Managing crisis situations, domain 5

A teletherapy client with two psychiatric hospitalizations in the past year reported worsening depression last session but denied a plan. He misses today's session and has not answered calls or texts for two days. At intake he signed an emergency plan naming his sister. What should the therapist do NEXT?

1. Send a letter and wait for him to reschedule
   A letter and waiting leave a high-risk client unchecked for days.
2. Contact his sister per the emergency plan
   A high-risk client out of contact for two days triggers the emergency plan made at intake: the therapist contacts the named sister and escalates to a welfare check if needed.
3. Close the case after documenting the attempts
   Closing the case after logging the calls abandons a client who may be in danger.
4. Wait a week to use the emergency plan
   Waiting another week leaves a high-risk client unchecked; the emergency plan exists for exactly this kind of silence.

A Muslim family seeks help after their mosque was vandalized with threatening graffiti. The father says the imam and their congregation have been the family's main support. Which approach BEST reflects culturally responsive crisis work?

1. Encourage time away from the mosque until fear eases
   Staying away from the mosque cuts the family off from its main support after an attack aimed at its identity.
2. Draw on their faith community as they wish
   Culturally responsive crisis work builds on the family's own sources of support, so the therapist involves their faith community in the ways the family chooses.
3. Explore whether their faith is adding to their anxiety
   Questioning whether their faith adds to their anxiety pathologizes the family's main source of strength.
4. Apply a standard trauma protocol without changes
   A standard protocol applied without changes ignores the meaning of a hate-based attack and the family's own resources.

A couple enters therapy one month after their infant died of sudden infant death syndrome. The wife cries daily and wants to talk about the baby; the husband has thrown himself into work and rarely mentions the loss. Each feels the other is grieving "wrong." What should the therapist do FIRST?

1. Challenge their guilt with cognitive restructuring
   Cognitive restructuring assumes distorted thoughts to correct; the problem described is mutual misreading of grief styles.
2. Set a timeline for moving through the grief
   Grief does not follow a set timeline; imposing one adds pressure and judgment.
3. Begin trauma processing of the night the baby died
   Trauma processing of the night of the death comes later, if at all, and skips the strain between the partners.
4. Normalize their different ways of grieving
   Partners often grieve differently, one expressive and one action-oriented, and misreading the difference strains the couple, so the first step is to normalize both styles.

After immigration raids in their neighborhood, a mixed-status family's children are too scared to go to school, fearing their parents will be taken. What is the MOST helpful intervention?

1. Encourage the parents to avoid talking about the raids
   Avoiding all talk of the raids leaves the children alone with their fear.
2. Treat each child individually for separation anxiety disorder
   Diagnosing separation anxiety disorder treats a realistic fear as individual pathology.
3. Help the family build a written care plan for the children
   A written care plan naming who will look after the children if a parent is detained restores some control, which is what helps after a community-level threat.
4. Tell the children that nothing bad will happen to their parents
   Promising nothing bad will happen is false reassurance the parents cannot guarantee, and it erodes trust.

At intake for couples therapy, a therapist wants a standardized measure of physical, psychological, and sexual aggression between the partners. Which instrument BEST fits this purpose?

1. Family Adaptability and Cohesion Scales IV
   FACES IV measures family cohesion and flexibility, not partner aggression.
2. Danger Assessment
   The Danger Assessment estimates the risk of intimate partner homicide in a known abusive relationship; it is not a general intake measure of aggression types.
3. Dyadic Adjustment Scale
   The Dyadic Adjustment Scale measures relationship adjustment and satisfaction, not aggression.
4. Revised Conflict Tactics Scales
   The Revised Conflict Tactics Scales (CTS2) measure physical assault, psychological aggression and sexual coercion between partners; each partner completes it separately.

A therapist treating a woman who left an abusive partner receives voicemails from the partner saying he knows where the office is and "will be waiting." What is the MOST appropriate response?

1. Delete the messages and keep them private
   Deleting the messages destroys evidence and keeps others who could protect the office uninformed.
2. End treatment so he has no reason to come
   Ending treatment abandons the client and rewards the abuser's intimidation.
3. Make a safety plan and notify the police
   A specific threat from outside the client system calls for a safety plan for the office (staff, building security, keeping the voicemails) and a report to police, plus an update of the client's own safety plan.
4. Call him back to calm him and set limits
   Calling him back can escalate the danger and confirms contact with someone who is threatening the practice.

A woman describes several incidents of partner violence. Which history MOST strongly signals a raised risk that she could be killed by her partner?

1. He has choked her until she nearly passed out
   Non-fatal strangulation is one of the strongest predictors of later intimate partner homicide, alongside threats to kill, gun access and recent separation.
2. He drinks heavily on weekends with his friends
   Heavy drinking is a risk factor for violence, but weekend drinking with friends is a much weaker lethality signal than strangulation.
3. He has been jealous since the start of the relationship
   Jealousy from the start is a warning sign of control, but on its own it is weaker evidence of lethal risk than strangulation.
4. He often yells and insults her during arguments
   Yelling and insults are verbal abuse and need attention, but they do not carry the homicide risk that strangulation does.

A woman says her husband controls all the money, keeps the car keys, and checks her phone. He has never hit her, but she says she is "scared of what he'll do" if she pushes back. What is the therapist's BEST next step?

1. Refer her to financial counseling to regain independence
   Financial counseling treats coercive control as a money-skills problem and skips the safety assessment.
2. Invite him in for a couples session on the dynamics
   Inviting him in for couple sessions is contraindicated when coercive control and fear are present; what she says there could put her at risk.
3. Assess her danger and build a safety plan together
   Control of money, car and phone plus her fear of his reaction mark coercive control, a risk factor for later violence, so the therapist assesses danger and safety-plans with her.
4. Encourage her to confront him about his control
   Encouraging her to confront him could provoke the very reaction she fears.

A husband completed a batterer intervention program, there has been no violence for a year, and the wife says she no longer fears him. They now request couple therapy. What should the therapist do FIRST?

1. Screen each partner separately for current risk
   Before any conjoint work after IPV, each partner is screened separately, where the wife can speak freely about current risk and fear.
2. Assess risk with both partners in the same room
   Assessing risk with both partners in the same room is exactly the setting in which a victim may not speak freely.
3. Begin conjoint therapy right away
   Starting conjoint therapy right away treats a completed batterer program as proof of safety; the program ending is not a current risk assessment.
4. Decline any form of couple therapy
   Declining any form of couple therapy is a blanket refusal that ignores specialized conjoint protocols for carefully screened couples.

During a family session with both parents present, a 7-year-old suddenly says her uncle "touches her private parts" when he babysits. What is the therapist's MOST appropriate immediate response?

1. Calmly acknowledge it without probing
   The therapist receives the disclosure calmly, without leading questions that could contaminate a forensic interview, then makes the mandated report.
2. Ask the parents what they know about the uncle
   Turning to the parents about the uncle in front of the child shifts the focus away from her disclosure and may pressure her before a report is made.
3. Praise her and move on to reduce the discomfort
   Praising her and moving on dismisses a disclosure that the therapist is required to report.
4. Question her in detail to confirm what happened
   Detailed questioning is investigation, the job of trained forensic interviewers; leading questions can taint the child's account.

In an individual check-in during couples therapy, a husband reveals passive suicidal thoughts and asks the therapist not to tell his wife. He denies a plan or intent. What is the BEST response?

1. Assess his risk and explore his wish for secrecy
   The therapist first assesses his suicide risk; without imminent danger the confidence holds, and exploring his wish for secrecy may lead him to tell his wife himself.
2. Tell his wife in the next joint session
   Telling his wife without his permission breaks his individual confidence (AAMFT 2.2) when there is no imminent danger.
3. Promise him that nothing he says will be shared
   Promising that nothing will be shared is false: confidentiality has limits if his risk rises.
4. Stop couples work and refer him for individual therapy
   Stopping couples work is premature; passive ideation is assessed and monitored, not a reason to end the conjoint work.

Before ending therapy with a family in which the father was violent toward the mother two years ago, which factor is MOST critical to assess?

1. The couple's satisfaction with the relationship
   Relationship satisfaction can coexist with ongoing coercion or fear, so it does not show the mother is safe.
2. Current safety and a working safety plan
   With a history of violence, current safety and a working safety plan must be confirmed before ending.
3. Whether the father has expressed remorse
   Remorse is common in the cycle of abuse and does not predict future safety.
4. The family's skill at resolving conflicts
   Conflict-resolution skills matter, but they come after safety has been confirmed.

A mother calls her family therapist to say her 24-year-old son with schizophrenia has been awake for two days, is shouting at voices and is frightening his younger siblings. He has no weapons and has not hurt anyone. What should the therapist advise FIRST?

1. Lock him in his room until he calms down
   Locking him in his room is unsafe and can escalate his fear and agitation.
2. Wait until the family's next scheduled session
   Waiting for the next session ignores two days without sleep and escalating symptoms.
3. Call 988 or the local mobile crisis team
   A worsening psychotic episode without weapons or violence fits a mobile crisis response, reached through 988 or the local crisis line, which can assess him at home.
4. Drive him to his psychiatrist's office right away
   Driving an agitated, psychotic young man to an office puts the family at risk in a car and may not reach the right level of care.

A family comes in the day after their 14-year-old was arrested for shoplifting. The parents are furious and the teen sits in silence. Which goal is MOST realistic for this crisis session?

1. Find out exactly why the teen chose to shoplift
   Pressing a silent, defensive teen for his motives now tends to deepen the standoff.
2. Agree on a long-term treatment contract with each member
   A long-term contract with each member comes after the crisis has settled.
3. Lower the tension enough to plan the next few days
   A crisis session aims to restore stability: lower the tension and agree on concrete steps for the next few days.
4. Resolve the parents' long-standing marital conflict
   A long-standing marital conflict is a later target, if relevant, not something to resolve the day after an arrest.

A family is assessed after a tornado destroyed their neighborhood. From a family systems perspective, which area is MOST important to assess?

1. Which member seems the most distressed
   Picking the most distressed member singles out an identified patient instead of looking at the system.
2. The disaster's financial toll
   Financial impact is real, but it is one stressor, not the family's organization.
3. How the household's daily life has changed
   A systemic assessment looks at how the disaster changed the family's organization: roles, routines and relationships, which shows where to rebuild stability.
4. Each member's individual trauma symptoms
   Individual trauma symptoms matter, but listing them member by member is an individual lens, not a systemic one.