Behavioral Emergencies: An Evidence-Based Resource


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Book about behavioral emergencies is practical, well-organized
(May 2009 Issue)

"Behavioral Emergencies: An Evidence-Based Resource for Evaluating and Managing Suicidal Behavior, Violence, and Victimization�
Edited by Phillip M. Kleespies
American Psychological Association
Washington, D.C., 2009

By Paul Efthim, Ph.D.

Nearly one-third of psychologists in clinical practice have experienced a patient suicide. Approximately 40 percent report having been assaulted by a patient. The vast majority of practitioners at least occasionally, if not regularly, find themselves assessing suicidal and violent behavior and treating victims of violence.

Statistics this high suggest the incidence of behavioral emergencies is probably greater than commonly recognized. Although we may associate such events with hospital emergency departments and inpatient units, outpatient clinicians encounter these high-risk situations in daily practice, often with few resources to lean on.

A new edited book takes aim at "behavioral emergencies" such as suicidality, violence, and patient victimization. Psychologist Phillip Kleespies of VA Boston and Boston University School of Medicine assembled a panel of 42 contributors, including 14 from Massachusetts and Connecticut, to produce a scholarly, yet user-friendly volume on key topics in this vital area of study.

The stated goals of this 500-page book are threefold: to provide an up-to-date knowledge base, to present a model for skill development and to offer a comprehensive resource on behavioral emergencies.

Well-organized and practical, the book uses several chapters to illustrate how to assess suicidal behavior across a wide variety of populations and settings. For example, when taking a history in any clinical setting, the reader is counseled to assess dangerousness with a very broad inquiry: "Have you, at any time in your life, ever done anything that anyone could possibly have interpreted as self-destructive or even suicidal?" Such a direct, matter-of-fact approach is far more effective than vague questions such as, "Have you ever felt unsafe?" and so forth.

Later sections delve into assessment of patients where drugs, alcohol, personality disorders, serious mental illness, neurological and endocrine syndromes or medical problems may be complicating the picture. A superb chapter illustrates how self-injury can be understood as distinct from suicidal behavior in its function as a complex adaptation to traumatic experience that allows the individual to endure and carry on. Legal, ethical, and self-care considerations also receive focused and thorough attention.

Several surprises and controversies emerge from this hefty tome. For example, the authors argue that the 9/11 attacks and their aftermath have helped accelerate a trend in crisis intervention toward an almost total preoccupation with disasters, critical incidents, and traumatic stress, rather than focusing on more normative behavioral emergencies. This trend is understandable, given how trauma reverberates in the collective psyche.

However, certain clinical approaches to trauma, especially Critical Incident Stress Debriefing (CISD), do not appear helpful. Originally developed for military purposes, CISD is a single session group crisis intervention administered to first responders and others three or four days after an event. CISD emphasizes emotional ventilation, discussion of trauma symptoms and advice on how to deal with stress. Despite its growing popularity, CISD may be ineffective or in fact may be harmful due to affective flooding. The book cites research supporting an alternative approach, "psychological first aid," which calls for multiple individualized interventions offered on a voluntary basis several weeks after a traumatic event and promoting avoidance of discussing details of the event during the early phases of recovery.

This well-researched volume will serve as an excellent resource for trainees and educators as well as for clinicians who wish to increase their skill levels in handling behavioral emergencies.

Paul Efthim, Ph.D. is a licensed psychologist in full-time practice in Brookline, Mass. He holds faculty appointments at the Massachusetts School of Professional Psychology and the Boston Institute for Psychotherapy.