Steps For Fostering Availability Of Help In A Crisis

Once the client clearly understands how to contact the therapist by telephone between regularly scheduled appointments, the therapist and client can discuss appropriate arrangements for situations in which this system is inadequate. The client, for example, may experience an unanticipated crisis and be unable to reach the therapist promptly by telephone because the therapist's line is busy for an extended time, the therapist's answering service mishandles the client's call, the therapist is in session with another client who is in crisis, or any number of other typical or once-in-a-lifetime delays, glitches, or human errors. For the five reasons cited at the beginning of this chapter, planning for such "unanticipated" breakdowns in communication can enable access to prompt clinical services in time of crisis and can foster more careful therapeutic planning.

If the client's need for help is urgent and the therapist is unavailable, is there a colleague who is providing coverage for the therapist? Some organization settings, such as health maintenance organizations and community mental health centers, as a matter of policy and procedure assign clinicians to serve on-call rotations so that there is always someone available to provide coverage in a crisis when a patient's therapist is unavailable. However, many therapists, particularly those in solo independent practice, may need to create and implement their own plans to ensure coverage in an emergency should they be unavailable.

The decision of whether to arrange for coverage for a specific client is complex. Perhaps the first question is what sorts of information the covering clinician will be provided about the client. Will the coverage provider receive a complete review and periodic update of the client's clinical status, treatment plan, and therapeutic progress? Will the coverage provider have access to the client's chart? Will the coverage provider keep a separate set of notes regarding information supplied by the primary therapist? To what extent will the coverage provider need to secure independent informed consent for treatment by the client? The more foreseeable or the greater the risk is that the client will experience a serious crisis demanding prompt intervention, the more compelling the reason is for the primary therapist to brief the coverage provider in a careful, thorough manner.

Once the therapist has determined what degree of coverage seems appropriate for a specific client, a second question is how to introduce the possibility of or actually implement such coverage affecting the client's status or treatment. Some clients might feel greatly reassured to know that the therapist is taking his or her responsibilities seriously and is carefully thinking through possible, even if unlikely, treatment needs. Other clients may become alarmed and feel as if the therapist is predicting that a crisis will occur. Still other clients may stall in their progress; the strict privacy and confidentiality of therapy is essential for them, and the knowledge that the therapist will be sharing the contents of sessions with the coverage provider inhibit the client's ability to explore certain issues or feelings. In many cases, discussion between the therapist and client of the question of whether specific coverage will be provided is useful therapeutically.

If it is decided that specific coverage will be provided, a third question for the therapist is what will best ensure the client's right to adequate informed consent for sharing information with the coverage provider and otherwise making arrangements for the coverage.

A fourth question addresses the selection of a clinician to provide the coverage. The primary therapist may incur legal (that is, malpractice) liability for negligence in selecting the coverage. If, for example, the clinician providing the coverage mishandles a crisis situation or otherwise harms the client through inappropriate acts or failures to act, the primary therapist may be held accountable for failure to screen and select an appropriate clinician. However, the ethical and clinical issues are much more subtle. It is important to select a clinician who is well trained to provide the type of care that the client may need. The primary therapist may be tempted to select a clinician solely (and perhaps inappropriately) on grounds of expedience. The primary therapist may know that the clinician is not a very good one and is perhaps less than scrupulous in his or her professional attitudes and actions. Furthermore, the primary therapist may be aware that the clinician does not tend to work effectively with the general client population that the therapist treats. Nevertheless, the therapist may push such uncomfortable knowledge out of awareness because this particular clinician is handy, and it might take considerable effort to locate an appropriate and trustworthy coverage provider. As in so many other situations discussed in this book, the Golden Rule seems salient. If we were the patient, or if it were our parent, spouse, or child who desperately needed help in a crisis when the primary therapist is unavailable, if the careful handling of the crisis were potentially a matter of life and death, what level of care would we believe adequate in selecting a clinician to provide the coverage? If, for example, our parent became suddenly despondent, received a totally inadequate response from the clinician providing the coverage, and committed suicide, would convenience seem sufficient rationale for the primary therapist's selection of that clinician to provide the coverage?

If no clinician has been identified to provide coverage or if the identified clinician is for some reason unavailable, to whom does the client in crisis turn when the primary therapist is unavailable? It may be useful for the client to locate a psychiatric hospital, a general hospital with psychiatric services, or other facility providing emergency psychiatric services. There are at least five crucial questions. First, is the facility nearby? Second, are the services available on a twenty-four-hour basis? (If the crisis occurs in the middle of the night, on a weekend, or on a holiday, will the client find help available?) Third, can the client afford to use the facility? Some facilities charge exceptionally high prices and may offer services only to those who can provide proof of ability to pay—for example, an insurance policy currently in effect. Fourth, does the client know where the facility is located and what its telephone number is? Especially during a crisis, even basic information (such as the name of a hospital) may be hard to remember. In some instances—for example, both the therapist and client believe that there is a high risk for a crisis—it may be useful for the client to write down the name of the hospital, the address, and the telephone number to carry with him or her and to leave by the telephone at home. Sometimes close friends or family play a vital role in supporting a client in times of crisis. If the circumstances are appropriate, the client may also wish to give this information to a close friend or relative. Fifth, both the therapist and client must have justifiable confidence that the facility provides adequate care. Substandard care may make a crisis worse; in certain instances, no care from certain facilities may be better than an inappropriate response.

If the primary therapist, secondary coverage, and designated facility are all unavailable—for whatever reason—in time of crisis, is there an appropriate hot line or other twenty-four-hour telephone service that can provide at least an immediate first-aid response to the crisis and attempt to help the client locate a currently available source of professional help? Some locales have twenty-four-hour suicide hot lines. There may be a twenty-four-hour crisis line providing help for individuals with certain kinds of problems. At a minimum, such a telephone service may help a client survive a crisis. For some clients (for example, those who cannot afford a telephone at their residence), identifying locations of telephones that will be accessible in times of crisis will be an important part of the planning.

If all of the resources noted are inaccessible to the client, the client may nevertheless be able to dial 911, the operator, or a similar general call for emergency response. The client may then be guided to sources of help, or, if appropriate, an ambulance or other emergency response may be dispatched.

Whenever a therapist is assessing a client's resources for coping with a crisis that threatens to endanger or overwhelm the client, it is important to assess not only the professional resources but also the client's social resources. Individual friends and family members may play key roles in helping a client to avert or survive a crisis (though a friend or family member can also initiate, intensify, or prolong a crisis). In some instances, nonprofessional groups, such as Alcoholics Anonymous, may provide virtually twenty-four-hour access to support. The presence of such social supports gains in relative importance when the client's access to professional help tends to be difficult. For example, some clients (especially those who cannot afford a telephone) cannot gain easy access to a telephone, particularly if they are experiencing a crisis in the middle of the night. For many clients, the awareness of such social supports helps them to feel less isolated and thus less vulnerable to becoming overwhelmed by a crisis.

It is worth noting that sometimes therapy begins with the patient in crisis and that the patient's access to a team of clinicians or care-givers may be useful. The American Psychologist presented the following case study illustrating a situation in which the immediate creation of crisis team proved helpful when a person without funds or coverage needed help:

In an instance in which a woman required daily sessions during a critical time in her life, colleagues accepted [the therapist's] request that they serve pro bono as an interdisciplinary team, offering detailed daily consultation to him and providing periodic psychological assessment and clinical interviews for the woman. Her meetings with diverse professionals let her know that many people cared about her. These colleagues mobilized to help a battered woman, a victim of multiple sexual assault, now penniless and homeless, living in her car and hiding from a stalker. She and [the therapist] began meeting daily (later gradually reduced to weekly) for crisis intervention. They agreed that the first priority was her safety. [The therapist] gave her the number of an old college friend in another state. The friend immediately wired her $500 for food and housing and an airline ticket with an open date for use any time she felt in danger from the stalker. The friend asked her not to repay this loan directly to him but rather to give the money to someone else for whom it would make a difference as it did for her now. Within a year, the woman had taken legal action against the stalker and recovered enough to support herself ["Biography," 1995,p. 242].

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