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Safety Assessment and Crisis Intervention in Private Practice: Part II
By Chris Campassi
In the first part of this blog series Safety Assessment and Crisis Intervention in Private Practice: Part I, I discussed how to work with a client who is suicidal, and how to assess for risk of Suicide, Homicide, and Grave Disability. I also talked about how to consider risk factors and protective factors when determining if a client is in need of further evaluation and possible psychiatric inpatient hospitalization.
If you have already read Part 1 of this blog series, you are likely wondering “Now that I know that my client needs further evaluation, what do I do to make sure that happens?” Below I will outline the steps you may need to take to get your client the help they need.
Steps for Getting your Client the Help they Need
Once you have determined that a client is in need of further evaluation for Inpatient Psychiatric admission, you will want to consider if the client will voluntarily go to an Emergency Room for evaluation and how to initiate an involuntary commitment if necessary. You also will want to know how to arrange transportation to an emergency department, and how to communicate your concerns with Emergency Department staff.
Understanding the sequential steps of this process will not only help you in the moment you need to initiate a hold, but will also allow you to explain to your client what to expect during the process.
Initiating an Involuntary Commitment and Transport
Once you have determined whether a client needs to go to an Emergency Room for further evaluation for Inpatient Psychiatric Admission, you will first need to determine if the client can be admitted voluntarily, or if you will need to initiate the involuntary commitment process.
If the client is unwilling to agree to voluntarily admit themselves into an Emergency Room for further evaluation, or due to mental illness are unable to reasonably consent to treatment, you will need to initiate the involuntary commitment process. This is a legal mechanism that allows certain professionals the authority to ensure that the client is kept safe and evaluated further, even if the client is not agreeable.
Know your State’s Laws and Regulations
Each state has its own laws and regulations that outline how to determine if someone legally meets the criteria for an involuntary commitment, as well as the steps that need to be taken to initiate this process. If you are provisionally licensed, review your state laws to determine if you are able to initiate this process. Most states require an MD, Law enforcement officer, psychologist or licensed mental health clinician to initiate.
As discussed in Part I of this blog, it is critical that you review your state’s regulations and laws, familiarize yourself with the forms used to initiate, and get to know the legal language that speaks to why you believe the client meets criteria for involuntary commitment.
Remember that the decision to take someone’s rights away, even if in their best interest, is a big responsibility that should be respected and only used when absolutely necessary.
Writing a “Hold”
Each state uses different language and processes, but most share common language and phrases, such as “imminent risk”, “danger to self or others”, and “grave disability” to outline the definition and criteria for involuntary commitment.
Understanding the language will make it easier for you to write what is often called a “72-hour hold” or “mental health hold”. Oftentimes these terms refer to the legal form that you use to initiate this process. In filling out these forms, it is important to remember that this is a legal document with which you are making the case for a restriction of someone’s liberty and freedom.
It is critical in writing the hold that you are thorough and accurate with demographics, and concise and clear with your rationale for placing this individual on a hold.
Being concise, presenting client statements, your observations and any collateral information from family or community members, and using the legal phrases in your state’s regulations will ensure that you made a sound legal case for why you are restricting their freedoms. It will also provide information to the transporting entities and staff at the receiving hospital, who will be taking over your client’s care.
Involuntary Admission and Transport
In the event that you are going to initiate an involuntary admission, you will want to not only write the hold, but you will also need to call “911” to dispatch an ambulance and most often a law enforcement officer to the client’s location to coordinate transportation. Note that some states allow for ambulance transport of an involuntary client without law enforcement involvement, and others require either their presence or that they actually provide the transport.
In the event that you are a provisionally licensed therapist and there is not an onsite licensed clinician to initiate the paperwork, you can provide your clinical rationale for involuntary commitment to a law enforcement officer and request that they initiate the hold.
Once again, each state is different, and it is important that you understand your state’s resources and regulations. Some communities also have a Mobile Crisis Team that works independently of Law Enforcement. In other communities, Mobile Crisis works in concert with a Law Enforcement Mental health team. If you have these resources in your community, request assistance in making these decisions. Remember, they do this everyday and this is something that you hopefully only do on occasion.
Once the appropriate arrangements have been made, the client will be transported by the appropriate entity to the nearest Emergency Department, and their care will then be transferred into the care of the emergency room team. The involuntary commitment paperwork will be signed to reflect this change in responsibility.
Voluntary Admission and Transport
In some cases, it may be appropriate to coordinate with a friend, spouse or loved one to transport the client to an Emergency Room for further assessment, or to arrange a non-emergent ambulance ride for transportation to the Emergency Room.
If the client does wish to go with a trusted friend or family, it is recommended that you have a clear plan with the client and trusted party as to what Emergency Department they will go to and in what timeframe. I recommend following up with the Emergency Room after 1 hour to determine if they have admitted yet. If the client has not yet admitted, contact the client and trusted party. If you are unable to locate the client, call law enforcement, explain the situation and request a welfare check on the client.
If the client is willing to go voluntarily but is unable to arrange for transportation, you may call the non-emergency police department number in your jurisdiction and request a transport for a voluntary client needing a mental health evaluation. This is typically the preferred method, as the ambulance will not use sirens as they would in the case of a 911 call, and you can also be assured that the ambulance will ensure that they are admitted appropriately.
Coordination of Care
Once a client has been picked up for transport, call the Emergency Room where they will be admitted. You will want to provide basic demographic and concise clinical information as well as your recommendation for further psychiatric evaluation and possible inpatient admission.
Remember that you will likely be speaking with a nurse who is dispatching numerous medical emergencies. This person will have limited time and feedback. Provide the basic information for admission and then follow up with the psychiatric team, if there is one on-site.
After you have spoken with the Emergency Department nurse, it is recommended that you also try to speak with the Psychiatric Intake clinician (if available). They also are likely quite busy and understaffed, so again just provide basic information and your contact information so they can follow up with you once they see the client and are able to do the evaluation. Just note that the client will not see a psych intake clinician until after they have been medically cleared, which often takes several hours.
What the Client will Experience in the Emergency Room
It is helpful to fully understand the process the client will go through once they get to the Emergency Department. Having this knowledge will help you understand what to expect for yourself, but will also allow you to explain and answer any questions your client may have, as they will likely be anxious about going to the emergency room.
Once a client has been admitted to the Emergency Room, they will see numerous people over the course of several hours (expect this process to take at least 4-6 hours).
Please remember that the Emergency Department’s primary role in the community is to treat medical emergencies, which means that any medical emergency is going to take some precedence over mental health emergencies. See below for the steps the Emergency Room will take:
- The client will first be seen by a triage nurse, who will do a general medical and mental health screening
- The client will likely be asked to change into hospital scrubs, their clothes and belongings given to security, and they will likely be given a room on a locked Behavioral Health unit within the Emergency Room (if one is present)
- The client will likely not be able to use their cellphone, but will be given access to a phone on the unit to make phone calls
- The client will need to submit a Urinalysis test for substances, a Blood Alcohol Level for alcohol intoxication, and blood work to determine if there are any medical causes of what they are experiencing
- The client will be examined by a Physician, Physician Assistant or Nurse Practitioner, who will ultimately determine if client is “Medically cleared”, having ruled out any acute medical issues
- If a client is intoxicated on alcohol or another substance, the client will likely not be medically cleared until they are no longer intoxicated
- Once medically cleared, they will be referred to the Psych Intake team for evaluation (Please note that they may have several clients ahead of your client, awaiting assessment)
- Once a Psych Intake clinician is able to assess a client, they will then want to speak with any collateral sources of information, including yourself and family. Again, please note that this call could come in the middle of the night, so keep your phone on and be ready to be available.
- After the Psych Intake clinician has made a determination, the client disposition will be determined, unless the Psych Intake clinician feels that the client needs to be seen by a psychiatrist for final decision making
- Once a determination is made, the client will either be discharged home, held overnight for further observation, or referred for inpatient psychiatric hospital admission
- If client is admitted to Inpatient, the psych intake team will coordinate transport
- The intake team should inform you of this transfer, but if it happens in middle of the night, you may not receive a call and should follow up the next day
- If they determine that the client will be discharged, they will call you and ask that you set up a follow-up appointment within 48 hours of discharge. If you are unable to schedule, please consider a phone call with the client to check in and schedule the next appt.
- Remember that once you send a client for evaluation, the Emergency Room is in charge of their care. You can provide information and your opinion, but they will make the final decision, based on their evaluation and client’s presentation when they see them which may be different than when you saw the client last
Follow up and Debriefing
Whether the client is discharged from the Emergency Room or admitted to Inpatient Hospitalization, you will be contacted and requested to provide a follow-up appointment. It is recommended that you at least schedule a phone call within 48 hours to check in with the client and schedule an appointment.
Once you see your client, it will be important to debrief on the experience. The client may have had a traumatic experience, having been exposed to others with severe mental illness, psychosis or severe substance dependence. The client may also feel some resentment towards you for your role in the process. In most cases, the rapport can be repaired, but that will require you to be intentional about processing the experience and rebuilding that relationship.
While it may feel horrible to make these decisions, and while the client may be upset, always remember that an “Upset client is a client that is Alive”, and you can work through this with the client in a way that helps them understand that your care for them is so strong that you are willing to make hard decisions to ensure their safety and well-being. You will be surprised to find that most clients actually appreciate you more than they will resent you.
Safety Risk and Crisis Intervention Consultation
Staying sharp with safety assessment and crisis intervention skills is difficult when you do not face these situations regularly. Many therapists in private practice rarely, or never, have had to intervene and place someone on an involuntary commitment.
However, on any given day, your next intake or a client in crisis may require you to get them the help they need. If you are feeling unsure about your skill set and would like individual consultation, or if your private practice would like a training on these topics, please reach out to Firelight Supervision for consultation or for a Risk Assessment & Safety Intervention training.
Community in Private Practice
Here at Firelight Supervision, we are building a space of community and support for YOU! We offer virtual consultation groups as well as individual consultation. We have several Approved Clinical Supervisors that you can choose from, or you can work with several different supervisors. You have the option of either rotating supervisors to meet your current needs, or by seeing one individually and one in a consultation group. Our clinical supervisors are all unique in their style and modalities, so you can find someone that you can connect with and can meet your clinical needs.
And the best part is, everything is virtual, so no need to leave your office and disrupt your own client schedule. You can get the support you need from the comfort of your own office, or home!
How we can help
Sign up for our Burnout Prevention Check-List Email Series. You can also sign up for a free phone consultation to discuss options and learn more about us!
Author Bio
Chris Campassi is an Approved Clinical Supervisor (ACS) and Program Coordinator of Firelight Supervision. He is a licensed psychotherapist in Colorado and North Carolina, blogger, and clinical supervisor for provisionally-licensed and independently licensed therapists. Chris enjoys helping men, medical professionals, and former athletes manage their anxiety and stress so they can live fulfilled and balanced lives. Follow Firelight Supervision on Instagram and Facebook.
