Spring 2003 Newsletter Section 7

It is only in very recent years, with the formation of the Section on Clinical Emergencies and Crises, that the Society of Clinical Psychology (APA Division 12) gave recognition to an area of practice that is of great importance to all psychology practitioners. I have referred to this area as behavioral or mental health emergencies. A behavioral emergency has been defined as a state of mind in which there is an imminent risk that a patient or client will do something (or fail to do something) that will result in serious harm or death to self or others (Kleespies, 1998). Fortunately, there are only four situations in clinical practice that meet this definition, but they are situations that can, and often do, confront practitioners who have an active case load. They include: (a) serious suicidal states; (b) serious violent states; (3) vulnerability to interpersonal victimization (e.g., a child or elder in an abusive family); and (d) instances of impaired judgment that may imperil the individual.

There clearly have been psychologists within APA with great expertise in the evaluation and management of one or the other of these emergency conditions. There have also been numerous presentations at APA conventions and many research studies published in APA journals on suicidal behavior, violence, or victims of violence. From the perspective of one advocating for the development of behavioral emergencies as an area of practice, however, these efforts seem to have progressed in relative isolation from each other. If behavioral emergencies is to become an integrated area of practice for psychologists, and if Section VII is to develop as its representative organization, there is a need to demonstrate that those who work with these different emergencies have interests and concerns in common.

In this regard, I applaud the contribution to a recent issue of our newsletter entitled „Integrated Assessment of Suicide and Homicide Risk‰ by Marc Hillbrand (Behavioral Emergencies Update, 3 (2), 5). In this brief article, Hillbrand has drawn our attention not only to the phenomenon of homicide-suicide, but also to the fact that „risk of harm to self and risk of harm to others share some etiological factors (e.g., impulsivity) as well as protective factors (e.g., good peer relations)‰. He proposes that aggression against the self and aggression against others may be seen as co-existing on a continuum of severity. At the one end is suicidal ideation and/or homicidal ideation. Then, there are non-lethal acts of interpersonal violence and so-called parsuicidal behaviors. Finally, there are attempted and completed suicides and homicides, and occasionally homicide-suicides. He ends by pointing out that clinicians clearly need to be aware of, and examine for, both suicidal and homicidal tendencies in their patients. Another linkage that Hillbrand may fail to emphasize, however, is that where there is violence, there are victims, and it is often not possible to assess vulnerability to victimization without discussing the characteristics of the perpetrators of violence.

If clinicians and researchers from these now largely separate areas of inquiry and practice can begin to appreciate, as Hillbrand has, that there are often relationships and commonalities among different types of life-threatening behaviors, then they will begin to appreciate the importance of an integrated area of practice such as behavioral emergencies. The practice of clinical psychology can only benefit from such an alliance, and research in each specialty area can only be enriched.

References
Kleespies, P. (Ed.) (1998). Emergencies in Mental Health Practice: Evaluation and Management. New York: Guilford Press.