

A. call the police
B. call the neighbor
C. call the police and the neighbor
D. maintain your patient’s confidentiality

Answer 50

Maintain your patient’s confidentiality

Question 51

A client has told his psychologist that he intends to destroy his neighbor’s car. The psychologist may disclose privileged information to:

A. the neighbor
B. a mobile crisis team
C. the police
D. no one

Answer 51

The police

Question 52

Under the Welfare and Institutions Code 5300 (a 180-day hold), a court hearing is:

A. required
B. initiated only if requested by the patient
C. initiatied only if requeseted by a family member
D. not required

Answer 52

Required

Question 53

A client expresses suicidal ideation. When performing a suicide assessment, which of the following additional factor would most concern the psychologist?

A. the client is an unmarried white female who has threatened to cut her wrists
B. the client is an unemployed, divorced 67-year old male who has decided to overdose on aspirin
C. the client is middle-aged male who is currently very depressed and has access to tranquilizers
D. the client is 30-year old female who expresses a sense of hopelessness and says she has thought about buying a gun

Answer 53

The client is an unemployed, divorced 67-year old male who has decided to overdose on aspriin

Question 54

Which statement best describes a psychologist’s rights and duties if contacted by emergency room personnel regarding a patient who has made a suicide attempt?

A. Because the suicide attempt has already occurred and there is now no immediate threat to safety, the psychologist must uphold confidentiality
B. The situation constitutes a treatment emergency and the psychologist may divulge confidential information relevant to the patient’s immediate care
C. Evidence Code 1024 allows the psychologist to share confidential information in this situation because the patient is a danger to self
D. The psychologist may divulge confidential information only if the patient either gives consent or if the patient is hospitalized in accordance with Welfare and Insitutions Code 5150.

Answer 54

The situation constitutes a treatment emergency and the psychologist may divulge confidential information relevant to the patient’s immediate care

NOTE:

• Treatment emergencies are considered exceptions to confidentiality. In a treatment emergency (e.g., a patient has attempted suicide with a drug overdose), confidential information may be shared with health care providers to protect the patients from immediate physical harm.

EVIDENCE CODE 1024:

• exception to privilege that generally applies to legal proceedings
• Applies when a patient is a danger to self (others or property) and the disclosure is necessary to prevent the danger

Question 55

You are treating a married 35 year old Hispanic American man, Angel, who presents with depression secondary to a recent diagnosis of Multiple Sclerosis. Angel has a history of alcohol use disorder, and has been in remission for the past 6 months. Which of the following are not high risk factors for potential suicide?

A. Gender and age
B. Minority status and age
C. Martial status and diagnosis
D. Minority status and gender

Answer 55

Minority status and age

NOTE:

HIGH-RISK FACTORS:

• physical illness
• depression
• Men are 4 times as likely to die by suicide, though women attempt suicide at three times the rate of men
• Whites commit suicide at rates that are significantly higher than patients of minority status
• Unmarried, divorced, living alone
• highest rate: ages 45-64 years of age
  
  • second highest rate: 85 years or older
  • lowest suicide rate: 15-24 years of age

Question 56

For adolescent males, which of the following are MOST associated with an increased risk for suicide?

A. depression, substance abuse, and schizophrenia
B. bipolar disorder, social inhibition, and generalized anxiety
C. bipolar disorder, substance abuse, and schizophrenia
D. depression, substance abuse, and disruptive behavior

Answer 56

depression, substance abuse, and disruptive behavior

NOTE:

• The research has found that, in terms of psychiatric disorders, depression, substance abuse, and disruptive behavior disorders increase the risk for suicide among adolescent boys,
• The risk increasing dramatically when depression co-occurs with substance abuse and/or disruptive behavior.

Question 57

A client expresses suicidal ideation. When performing a suicide assessment, which of the following additional factors would most concern the psychologist?

A. the client is an unmarried white female who has threatened to cut her wrists
B. the client is an unemployed, divorced 67-year-old male who has decided to overdose on aspirin
C. the client is middle-aged male who is currently very depressed and has access to tranquilizers
D. the client is a married 30-year-old female who expresses a sense of hopelessness and says she has thought about buying a gun

Answer 57

The client is an unemployed, divorced 67-year-old male who has decided to overdose on aspirin

HIGHEST RATES FOR COMPLETED SUICIDE

• highest among aged 65 and over
• Male
• divorced, separated, and widowed, followed by those who are single
• unemployed
• overdose of aspirin
• lethal suicide plan AND the means available to carry it out

Answer A: the client is an unmarried white female who has threatened to cut her wrists

• wrist cutting is associated with l_ow lethality._
• women attempt more whereas men are more successful at completing suicide
• married has less risk

Answer C: the client is middle-aged male who is currently very depressed and has access to tranquilizers

• When suicide is associated with depression, most likely to occur within three months after depressive symptoms begin to improve.
  
  • This client is currently very depressed.
• Middle aged (lower risk)
• overdose of tranquilizers are not among the factors associated with the highest risk level.

Answer 4: the client is a married 30-year-old female who expresses a sense of hopelessness and says she has thought about buying a gun

• his age and gender are associated with a high risk for a suicide attempt
• hopelessness has been found to be more predictive of suicide than the intensity of depressive symptoms.
• No means to carry out her suicide plan.

Question 58

Which of the following includes four risk factors associated with a high risk for violence?

A. previous act of violence; isolation; unstable vocational history; labile affect
B. previous act of violence; unwillingness to use available outside resources; high IQ; alcohol or drug use
C. previous act of violence; male; labile affect; age 30-45
D. previous act of violence; male; chronic depressed mood; poor impulse control

Answer 58

Previous act of violence; isolation; unstable vocational history; labile affect

NOTE:

HIGH RISK OF VIOLENCE

• previous acts of violence (#1 high violence risk)
• male
• isolation
• unstable vocational history
• labile affect.
• Low IQ
• Young age: 15-18 up to age 30-35

Psychiatric diagnoses:

• SUD
• ETOH intoxication or withdrawal;
• Delirium
• Paranoid or Catatonic schizophrenia
• Delusional disorder
• Mania
• Temporal lobe epilepsy
• Antisocial PD
• Paranoid personality disorder
• Dissociative disorder
• Impulse control disorder

NOT ASSOCIATED WITH VIOLENCE:
High IQ
depression

Question 59

Maria is a 53-year-old woman who was referred by her physician. Maria recently spent time in the hospital after complaining of shortness of breath and painful swelling in her legs. The doctors diagnosed early stage heart failure, prescribed medication, and recommended lifestyle changes, including weight loss and reduced stress. Maria’s husband is angry at her for letting herself gain weight and get sick. He is upset that she can’t work now because he already works hard to support them. At night, Maria wakes up feeling as though she can’t breathe and then can’t fall back asleep because her worries and sense of guilt keep her awake. She blames herself for her illness and wonders whether she should bother following her doctor’s advice. Maria is weepy. She asks whether you believe what her doctors have said about her having a “bad heart.” When you ask her what she believes, she begins crying uncontrollably.

What are the most important initial assessment issues in the case presented in the exhibit?

A.

• Maria was recently diagnosed with a serious medical illness
• Maria has difficulty sleeping through the night
• Maria’s understanding of her illness is inconsistent with what the doctors have said
• Maria lacks an adequate emotional support system

B.

• Maria was recently diagnosed with a serious medical illness
• Maria is preoccupied with a sense of guilt about her medical illness and wonders whether she should bother following her doctor’s advice
• Maria lacks an adequate emotional support system
• Maria began crying uncontrollably when asked what she believes about her medical condition

C.

• Maria has difficulty sleeping through the night
• Maria is preoccupied with a sense of guilt about her medical illness and wonders whether she should bother following her doctor’s advice
• Maria’s family is unable to support her emotionally
• Maria’s coping abilities are poor

D.

• Maria has been having panic attacks at night
• Maria is not following her doctor’s advice
• Maria’s coping abilities are poor
• Maria began crying uncontrollably when asked what she believes about her medical condition

Answer 59

• Maria was recently diagnosed with a serious medical illness
• Maria is preoccupied with a sense of guilt about her medical illness and wonders whether she should bother following her doctor’s advice
• Maria lacks an adequate emotional support system
• Maria began crying uncontrollably when asked what she believes about her medical condition

CRISIS INDICATORS:

1. SITUATIONAL CRISIS: a sudden, uncontrollable, unanticipated event that threatens the person’s psychological, biological, and/orsocial well-being
   * Maria was just diagnosed with a serious medical illness
2. LACK OF SOCIAL SUPPORT:
   * The case suggests that Maria’s husband is emotionally unavailable at this time
3. AFFECTIVE SX’S

• guilt, sense of helplessness or hopelessness, anixiety, irritability, sadness, guilt or shame, disbelief, shock, numbness
• Among the distress signals highly associated with crisis include difficulty in managing feelings. Clients in crisis often lack emotional control.

EX:

• Maria feels guilty and blames herself for not following her doctor’s advice
• Maria began crying uncontrollably when asked what she believes about her medical condition

NOTE:

• Sleep difficulties can occur both when in crisis and ALSO in the ABSENCE of a crisis, not ONLY when in crisis, which is why this is not the best answer
  
  • Furthermore, her medical illness or the medication she is taking could be causing her sleeping problems
• Her episodes during the night are not necessarily panic attacks, however; panic-like symptoms, such as shortness of breath, may be caused by her medical condition.
• There is no evidence in the vignette that her family is not supporting her emotionally, just her husband at this point

.

Question 60

You are a staff psychologist at a VA Outpatient Clinic. Joshua, a 45 year old patient, came to you for psychotherapy six months ago with a diagnosis of generalized anxiety disorder. He had been on high doses of multiple anxiolytic medications for several years. In the most recent session he reports, “You have helped me so much. This morning I threw away all of my medication!” You should:

A. encourage him to notify the physician who prescribed the medication.
B. inform him of possible withdrawal symptoms
C. arrange for an immeidate medical consultation for him
D. consult with the prescribing physician before the next psychotherapy session

Answer 60

Arrange for an immeidate medical consultation for him

NOTE:

• The withdrawal symptoms experienced after abruptly stopping to take high doses of multiple anti-anxiety medications can be fatal. Because of the potentially fatal implications of your patient’s decision, immediate medical consultation is necessary
• All other responses are insufficient to address the potential life-threatening consequences of your patient’s recent behavior

Question 61

A 15-year-old, Stacy, presents to your office and asks to see you without her parent’s knowledge. She is particularly worried that if her deranged father knew she had come to you for help, it would only make matters worse. Stacy is attractive yet extremely thin. She has an apologetic manner and trembles as she speaks to you. The first concenr you should address is:

A. whether you are legally able to treat Stacy without parental consent.
B. child abuse
C. anorexia
D. suicide

Answer 61

Child abuse

NOTE:

• Given the situation described, the most pressing concern is whether Stacy is the victim of child abuse.
  
  • The fact that Stacy describes her father as “deranged,” when taken in context with her manner and appearance (extremely thin, apologetic manner, trembles as she speaks to you) are all reasons to suspect child abuse
• After making a determination regarding abuse, you can then can then consider whether you are legally able to treat Stacy (whether she is mature enough to participate intelligently) and deal with the possibility of anorexia that may ALSO account for her presenting symptoms
• While suicide is always a clinical concern to be mindful of, the quesiton contains no indication is an issue for Stacy