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REPORT ON
EDUCATION AND TRAINING IN BEHAVIORAL EMERGENCIES
by
REPORT ON
EDUCATION AND TRAINING IN BEHAVIORAL EMERGENCIES
Executive
Summary
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.
Definitions
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.
Respectfully submitted:
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
I. Foundations
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
hasten death
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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