Behavioral Emergencies

A behavioral emergency is defined as a situation in which a client presents as being at imminent risk of behaving in a way that could result in serious harm or death to self or others. Discerning a behavioral emergency requires careful evaluation. Once an evaluation uncovers an imminent risk, therapists are required to respond immediately to prevent any harm from occurring.

The teaching examples presented in this video illustrate a course of action for swift and thoughtful decision-making in a stressful situation, demonstrate how to cope with stress that may result from such situations, and help distinguish a behavioral emergency from a behavioral crisis.

In this video Dr. Phillip Kleespies evaluates and manages a behavioral crisis that could develop into an emergency if not given appropriate clinical attention with a middle-aged man who is considering suicide.

This video features a client portrayed by an actor on the basis of a composite of case details.

Dr. Phillip Kleespies' approach to evaluating and managing behavioral emergencies includes the assessment of a client's behavior within one or more of the following:

• a suicidal state
• a state of potential violence toward another
• a circumstance in which a relatively defenseless individual (such as a child or a person with a disability) is at risk of being victimized
• a condition in which an individual's judgment is so impaired that he or she is unable to keep himself or herself safe from harm in the community

It has been noted that experienced decision makers can come to good decisions quite quickly and without considering all the possible alternatives. This realization, in part, gave rise to what has been referred to as the naturalistic decision making (NDM) models. These models generally posit that the experienced decision maker becomes "recognition primed" or develops a store of memories in which he or she can quickly identify a situation as similar to situations that have been experienced in the past, and he or she also recognizes a typical course of action.

If confronted with a situation for which he or she has no match, the individual tries to identify relevant features of the situation in order to place it into a known category. In this way, the decision maker can find a plausible option as one of the first considered and without needing to generate a large option set.

In at least one NDM model (the recognition/metacognition model), it is posited that there is also a process of critiquing that can identify if there are problems with the recognition or match. The NDM models of decision making are crucial to understanding what must be learned to acquire the skills necessary to become competent in the evaluation and management of behavioral emergencies.

Not only do clinicians who work with behavioral emergency cases need to have models for decision making, but they also need to be able to cope with the stress that is generated in such situations in order to minimize its potentially negative impact on their decision making. Stress training has its roots in the stress inoculation training (SIT) of Donald Meichenbaum. Meichenbaum (1985; 2007)¹ has noted that the object of stress management training is not to eliminate stress "but to encourage clients to view stressful events as problems-to-be-solved rather than as personal threats. The goal is to make clients better problem solvers to deal with future stressful events as they might arise" (Meichenbaum, 1985, p. 30)².

The SIT model was originally developed as a clinical treatment program for those struggling with pain, anger, phobias, and so forth. In an effort to extend stress training beyond the clinical domain, Johnston and Canon-Bowers (1996)³ developed a modification of the SIT model (i.e., stress exposure training or SET) to be used in training professionals who must perform tasks under high-stress conditions.

This is the model that Dr. Kleespies commonly employs while training clinicians for work with behavioral emergencies.

References

1. Meichenbaum, D. (1985). Stress inoculation training. New York, NY: Pergamon Press.
2. Meichenbaum, D. (2007). Stress Inoculation training: A preventive and treatment approach. In R. Lehrer, R. Woolfolk, & W. Sime (Eds.): Principles and practice of stress management (3rd ed.; pp. 497–516). New York, NY: Guilford Press.
3. Johnston, J., & Cannon-Bowers, J. (1996). Training for stress exposure. In J. Driskell & E. Salas (Eds.): Stress and human performance (pp. 223–256). Mahwah, NJ: Erlbaum.

Phillip M. Kleespies, PhD, is a Diplomate in Clinical Psychology of the American Board of Professional Psychology and a fellow of APA. He is a clinical psychologist at the VA Boston Healthcare System and an assistant clinical professor in the Department of Psychiatry, Boston University School of Medicine.

Dr. Kleespies was awarded his PhD in clinical psychology from Clark University in 1971. Upon graduation, he took a position as a clinical psychologist on inpatient psychiatry at the VA Medical Center in Boston.

Over the course of his 42 year career at VA Boston, Dr. Kleespies spent 31 years delivering direct clinical services to psychiatric inpatients who had serious mental illness. He also supervised interns in clinical psychology in their work with these patients. For 11 years, he was the director of psychology training for VA Boston. When the opportunity arose for the VA Boston Psychology Service to become involved in evaluating and managing patients in the emergency room (ER) who were seeking or in need of inpatient admission, Dr. Kleespies became a mental health clinician on-call to the ER and developed a training rotation for psychology interns in emergency services.

Given what he had learned in developing a training experience in emergency services for psychologists, Dr. Kleespies has edited (and been a contributing author in) two books that he organized as a curriculum for learning a knowledge base in behavioral emergencies. The first was entitled Emergencies in Mental Health Practice: Evaluation and Management (New York: Guilford Press, 1998) and the second was an enhancement of the first book and entitled Behavioral Emergencies: An Evidence-Based Resource for Evaluating and Managing Risk of Suicide, Violence, and Victimization (Washington, DC: American Psychological Association, 2009). Most recently, he has authored a book entitled Decision-Making in Behavioral Emergencies: Acquiring Skill in Evaluating and Managing High Risk Patients (Washington, DC: American Psychological Association, 2014).

In addition to publishing these works and numerous articles and book chapters on topics related to behavioral emergencies, Dr. Kleespies initiated and was the founding president of the Section VII (Emergencies and Crises) of APA Division 12 (Society of Clinical Psychology).

Dr. Kleespies has remained actively involved in the section as an advisor to the board of directors. With these activities, he has been referred to as a pioneer in the development of behavioral emergencies as an area of clinical practice for psychologists.

Although now retired from a full-time staff position, Dr. Kleespies continues to provide part-time direct service evaluating and managing patients at risk in the Urgent Care Clinic at VA Boston where he also continues to provide training for two psychology interns and a post-doctoral fellow.

• Hughes, D., and Kleespies, P. (2003). Treating Aggression in the Psychiatric Emergency Service. Journal of Clinical Psychiatry, 64 (Suppl 4), 10–15.
• Kleespies, P. (2014). Decision Making in Behavioral Emergencies: Acquiring Skill in Evaluating and Managing High Risk Patients. Washington, DC: American Psychological Association Books.
• Kleespies, P. (Ed.). (2009). Behavioral Emergencies: An Evidence-Based Resource for Evaluating and Managing Risk of Suicide, Violence, and Victimization. Washington, DC: American Psychological Association Books.
• Kleespies, P. (Ed.) (1998). Emergencies in Mental Health Practice: Evaluation and Management. New York: Guilford Publications.
• Kleespies, P., and Dettmer, E. (2000). The Stress of Patient Emergencies for the Clinician: Incidence, Impact, And Means Of Coping. Journal of Clinical Psychology, 56, 1353–1369.
• Kleespies, P., Penk, W., and Forsyth, J. (1993). The Stress of Patient Suicidal Behavior During Clinical Training: Incidence, Impact, and Recovery. Professional Psychology: Research and Practice, 24: 293–303.
• Schmitz, W., Jr., Allen, M., Feldman, B., Gutin, N., Jahn, D., Kleespies, P., Quinnett, P., & Simpson, S. (2012). Preventing Suicide through Improved Training in Suicide Risk Assessment and Care: An American Association of Suicidology Task Force Report Addressing Serious Gaps in U.S. Mental Health Training. Suicide and Life-Threatening Behavior, 42, 292–304.

APA Videos

• Accelerated Experiential Dynamic Psychotherapy (AEDP) With a Male Client
  Diana Fosha
• Adolescent Boys Who Are Suicidal
  David A. Jobes
• Adolescent Girls Who Are Suicidal
  David A. Jobes
• Attachment-Based Family Therapy
  Guy S. Diamond
• Dialectical Behavior Therapy for Adolescents With Multiple Problems
  Alec L. Miller
• Emotion-Focused Therapy for Trauma
  Sandra C. Paivio
• Men and Depression
  Fredric E. Rabinowitz

APA Books

• Attachment-Based Family Therapy for Depressed Adolescents
  Guy S. Diamond, Gary M. Diamond, and Suzanne A. Levy
• Building Psychological Resilience in Military Personnel: Theory and Practice
  Robert R. Sinclair and Thomas W. Britt
• Decision Making in Behavioral Emergencies: Acquiring Skill in Evaluating and Managing High-Risk Patients
  Phillip M. Kleespies
• Strategic Decision Making in Cognitive Behavioral Therapy
  Amy Wenzel
• The Suicidal Patient: Clinical and Legal Standards of Care (3rd. ed)
  Bruce Bongar and Glenn R. Sullivan