REPORT ON EDUCATION AND TRAINING IN BEHAVIORAL EMERGENCIES
The Task Force on Education and Training
Section on Clinical Emergencies and Crises (Section VII),
Society of Clinical Psychology (Division 12),
American Psychological Association
February 10, 2000
REPORT ON EDUCATION AND TRAINING IN BEHAVIORAL EMERGENCIES
This report has been compiled by a Task Force of the Section on Clinical Emergencies and Crises, Section VII of Division 12, with the purpose of documenting the critical need for improved clinical education and training in the evaluation and management of such behavioral emergencies as imminent risk of suicide, imminent risk of violence, and vulnerability to victimization. The term behavioral emergency refers to situations such as those just mentioned in which a client or patient is at imminent risk of behaving in such a way as to bring about serious harm or death to self or others unless there is some intervention.
The report reviews the incidence in clinical practice of patient suicidal behavior, patient violent behavior, and those circumstances when patients are vulnerable to being victims of violence. Thus, for example, it points out that national surveys (e.g., Pope and Tabachnick, 1993) have found that approximately 1-in-4 psychologists are likely to have a patient who actually commits suicide, while another survey has suggested that approximately 40% of graduate students in clinical psychology are likely to have a patient who either attempts suicide or commits suicide during their training years (Kleespies, Penk, and Forsyth, 1993). In terms of patient violence, the report provides data suggesting that nearly 80% of patient assaults on therapists occur to those who are either still graduate students or are within the first 5 years after completing the doctoral degree (Guy, Brown, ans Poelstra, 1990).
The available studies on the impact of work with these difficult and urgent cases on the clinician him or herself are also reviewed. The data indicate that for patient suicide attempts or suicide completions, it is common for therapists to react with shock, self-blame, guilt, and shame (Kleespies, et al, 1993). The impact of such events on psychology interns or trainees has been found to be as high or higher than on those at the professional level. In fact, the earlier in training that a patient suicide occurred, the greater the perceived acute impact. With regard to patient violence, a national survey has indicated that therapists who were victims experienced a dramatically increased sense of vulnerability and were much more likely to try to avoid treating potentially violent patients in the future (Guy, et al, 1990). Therapists who work with victims of violence and cruelty have reported what Pearlman and McCann (1990) have referred to as “vicarious traumatization”. These same investigators (Pearlman and McCann, 1995) have noted that therapists who were newer to trauma work experienced greater emotional and psychological difficulty.
Despite the data on the incidence and impact of patient life-threatening behaviors on psychologists, the profession appears to have done little to prepare clinicians specifically to cope with such events. Kleespies, et al, (1993) reported that only an estimated 55% of a sample of former graduate students in clinical psychology had some form of didactic instruction on suicide in their graduate school years, and the instruction was quite limited (i.e., one or two lectures). Guy, et al, (1990) found that psychologists in their national sample had a mean of 1 hour of clinical training on the management of patient violence during their predoctoral training years. Pope and Feldman-Summers (1992), in another national sample, reported that “very poor” was the rating most frequently given to graduate training in the areas of sexual and physical abuse.
Behavioral emergencies confront psychologists with the need to make decisions that can have very serious, possibly irreversible consequences. They can occur in virtually any clinician’s practice, and they can have far reaching emotional, ethical, and legal repercussions. In this regard, if psychologists are to have a more sound basis for fulfilling the duties attendant to their professional role, it seems incumbent that they be provided with more explicit education and training on the evaluation and management of clinical emergencies. This report proposes a curriculum and a training model that can be used as a starting point for discussion of how such training might be implemented. It recommends that there be a dialogue between members of the Task Force and APA Board of Educational Affairs to begin consideration of the case for improved education and training on behavioral emergencies.
REPORT ON EDUCATION AND TRAINING IN BEHAVIORAL EMERGENCIES
Statement of Purpose
The purpose of this report is to document the critical need for improved clinical education and training in the evaluation and management of psychological or behavioral emergencies. The report presents evidence on the incidence of behavioral emergencies in clinical practice; the impact of dealing with behavioral emergencies on practitioners (particularly those in training); the status of current psychological training in evaluating and managing emergencies; and recommendations for how the profession might improve its education and training in this regard.
The term “emergency” can have different meanings. In a general sense, it may mean an unforeseen circumstance that calls for immediate action. In regard to mental health emergencies, however, Callahan (1994; 1998) has argued for a more specific use of the term, a use that implies risk of serious harm or death to self or others unless there is some immediate intervention; and he distinguishes it from the term “crisis”. His point is that, in clinical practice, the definition of these terms can guide our thinking, our decision making, and our interventions. For the purposes of this report, therefore, a behavioral emergency will be said to occur when a patient or client has reached a state of mind in which there is an imminent risk that he or she will behave in such a way as to bring about serious harm or death to self or others unless there is some intervention. The behavior is potentially life threatening, appears to be imminent (i.e., likely to occur in the next few minutes, hours, or days), and requires an immediate response to avoid serious and irreversible harm. Fortunately, there are relatively few situations in psychological practice that qualify as behavioral emergencies. They include (1) serious suicidal states, (2) potential violence, (3) states of very impaired judgment in which the individual is endangered, and (4) situations of grave risk to a relatively defenseless victim (e.g., an abused child or elder).
A behavioral crisis, on the other hand, is said to occur when a patient or client is faced with a set of circumstances for which his or her resources for coping are insufficient and overwhelmed. A marked increase in anxiety or tension usually occurs, and the person searches for alternative methods of coping. If these other methods also fail, the individual enters a state of crisis. A state of crisis, however, does not necessarily imply that the patient or client will engage in life threatening behavior, and consequently it does not require as immediate a response to avoid serious physical harm. As Kleespies, Deleppo, Gallagher, and Niles (1999) have pointed out, a crisis often precipitates an emergency, but it is never sufficient to explain it. Behavioral emergencies are determined by many factors including predisposing or distal factors, acute or proximal factors, and a relative lack of protective factors (Rudd and Joiner, 1998 ; Moscicki, 1995).
In clinical practice, the practitioner is asked to assess a variety of behavioral or psychological crises, and an important part of the work is attempting to distinguish between crises that may progress to emergencies and those that will not.
The Incidence of Patient Emergencies in Clinical Practice
Although some might say that patient emergencies are primarily in the province of the emergency room or crisis team clinician (Dubin and Weiss, 1991), this is clearly not the case. A patient emergency can arise in the course of any clinician’s routine practice. In the section ahead, the evidence supporting this position is presented for patient suicidal behavior, patient violent behavior, and patient victimization.
Patient Suicidal Behavior
Those who have studied the incidence of actual patient suicide have referred to it as “an important occupational hazard for psychotherapists” (Chemtob, Bauer, Hamada, Pelowski, and Muraoka, 1989; p. 294). In a national survey of psychologists, 97% of the respondents reported being afraid of losing a patient to suicide (Pope and Tabachnick, 1993).
Several studies have been conducted in recent years that have helped to document the incidence of patient/client suicidal behavior in clinical practice, although much of the research has been limited to the incidence of completed suicide. Thus Chemtob and his colleagues surveyed both psychologists and psychiatrists concerning the incidence of patient suicide in their practice. Chemtob, Hamada, Bauer, Kinney, and Torigoe (1988) found that of 259 psychiatrist respondents (46% response rate), 51% reported having had a patient commit suicide. In a parallel study with psychologists, Chemtob, Hamada, Bauer, Torigoe, and Kinney (1988) found that of the 365 respondents (68% response rate), 22% reported having had a patient commit suicide. Also surveying psychologists, Pope and Tabachnick (1993) found that 28.8% of the clinicians in their study experienced the completed suicide of a patient. Based on these studies, it appears that approximately 1-in-2 psychiatrists and 1-in-4 psychologists are likely to have a patient commit suicide at some time during their professional careers.
Kleespies, Penk, and Forsyth (1993) examined not only the incidence of patient suicide, but also a broader spectrum of patient suicidal behavior during the pre-doctoral training years of psychologists. They contacted 292 of a possible 307 recent graduates from 11 different internship programs. Of those contacted, 100% participated in the survey. It was found that 97% of the respondents had had at least one patient with some form of suicidal behavior or ideation during their training years (i. e., up to and including the internship year). Eighty-five (or 29.1%) reported having had a patient who made a suicide attempt, and 33 (or 11.3%) reported having had a patient who actually completed suicide. Thus, it appears that approximately 40% of graduate students in clinical psychology are likely to experience some form of serious patient suicidal behavior (either a suicide attempt or a completed suicide) while still in training.
Chemtob, et al, (1989) investigated therapist or practice variables associated with greater risk of having a patient suicide. They found that clinicians who spent a larger proportion of their professional time working in psychiatric hospitals or psychiatric wards or in outpatient mental health agencies were significantly more likely to experience a patient suicide than their colleagues who worked in private practice, academia, or research settings. Moreover, clinicians were more likely to experience a patient suicide if their patients had organic, schizophrenic, affective, substance abuse, or other psychotic disorders; while clinicians who worked with patients with adjustment, anxiety, or personality disorders were less likely to experience a patient suicide. The investigators also found that postgraduate training and gender of the therapist were related to patient suicide rates largely to the extent that they affected opportunities and choices regarding job decisions, patient populations, and work settings.
The studies reported above have methodological limitations such as small and restricted samples and, in some cases, low response rates. The findings nonetheless seem to highlight the fact that patient/client suicidal behavior is not rare in the experience of mental health clinicians and that those clinicians who work with more impaired patients and in settings where such patients are seen are at greater risk of having a patient suicide.
In recent years, an increasing number of psychologists have specialized in behavioral medicine and taken positions in primary care settings. Epidemiologic studies (e.g., Coyne, Fechner-Bates, and Schwenk, 1994) have suggested that the majority of patients with depression are seen in primary care medicine. Depression is, of course, the disorder most highly associated with suicide. Moreover, it has been found that up to 60% of the elderly who committed suicide saw a primary care provider within 30 days of death and approximately 35% saw a primary care provider within a week of death (Conwell, 1997). Thus, it seems likely that, even in these less traditional settings for psychologists, they will encounter suicidal patients.
Patient Violent Behavior
Patient violence can be considered another occupational hazard for psychologists. In a national survey of psychologists, Pope and Tabachnick (1993) found that 89% of their sample reported episodes in which they were afraid that a patient might attack a third party, and 60.7% reported having had a patient who had physically attacked a third party. In addition, Whitman, Armao, and Dent (1976) reported that, during a one year period of practice, 81% of their sample of psychologists perceived a patient of theirs as a threat to others. Although one must be careful not to stereotype mental patients as violent, recent research has indicated that patients with certain diagnoses and symptoms have an elevated risk for engaging in violent behavior (McNiel and Binder, 1994; Swanson, Holzer, Ganzu, and Jono, 1990)
The threat of a patient harming a third party is distressing, but Guy and Brady (1998) have asserted that few challenges facing psychotherapists are more upsetting than the possibility of patient violence toward the clinician himself or herself. In terms of the incidence of violence directed at therapists, Tryon (1986) reported on a national survey in which it was found that 12% of therapists in private practice and 24% in hospitals and clinics had been victims of patient violence at some point in their careers. Moreover, 81% of those surveyed had experienced some form of verbal abuse or threat. In a more recent national survey, Guy, Brown, and Poelstra (1990) reported that nearly 50% of their sample of psychologists had been threatened with physical attack by a patient and 40% indicated that they had actually been attacked. The data from these studies suggests that 35-40% of psychologists in clinical practice are at risk of being assaulted by a patient at some time during their professional careers.
Guy, et al, (1990) found that a majority of reported attacks occurred in inpatient psychiatric settings; that is, 41% in public psychiatric hospitals and 22% in private psychiatric facilities. Other studies, however, have found that a significant number of attacks (47%) occurred in outpatient settings and private practice offices (Bernstein, 1981). Such findings suggest that clinicians must be aware of the possibility of patient violence in virtually any setting.
Although any clinician can become a victim, there are some findings that suggest that the risk is greater for newer and less experienced therapists. Thus, Guy, et al, (1990) found that 46% of all attacks on therapists involved graduate students or trainees, and another 33% occurred in the first 5 years after completing the doctoral degree. This data suggests that nearly 80% of patient assaults on therapists occur in their first 8-10 years in the field. Guy and Brady (1998) have suggested that there may be a number of reasons for this phenomenon. Newer therapists may be less alert to cues of violence. They may set fewer limits and allow aggressive behavior to escalate. They may be more likely to work in inpatient settings, and there is a practice in these settings to assign more severely impaired patients to clinicians in training.
While there have been instances in which a patient assault resulted in serious injury or death for the therapist, most patient attacks seem to result in minor injury or no injury at all. In their national survey, Guy, et al, (1990) reported that only 30% of those assaulted suffered any physical injury, while only 10% reported moderate injury. Typically, the emotional distress was far more disturbing than any physical injury.
Aside from years of clinical experience, there is little in the literature that would suggest a set of characteristics attributable to a typical therapist victim (Guy and Brady, 1998). There is some demographic and diagnostic data, however, on patients who are more likely to become violent toward their therapists. The majority of assailants have been found to be young (between 20 and 40 years of age) and predominantly (74%) male (Guy, et al, 1990). Patients with a diagnosis of schizophrenia are the most frequent assailants, while those with Axis II disorders of borderline and antisocial personality disorders rank second.
Patients as Victims of Violence
In the national survey by Pope and Tabachnick (1993), 79% of the therapists in the survey reported having been afraid that a patient of theirs would be attacked by a third party. Victimization by interpersonal violence is, unfortunately, not a statistically rare event. By way of example, Boney-McCoy and Finkelhor (1995) did a national survey of 2000 youths between the ages of 10-16 and found that 40.5% reported having experienced some form of violent victimization. For female adolescents, the most common form of victimization was sexual assault (15.3%), and for male adolescents, the most common form was aggravated assault by a nonfamily perpetrator (18.4%). In a national survey of over 4000 women, Resnick, Kilpatrick, Dansky, Saunders, and Best (1993) found that 35.6% of the sample reported at least one lifetime experience as a victim of crimes such as rape, other sexual assault, or physical assault. Nearly 52% of this group reported having experienced multiple incidents of violent victimization. Koss, Gidycz, and Wisniewski (1987) sampled over 6000 college age students from 32 different institutions and found that 53.7% of women respondents revealed some form of sexual victimization, while 25.1% of men revealed involvement in some form of sexual aggression.
Not all victims of violence develop symptoms of post-traumatic stress disorder; however, it is known that rates of PTSD are high in this population. Resnick, Acierno, Holmes, Dammeyer, and Kilpatrick (1999) estimated that 30%-50% of women who reported a history of assault had PTSD. While studies comparing victims to non-victims have found much higher rates of PTSD in violence samples as opposed to controls, it is difficult to estimate how many of these individuals seek psychotherapeutic treatment in the aftermath of a violent event. As Pearlman and MacIan (1995) have pointed out, it is only in recent years that survivors of violent crimes have come forward for psychotherapy. In one survey of psychologists and family therapists (Follette, Polusny, and Milbeck, 1994), the clinicians reported that 42% of the clients in their caseloads claimed to have a history of childhood sexual abuse. Given such reports, it would not be surprising for a clinician, at some point in his or her career, to treat a patient who has been traumatized by violence.
The Impact of Patient Emergencies on Clinicians
Work with suicidal patients, potentially violent patients, and victims of violence can be very affect-laden and stressful. In the section that follows, the findings on the impact of dealing with such patients on the clinician are presented. Unfortunately, the emotional distress can sometimes linger long after a critical clinical event.
The Impact of Working with Suicidal Patients
Feelings of guilt, shame, disbelief, incompetence, anger, depression, and fear are some of the emotional responses reported by psychology interns following patient suicides (Kleespies, Smith, & Becker, 1990). Even clinicians who acknowledge that they work with high risk patients, frequently use the term "shock" to describe their feelings upon hearing about a patient suicide (Kleespies et al., 1990). In 1993, Kleespies, et al, found a positive correlation between the severity of patient suicidal behavior and the clinician's emotional reaction when a full range of suicidal behavior was included. In other words, more severe suicidal behavior (attempts and completions) was associated with more severe reactions on the part of clinicians; e.g., shock, disbelief, failure, sadness, self‑blame, guilt, shame, and depression. By contrast, less severe behavior (e.g., suicide ideation) was associated with more attenuated reactions (Kleespies et al., 1993).
In regard to the more severe reactions, several studies which used the Impact of Event Scale (IES) indicated that patient suicide can and often does result in intrusive symptoms of stress for the therapist that are comparable to post‑trauma symptoms found in patient groups (Zilberg, Wiess, & Horowitz, 1982; Chemtob, Hamada, Bauer, Kinney, et al., 1988; Chemtob, Hamada, Bauer, Torigoe, et al., 1988; Chemtob et al., 1989; Kleespies, et al., 1990, 1993). Kleespies et al, (1990) and Brown (1987b) illustrated that such intrusive symptoms usually diminish substantially over a period of weeks or months but that some longer term emotional effects (e.g., heightened anxiety when evaluating suicidal patients) can remain indefinitely for some clinicians.
Fox and Cooper (1998) have written that "working with suicidal clients produces all the effects frequently associated with burnout including loss of drive and motivation, mental, physical and emotional exhaustion, professional isolation, the drain of always being empathetic and ambiguous successes, and observable decrements in the typical quality and quantity of work performed" (pg. 146). They go on to state that unrealistic self‑expectations have been identified as the single most critical factor in the development of burnout (Scully, 1983; Freudenberger, 1980) and that clinicians who work with suicidal patients are especially prone to this. Most therapists have great faith that their interventions will be successful and find it difficult to accept that some patients will remain unaltered in their "preoccupation with death, dying, or self mutilation" despite concentrated treatment (Fox & Cooper, 1998). Freudenberger (1980) has speculated that "unless an individual has strong compensatory factors [e.g. a strong social support system] in life he can fall victim to the constant onslaught of despair his clients bring him" (pg. 152).
The issue of whether trainees are more vulnerable to negative reactions to clients' suicidal behaviors than professionals has been addressed in several investigations (e.g. Kleespies ,et al, 1990, 1993; Rodolfa, et al, 1988; Brown, 1987b). One theory is that clinicians in training who have a patient commit suicide or make a serious suicide attempt have a "protective advantage" from any resulting negative emotional effects because they are under direct supervision and do not bear ultimate ethical or legal responsibility for the case (Brown, 1987a, 1987b). Others have suggested that trainees are more likely to assume responsibility for "fixing the client" (Rodolfa, et al, 1988, p.47) and thus have stronger feelings of inadequacy when treatment interventions are unsuccessful. Empirical studies support the contention that mental health trainees are at least as vulnerable as those who have completed their training. Kleespies, et al, (1993) found that the impact of suicidal behavior on psychology interns/trainees as measured by the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) was as high, if not higher, than that found in comparable studies of professional psychologists. Furthermore, Kleespies, et al, (1993) found a negative relationship between intrusive thoughts and images and the year of training in which a patient suicide was experienced (i.e., the earlier in training that the suicide occurred, the greater the perceived acute impact). Rodolfa, et al, (1988) examined three levels of clinicians (professionals, interns, and practicum students) and found that patient suicidal statements and attempts were rated by all groups as highly stressful. Thus, even though trainees do not bear legal responsibility for their patients, patient suicidal behavior seems to impact them as much or more than it impacts those at a staff level. This may be because trainees are less experienced, feel less prepared, feel less secure in their roles, and are more surprised or shocked by suicide threats, gestures, attempts, or completions than professionals.
Included in reactions to suicide is the fear that one has failed the patient clinically. Jobes and Maltsberger (1995), for example, noted that “the suicide death of a patient in active treatment is commonly taken as prima facie evidence that the therapist, somehow or another, has mismanaged the case. (pp. 200-201)”
Several recent articles suggest that many clinicians, whether working alone, as a trainee, or as a supervisor, are hesitant to discuss their emotional reactions to patient suicide with others due to concerns that what is said might be used against them in subsequent legal proceedings (Ellis & Dickey, 1998). In fact, Bongar (1991) has cautioned clinicians that discussions with a colleague or friend is considered non-privileged information and is open to the legal discovery process. Such fears have the potential to block the most effective coping method available to clinicians, the sharing of their emotional reactions in discussions with other clinicians. Without this opportunity, clinicians can become effectively isolated with their reactions. Further, clinicians-in-training may be left with the fear that there will be academic and/or professional consequences resulting from the client suicide (Spiegelman and Rogers, 1999).
The Impact of Patient Violence on the Clinician
Guy, Brown, and Poelstra (1991) found that 40% of clinicians who reported one or more instances of patient violence experienced a dramatically increased sense of vulnerability in the aftermath. The greater the extent of the resulting physical injury, the greater was the sense of fear and vulnerability that followed. These same investigators also found that some clinician victims reported a decrease in overall emotional well‑being and in a sense of professional competency. Despite the great difficulty in predicting patient violence, 39% of those clinicians who had been attacked felt that the attack could have been predicted and 30% felt that it could have been avoided and dealt with in a more helpful manner. This sense of personal responsibility tends to heighten feelings of guilt, shame, and failure. Since, as noted, many of the victims of patient attacks are students or early in their post‑doctoral years, it is easy to see how a sense of self doubt and incompetence can be heightened even though our ability to predict and prevent patient violence is quite limited.
Some episodes of patient violence required that the clinician use physical restraint or aggression in self‑defense. As Guy and Brady (1998) have pointed out, it is not unusual for these practitioners to have lingering fears about possible litigation or malpractice claims. In reality, however, few patients file complaints or lawsuits against clinicians whom they have physically attacked.
Although most of the clinicians in the survey by Guy, et al, (1990) did not reduce their workload after a patient attack, they did not carry on business as usual either. The most common protective measure was the refusal to accept certain patients who presented for treatment. This was especially true among those clinicians who believed that they could have predicted and/or prevented the previous episodes of violence. They apparently tried even harder to identify and avoid potentially violent patients. Rather than see potentially violent patients themselves, they were much more likely to refer such individuals to other clinicians.
Therapist victims were also much more likely to have an increased concern for the safety of their families as well as for their own safety. Guy, et al, (1990) reported that they were typically more aggressive about implementing measures to reduce personal risk such as having their home phone number unlisted and/or setting firmer limits. They were also more likely to formulate a contingency plan for obtaining assistance in the event of another event in the future. Some were reported to have relocated to a safer building or office. Others avoided working alone in the office, hired a secretary, or had a security alarm system installed.
The Impact of Working with Victims of Violence
McCann and Pearlman (1990) define vicarious traumatization as the effect that the clients' graphic and painful material has on the therapist's unique cognitive schemas, beliefs, expectations, and assumptions about self and others. Often included in such a reaction are symptoms of anxiety and intrusive thoughts about the patient's trauma. Some clinicians report experiencing emotional numbing or engaging in forms of avoidance of traumatic material in sessions. Moreover, bearing witness to human cruelty can challenge the clinician’s own beliefs and affect his/her own outlook on life.
Astin (1997) has explained that the trauma therapist is put into a similar situation as his/her patient in that he or she must incorporate what is often a schema discrepant event into an existing world view. One can change or re‑interpret the event so that it is congruent with already existing schemata (assimilation) or one can alter the schemata to incorporate the previously discrepant event (accommodation). Like the patients themselves, however, the clinician is at risk of either (1) over-accommodation which can cause him or her to be overly cynical in his/her world view or (2) blaming the victim to explain away the trauma as less severe or avoidable. Both of these are potentially damaging to the self of the therapist as well as to that of the patient, and either can be destructive to the therapeutic relationship.
Although the body of literature on vicarious traumatization is small, there are several studies which have found a positive correlation between exposure to trauma clients and symptoms of vicarious traumatization. For example, Schauben and Frazier (1995), in a sample of 118 female psychologists and 30 female rape crisis counselors, found that the higher the number of survivor clients in the therapist’s caseload the higher the reported extent of vicarious traumatization. Similarly, Munroe (1990), in a sample of 138 therapists in Veterans Administration facilities, found that current and cumulative exposure to combat related trauma clients was positively correlated with intrusive symptoms. Finally, Kassam‑Adams (1994), through a survey of 100 psychotherapists, found the percentage of clients who presented sexual trauma over the therapist's career was directly and positively correlated with the therapist’s PTSD symptoms. Only the survey by Follette, et al, (1994) failed to find that the proportion of the therapist’s caseload involving sexual abuse victims was predictive of trauma symptoms in the therapist.
A seemingly unresolved issue in this area is the extent to which a therapist’s personal trauma history is related to the development of symptoms of vicarious or secondary trauma. Pearlman and MacIan (1995) found that a therapist's trauma history was a powerful variable in this regard; i.e., therapists with a personal trauma history were found to have experienced more disruptions in their beliefs about safety, trust of self and others, and intimacy with others than those without such a history. It was also found that those with a trauma history experienced a significant increase in intrusive thoughts, avoidance of traumatic material, and overall symptomatology. The studies by Follette, et al, (1994) and Schauben and Frazier (1995), however, did not find that the therapist’s trauma history was significantly predictive of the development of secondary trauma symptoms; while Kassam-Adams (1994) distinguished between childhood and adult traumatization and found that only a history of childhood trauma was significantly associated with the development of vicarious or secondary trauma in the therapist.
In the survey of mental health professionals by Follette, et al, (1994), it was found that, for those who worked with childhood sexual abuse survivors, the use of negative coping strategies such as substance abuse, attempting to forget disclosures of traumatic material, withdrawing, etc. as well as the therapist's level of personal stress were important in the formation of post‑trauma symptoms. Pearlman and MacIan (1995) reported that therapists who were newer to trauma work experienced greater emotional and psychological difficulty. Moreover, they noted that few of the newest trauma therapists were receiving supervision and they tended to be working in hospitals where the most acutely distressed patients are seen.
The Status of Psychological Training in Evaluating and Managing Behavioral Emergencies
Despite the data on the incidence and impact of patient life-threatening behaviors on clinicians, the profession of psychology appears to have done little to prepare clinicians specifically to cope with such events. In the study by Kleespies, et al, (1993) on the stress of patient suicidal behavior during clinical training, it was reported that only an estimated 55% of a sample of former graduate students in clinical psychology had some form of didactic instruction on suicide during their graduate school years. The instruction (when given) was quite limited (i.e., one or two lectures). In a more recent survey of psychology internships and psychiatry residency programs, Ellis and Dickey (1998) found that psychology programs seemed to lag behind psychiatry programs in suicide-related training in most formats; e.g., seminars, journal clubs, case conferences, and assigned readings. Even in a format that psychology utilized more (i.e., workshops), the overall utilization rate was low. In a similar vein, Bongar and Harmatz (1991) conducted national surveys of the Council of University Directors of Clinical Psychology Programs and the National Council of Schools of Professional Psychology and found that when all the efforts of these groups were combined, only 40% of all graduate programs in clinical psychology offered some formal training in the study of suicide.
In their survey of patient violence, Guy, et al, (1990) reported that the psychologists in their sample had a mean of 1 hour of clinical training on the management of patient violence during their predoctoral training years. After graduation, the mean was 2.3 hours. Could it be that lack of adequate training is related to the findings that less experienced therapists are at greater risk from patient violence?
In terms of working with victims of violence such as sexually abused children, Alpert and Paulson (1990) reported that most professional degree programs in psychology had not incorporated child sexual abuse in their training. Moreover, in a national sample of psychologists, Pope and Feldman-Summers (1992) reported that “very poor” was the rating most frequently given to graduate training in the areas of sexual and physical abuse. Although the ratings were higher for more recent graduates, their ratings were still extremely low for both graduate school and internship training in these areas.
Kranz (1985) and Covino (1989) have suggested that psychology graduate and professional school programs have been deficient in teaching the skills needed for dealing with behavioral emergencies. Data that supports their contention has been presented in the survey of after-hours coverage in psychology training clinics by Bernstein, Feldberg, and Brown (1991) who concluded that “the current standard for training clinics in emergency coverage appears to be less than adequate” (p. 207). Twenty-five percent of the clinics in their sample provided no emergency coverage. Among those that did, there were reports of disarray in the emergency policies and procedures, concern that the services would not be sufficiently responsive, and uncertainty about continuity of student and supervisor availability, particularly during vacations and semester breaks. The authors suggested that this state of affairs reflects a general inattention to emergency services in the field of professional psychology.
As noted earlier, behavioral emergencies confront the clinician with the need to make decisions that can have very serious, possibly irreversible consequences. They can occur in virtually any clinician’s practice. They can have far reaching emotional, ethical, and legal repercussions. Society at large through our legal system holds psychologists responsible for observing a reasonable standard of care in managing behavioral emergencies. They can be held liable for negligence in malpractice litigation if their emergency care is found to be sub-standard. In this regard, if psychologists are to have a sound basis for fulfilling the duties attendant to their professional role, it seems incumbent that they be provided with explicit education and training on the evaluation and management of clinical emergencies. Some might also say that there is an issue of professional ethics involved. Psychologists are not to practice outside of their area of competence, yet is this not what may happen if it is assumed that psychologists will be able to deal with patients who are imminently suicidal or potentially violent or at serious risk of victimization without specific training on how manage such difficult and complex cases and circumstances?
Task Force Recommendations
The Surgeon General has declared suicide a major public health problem in this country, and he has issued a call to action to prevent suicide (U. S. Public Health Service, 1999). The last several decades have seen an elevated rate of youth suicide, and, in the wake of a series of school shootings, both youth violence and youth suicide have, unfortunately, emerged as matters of national concern. Domestic violence, child abuse, and violence against women have increasingly come to attention as major problem areas in the U. S. The American Psychological Association, by identifying behavioral emergencies as a core topic for professional education and training, is in a position to have a constructive impact on the education of psychologists while also supporting action on these national concerns.
As noted earlier in this report, virtually all psychology practitioners have behavioral emergencies of one type or another in their practice. It is the position of this Task Force that all practitioners need to be formally educated and trained to deal with them. There may be a number of options for achieving this goal. Kleespies (1998), in the book Emergencies in Mental Health Practice: Evaluation and Management, has developed a curriculum for teaching a knowledge base in behavioral emergencies. The curriculum is presented in Table 1. In addition to knowledge, however, psychologists need to learn the clinical skills that are required to manage life-threatening behaviors. To this end, Kleespies (1998) has also proposed a model program for teaching emergency service skills at the internship level (See Attachment A - “The domain of psychological emergencies: An overview” [Kleespies, 1998, pp. 9-21]). The Task Force recommends that the curriculum and training model proposed by Kleespies (1998) be taken as a starting point for discussion of the content and method of implementing this training at the graduate level. At the professional level, it suggests that post-doctoral courses and workshops be offered for continuing education credit. It further recommends that there be a dialogue between members of the Task Force and the APA Board of Educational Affairs to begin consideration of the case for improved education and training in the evaluation and management of behavioral emergencies.
Phillip M. Kleespies, Ph.D.
Chairperson, Task Force on Education
And Training, Section VII, APA Division 12
Task Force Members
Alan L. Berman, Ph.D.
Thomas E. Ellis, Psy.D.
Phillip M. Kleespies, Ph.D., Chair
Richard McKeon, Ph.D.
Dale McNiel, Ph.D.
Heidi Resnick, Ph.D.
Joe Scroppo, Ph.D.
Edwin S. Shneidman, Ph.D.
Anthony Spirito, Ph.D.
Robert I. Yufit, Ph.D.
Graduate Student Members
Matthew Nock, Yale University
Jason S. Spiegelman, M.A., University of Akron
Table 1. PROPOSED CURRICULUM FOR A KNOWLEDGE BASE
IN MENTAL HEALTH EMERGENCY SERVICES
1. The domain of mental health emergencies
2. Crisis theory and crisis intervention in emergencies
3. The emergency interview
4. The emergency telephone contact
II. The evaluation and management of life-threatening behavior
5. The evaluation and management of the suicidal patient
6. The evaluation and management of the violent patient
7. The evaluation and management of the victim of violence
8. The evaluation and management of the terminally ill patient who wishes to
III. Risk management in a mental health emergency
9. Risk management with the suicidal patient
10. Risk management with the violent patient
IV. Emergency-related crises and conditions
11. The evaluation and management of the self-mutilating patient
12. The evaluation and management of alcohol- and drug-related crises
V. Medical conditions presenting as mental health or behavioral crises
13. Side effects of and reactions to psychotropic drugs
14. Psychological/behavioral symptoms in neurological disorders
15. Psychological/behavioral symptoms in endocrine disorders
16. Psychological/behavioral symptoms in cardiac conditions
VI. The impact of emergency service on the clinician
17. The stress of patient suicidal behavior for the clinician
18. The stress of patient violent behavior for the clinician
19. “Vicarious traumatization” in working with victims
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