Crisis/Risk Management Flashcards
[CRISIS INTERVENTIONS]
A therapist working in private practice has been working with a 15-year-old girl with a history of non-suicidal cutting. The parents consented to their daughter’s treatment and have, on occasion, attended conjoint therapy sessions. The client appears for an individual session with tears streaming down her face. She tells the therapist that she had sent a nude picture of herself to her ex-boyfriend several months ago and now it is being circulated at school. She tells the therapist that she is so embarrassed and doesn’t know how she can face anyone ever again. The girl tells the therapist that she doesn’t want her parents to know about this.
Which of the following interventions should the therapist take to manage the situation presented in this case?
A. Inform client that her parents must be notified
Make a child abuse report to the appropriate authorities
Assess client for potential risk to self
B. Inform client that her parents must be notified
Assess for child abuse & determine need to report
Process child abuse report w/CT
C. Explore CT’s fears RE: parents learning of situation
Make a child abuse report and process with client
Safety plan w/CT and identify healthy coping skills
D. Explore CT’s fears re: parents learning of situation
Make a child abuse report and process w/CT
Assess client for potential risk of self-harm
CORRECT ANSWER = D
“Explore CT’s fears re: parents learning of situation
Make a child abuse report and process w/CT
Assess client for potential risk of self-harm”
= The final part of answers C and D are quite different. Answer D, “ Assess client for potential risk of self-harm” > would be the best crisis intervention to start.
We would absolutely want to understand why CT is scared of informing her parents > b/c this info would allow the TH to determine how to proceed. This could lead to engaging in role play with CT to prepare her to tell parents, or possibly to conducting a conjoint session. We would also want to discuss the need for a child abuse report, and what this will mean for the CT.
This vignette is tricky b/c several issues require immediate attention. We see the issues of: confidentiality of a minor + child pornography + mandated reporting requirements + risk of self-harm.
We want to find an answer that addresses all of the issues presented and interventions that align with the level of risk indicated in the vignette.
[RATIONALE]
A = RULED OUT > TH not required to inform CT’s parents about the situation
(Even if parents consent to TX, minors who are old
enough to consent to their own TX, have a right to
confidentiality)
B = Similar to (A); (B) RULED OUT> TH not required to inform CT’s parents about the situation + we DO NOT need to assess for child abuse (“distribution of child pornography”) even if initially shared by the minor b/c it’s a mandated report.
C = first 2 parts are correct (same as “D); but last part > “Safety planning” will be appropriate if the assessment indicates a risk. However, safety planning prior to assessment would not make sense.
[DOMESTIC VIOLENCE]
A therapist has been working with a 54-year-old woman who has two grown children from two separate marriages. The woman was referred for therapy through a domestic violence support group. Her second husband, whom she still lives with, struggles with alcohol abuse and has a history of being physically aggressive when under the influence. After ending up in the hospital as a result of a physical assault perpetrated by the husband, the woman spent several weeks in a shelter. She has since returned back to the house and tells the therapist that she wants to make it work with him and is hopeful he will change, though she acknowledges he continues to drink.
What actions should the therapist take in this case?
A. Direct the CT to return to the shelter since the husband is continuing to abuse alcohol.
B. Acknowledge the CT’s desire to make the relationship work and collaborate with CT on safety planning.
C. Acknowledge the CT’s desire to make the relationship work and provide education about the cycle of violence.
D. Inform the CT of safety concerns and encourage her to return to domestic violence shelter.
CORRECT ANSWER = B
“Acknowledge the CT’s desire to make the relationship work and collaborate with CT on safety planning.”
= The question is asking what action we should take in this case, and based on legal and ethical obligations, we would look for the answer that manages the CT’s safety while also respecting their right to self-determination. Answer B allows us to meet the client where she is at—that she is hopeful things will get better—but also allows us to collaboratively a safety plan with her should the husband become violent again
[RATIONALE]
A key aspect of domestic violence is power and control. The perpetrator will often use physical or emotional violence as a way to maintain power and control over their victim. With this in mind, it will always be important to empower CT’s rather than impose the TH’s own agenda, even if this means the client makes decisions that are considered unwise or unsafe. To do otherwise would put the TH at risk of re-victimizing the CT.
A = does not take into account the CT’s desire to stay in the relationship and will likely make the CT feel disempowered.
C = while acceptable > it’s not as strong as B. If you must choose between psychoeducation on the cycle of violence and safety planning = you would generally choose “SAFETY PLANNING”
D = better than A, but wrong because > it ignores CTs stated desire to stay in the relationship and is pushing the THs will onto CT.
[ELDER & DEPENDENT ABUSE AND NEGLECT]
A therapist works with clients residing in a long-term living facility. One of the therapist’s newer clients shares in a session that he is upset because he witnessed an employee rough handling and yelling at one of the residents during their daily activities. In response to the employee’s actions, the resident appeared visibly shaken and began crying. He asks the therapist to please not say anything because he is concerned the employee will know he was the one to complain.
Based on the information and concerns shared by the client, how should the therapist manage the ethical and legal obligations in this case?
A) Report the client’s concerns to management and follow the facility’s guidelines for reporting abuse
B) Ask the client for more detailed information regarding the incident before making a report and safety plan with the client.
C) Report the abuse to law enforcement and local ombudsman and process report with client.
D) Report the suspected abuse to a supervisor to address client’s concerns and safety plan with the client.
CORRECT ANSWER = C
“Report the abuse to law enforcement and local ombudsman and process report with client.”
= addresses legal & ethical obligations >
(legal) theres suspicion of abuse at long-term care facility > which requires a report to police & ombudsman
+ (ethical) processing the report will allow us to address any safety concerns & trust issues with our CT
This question is not only asking how we would manage our legal obligations, but our ethical obligations as well. Based on the info presented, there’s reasonable suspicion that abuse is taking place in the long-term care facility. When abuse occurs in a long-term care facility, we must file a report with law enforcement and the local ombudsman
[RATIONALE]
A = incorrect b/c it’s > prioritizing management’s reporting requirements over the law, which may or may not match our legal mandate.
B = is shifting toward investigation > which is NOT our role as TH. Once there’s reasonable suspicion, report what you know!
D = while addressing the client’s concerns, again ignores our legal mandate
[CHILD ABUSE & NEGLECT]
A 17-year-old client with a diagnosis of Bipolar Disorder comes to a first session with her parents. The mother informs you that their daughter met with a psychiatrist who prescribed medication, but the family’s faith prohibits her from taking it. The parents tell the therapist they have been trying to “rid her of her demons by praying and relying on our faith.” You notice that the girl appears disheveled, is frequently distracted during the session, and seems agitated. What actions should the therapist take in this case:
A. Report the situation to CPS because client is a minor and she is not receiving proper treatment
B. Initiate involuntary hospitalization since the client is exhibiting clear signs of psychosis
C. Begin treatment with the client and maintain confidentiality due to religious exemptions with child abuse reporting
D. Explore the pros and cons of taking psychotropic medications with the parents and their daughter, while acknowledging their religious rights.
CORRECT ANSWER = D
“Explore the pros and cons of taking psychotropic medications with the parents and their daughter, while acknowledging their religious rights.”
= gives an opportunity to have an honest conversation w/the family regarding medication *while still respecting the family’s religious beliefs. This answer addresses all of the concerns mentioned in the question stem.
The question is asking what action we should take in this case, and based on legal and ethical obligations, we would look for the answer that manages the CT’s safety while also respecting their right to self-determination.
This scenario is particularly challenging because the law is a bit vague when it comes to child abuse reporting and religious freedom. If religion were not mentioned in this question, we would search for an answer that includes reporting neglect and be justified in doing so. However, religion is mentioned and the parents state medication is expressly prohibited within their religion. This makes choosing the right answer trickier.
According to the Child Abuse and Neglect Reporting Act, “a child receiving treatment by spiritual means…or not receiving specified medical treatment for religious reasons, shall not for that reason alone be considered a neglected child (CA Penal Code 11165.2).”
[RATIONALE]
A = As the law indicates, if a child is receiving TX by
religious means, or not receiving TX due to religious
reasons, this does not necessarily constitute neglect.
AND
Failure to take the medication is not a life or death
decision.
In this case, the child is receiving care, has been seen by a psychiatrist & is now seeing a TH—the parents have just decided against psychotropic medication for religious reasons.
B = ruled out > since we’d only initiate a 5150 (involuntary
hospitalization) if there’s a grave concern for CT’s
immediate safety (something that is NOT indicated
based on the info shared)
C = ruled out > since it completely overlooks several of
the key concerns specifically noted in the question
stem. Namely, the potential risks facing the client and
medication compliance.
[ELDER/DEPENDENT ABUSE vs. CHILD ABUSE]
There are a total of 7 categories of ELDER/DEPENDENT abuse and neglect that require us to report _____
VS. CHILD ABUSE CATEGORIES _____
7 categories of ELDER/DEPENDENT abuse and neglect that require us to report:
–physical abuse,
–abandonment,
–abduction,
–isolation,
–financial,
–neglect,
–deprivation of necessary goods or services.
In cases of child abuse and neglect, the law does not address *abduction or *financial abuse.
[true or false]
ELDER/DEPENDENT ABUSE vs. CHILD ABUSE
[differences]
- When, how, and where to report elder/ dependent abuse and neglect will vary based on where it occurred, which is not the case with child abuse and neglect.
TRUE =
When, how, and where to report elder/ dependent abuse & neglect will vary based on = where it occurred
*which is not the case with child abuse and neglect.
true or false
[CHILD ABUSE / NEGLECT & RELIGION ]
According to the Child Abuse and Neglect Reporting Act, “a child receiving treatment by spiritual means…or not receiving specified medical treatment for religious reasons, shall not for that reason alone be considered a neglected child (CA Penal Code 11165.2).”
TRUE =
According to the Child Abuse and Neglect Reporting Act, “a child receiving treatment by spiritual means…or not receiving specified medical treatment for religious reasons, shall not for that reason alone be considered a neglected child (CA Penal Code 11165.2).”
If religion were not mentioned, we would search for an answer that includes reporting neglect and be justified in doing so.
However, IF religion is mentioned and the parents state, for example, that medication is expressly prohibited within their religion = NOT EXPLICITLY CONSIDERED NEGLECT
[SUICIDAl CLIENTS]
CORRECT ANSWER =
“
[RATIONALE]
A =
B =
C =
D =
[SUICIDAl CLIENTS]
Jill, an 18-year-old college student who is living at home, has been meeting with a therapist on a weekly basis for several months. She was referred for therapy after receiving medical treatment for alcohol poisoning. Jill reports feeling alone, lacking direction, and does not believe the future has much to offer her. She cut back on drinking after her experience with alcohol poisoning, but continues to smoke marijuana on a regular basis and has experimented with other drugs. In session, she shares that her boyfriend broke up with her over the weekend and now that she is completely alone she wants to go to sleep and not wake up.
How should the therapist manage the legal and ethical issues presented in this case?
a. Determine if she has a plan and means to commit suicide before taking other steps
b. Inform parents of risk because client lives with them and is a danger to self
c. Initiate involuntary hospitalization due to stated suicidal ideation and substance use
d. Validate client’s feelings of helplessness and help her identify healthier coping strategies
CORRECT ANSWER = A
“Determine if she has a plan and means to commit suicide before taking other steps”
= The CT has expressed suicidal ideation, but has not indicated a plan or means to carry out a plan. Before we decide what level of intervention is appropriate, we would need to assess the level of risk.
The question is asking what action we should take in this case, and based on legal and ethical obligations, we would look for the answer that manages the CT’s safety while also respecting their right to self-determination.
This question provides you with some information about risk factors, but the clinical picture is incomplete and until you gather more info it will be hard to determine the most appropriate intervention.
The BBS is not only testing that you:
– know when to intervene, but is also testing that you will – take reasonable, measured steps based on the level of risk and not overreact.
*Breaking confidentiality or initiating hospitalization prematurely could rupture the therapeutic relationship and cause greater harm than help to the client.
**Remember, our legal and ethical responsibilities are to assess and manage our CT’s safety & overall well-being.
[RATIONALE]
B = Based on the info provided, it’s not clear if breaking confidentiality is necessary, or if it’s even appropriate to involve the parents, so we would hold off on B
Before we decide what level of intervention is appropriate, we would need to assess the level of risk.
C = may be tempting b/C of the risk linked to substance abuse, feelings of hopelessness and suicidal ideation > Again, this would be a jump without assessing plan and means.
D = not strong because validating CT’s feelings of helplessness & identifying healthier coping strategies does not directly address the suicidal ideation and potential danger to self and would fall short of fulfilling our legal and ethical obligations.
ARE WE MANDATED TO BREAK CONFIDENTIALITY IF OUR CT IS SUICIDAL?
ARE WE MANDATED TO BREAK CONFIDENTIALITY IF OUR CT IS SUICIDAL?
= NO
Although we are not mandated to break confidentiality, we are LEGALLY and ETHICALLY obligated to:
– assess a client’s level of risk and
–take a measured approach to address their safety.
What this looks like will depend on the information shared by the client and the therapist’s understanding of risk factors.
Breaking confidentiality or initiating hospitalization prematurely could rupture the therapeutic relationship and cause greater harm than help to the client. Remember, our legal and ethical responsibilities are to assess and manage our client’s safety and overall well-being.
[DOMESTIC VIOLENCE]
A therapist meets with an 18-year-old woman who arrives at the session with her 2-year-old son. The woman explains that she moved out of her parents’ home about eight months ago and subsequently moved in with the father of her child. She reports that her partner is a great father, but the couple’s relationship is volatile and sometimes becomes physically violent. The woman states, “He is very controlling and questions my every action with our son. If I try to defend myself, we end up in a yelling match that often ends with him hitting me.”
What initial actions should the therapist take when considering the legal and ethical obligations in this case?
A. Inform the client that the therapist must break confidentiality and report child abuse since the minor is being exposed to domestic violence.
B. Provide psychoeducation regarding the cycle of violence and discuss alternative living arrangements.
C. Provide psychoeducation regarding the cycle of violence and develop a safety plan for the client.
D. Determine the client’s goals for therapy and collaboratively develop a safety plan.
CORRECT ANSWER = D
“ Determine the client’s goals for therapy and collaboratively develop a safety plan.”
= best answer available > It’s unclear what the client wants from therapy. It would be important to gather this information to develop a treatment plan and guide therapeutic interventions. In addition, the second part of the answer is strong because it is collaborative and addresses the safety concerns presented in the question.
[RATIONALE]
A = incorrect > we do not have reasonable suspicion of child abuse. A minor in a home with active domestic violence is not sufficient reason to break confidentiality and make a report. We would want to see an indication of child abuse to warrant a report.
B = incorrect > it is unclear the client is interested in pursuing alternative living arrangements. This answer does not honor a client’s self-determination. Psychoeducation would be appropriate, but the second part of the answer makes B wrong.
C = incorrect because therapists do not create safety plans for their clients. Again, psychoeducation would be a possible answer, but the second part of C is incorrect.
