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