NCMHCE Exam Review
Dangerousness and Abuse
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Executive Director, AllCEUs Counseling Education
Host: Counselor Toolbox Podcast
Objectives
– Identify the characteristics of a dangerousness assessment
– Identify factors associated with a high risk for violence
– Identify steps in preventing danger to others
– Review special cases
– Domestic violence
– Child Abuse
– Elder Abuse
– Substance Abuse
– Eating Disorders
– Emergency calls from nonclients
Dangerousness Assessment
– Identify the cause of the crisis
– Determine the probability the client will hurt someone
– Gather information using a mental status exam
– Ask the client about a history of violence and current plans
– Asses the client’s support system
Factors Associated with a High Risk
– Male
– Alcohol use
– History of violence or threats of violence
– Antisocial behavior
– History of child abuse
– Recent provocation
– Diagnoses: Substance use disorder, delirium, schizophrenia, mania, personality disorders, intermittent explosive disorder
– Agitation
– Loud or abusive speech
– Poor impulse control
– Emotional lability
Duty to Warn
– Must involve a reasonably identifiable victim and a credible threat of imminent danger
– Contact law enforcement and the intended victim
– Divulge only information necessary: You name, the client’s name and the threat (Diagnosis and other information is not necessary and still protected)
– Inform the client ahead of time if appropriate
Immediate Intervention
– Provide a calm, controlled environment
– Allow the client to vent feelings
– Build self-esteem
– Explore options for addressing the issue
– Mobilize support
– Help client understand the cause of the crisis*
– Make a no violence contract
– Ensure the client is calm prior to leaving
– If client is unable to regain composure, encourage voluntary commitment
– Use involuntary commitment as a last resort
Domestic Violence
– Indicators
– Injuries at various stages of healing
– Depression, anxiety, insomnia, nightmares, ASD
– Vague somatic complaints
– Complaints of relationship issues
– Over-dependence on partner
– History of substance abuse
– Behavioral problems in children
– If kids in the house, assess for child abuse
DV Intervention
– Use open ended questions
– “How did you get that bruise” instead of “Did your spouse do this to you-”
– If the perpetrator is present, assess for substance abuse
– For victim
– Get medical treatment as needed
– Help victim protect herself—referral, escape plan
– Challenge victim’s denial and self blame
– Help client understand the situation (cycle of violence) and their options
– Support group referral
DV Intervention
– For Perpetrator
– Break through denial
– Get commitment to a no-violence contract
– Teach anger management skills
– Support group referral
Child Abuse Indicators
– In Children
– Sudden change in behavior
– Excessive clinginess
– Regression
– Suicidal behavior
– Antisocial behavior
– Fear of adults
– Overly sexualized behavior
– Sleep disturbances
– Childhood pregnancy or STD
– School problems
– In Adults
– Unconcerned about child’s injuries
– Provides false explanations
– Conceals injuries
– Uses harsh discipline
– Has overly high expectations for the child
– Was abused as a child
– Extremely jealous or overprotective
– Lacks social support outside the family
Child Abuse Interventions
– Mandatory reporting
– Medical treatment
– Ensure safety
– Mobilize family support systems
– Refer parents to support groups
– Clarify events that caused the crisis
– Build self esteem, reduce shame and self-blame
– Support and validate positive behaviors in the parents
– Teach parenting skills or refer
– Increase parent’s understanding of the triggers and dynamics of abuse
Elder Abuse
– Mandatory Reporting
– You see the abuse
– The client tells you of abuse
– You observe physical injuries that clearly indicate abuse
– Caregiver won’t let you see client alone
– Client appears afraid of caregiver
– Types of Abuse
– Emotional
– Financial
– Physical incl. neglect
– Sexual
Elder Abuse Interventions
– Get medical assistance
– Mobilize support system and resources
– Be empathetic and validating
– Explore events leading up to the current crisis
– Help clients and caregivers identify alternate coping strategies an resources which could prevent future problems
Severe Eating Disorder or Addiction
– Conduct a mental status exam
– Assess the client’s support system
– Encourage voluntary commitment or involuntary if needed
– After the crisis is stabilized, proceed with treatment
– Refer the client to a physician for medical evaluation
– Consider involving a dietician and psychiatrist
– Instill hope
Crisis Call from a Non-Client
– Get the phone number and address of the caller
– Assess the caller’s level of crisis and ability for self-management
– Be directive and advocate for steps to ensure the caller’s safety
– Consider offering an appointment as soon as possible
Summary
– It is imperative for clinicians to be prepared for dealing with clients who may be violent or in abusive situations
– Know your ethical imperatives regarding mandatory reporting.
– Get additional training on safety practices for working with victims of abuse
– If confronted with a call from someone who is in crisis but not your client, it is your responsibility to provide initial triage and assist the individual in getting to safety.
Test Taking Tips
– Sally is a 25 year old graduate student who was recently raped. She was referred to you by victim services. Her father, a doctor, whom she is estranged from calls your office wondering how Sally is doing
– What information do you need to make a diagnosis
Test Taking Tips
– What are possible diagnoses
– GAD, ASD, PTSD, MDD, Adjustment Disorder
– What information do you need to make a diagnosis
Test Taking Tips
– You determine that Sally has Acute Stress Disorder.
– Which of the following would be appropriate referrals
Test Taking Tips
– You determine that Sally has Acute Stress Disorder.
– Which of the following would be appropriate to monitor progress-