The Sequential Intercept Model was developed by Mark Munetz and Patricia Griffin (2006) to help communities understand the way people with mental health issues interact with the criminal justice system and to target interventions to prevent people from getting deeper involved in the system.
The Sequential Intercept Model is usually focused around 5 broad target points, or areas where people with mental health issues may find themselves in contact with police or legal officials.
The five Intercepts are:
Initial Detention / Court Hearings
Jail / Court
The model was based on ensuring that people with mental health issues are not forced into the criminal justice system at greater rates than people without mental health issues.
Law Enforcement and Emergency Services
Noting that up to 10% of police calls by patrol officers involve mental health issues (Cordner, 2006), the first interception point is front-line police and emergency services workers. Munetz & Griffin (2006) describe several strategies to help intervene at this point:
Mobile Crisis Teams of mental health workers
Employing mental health workers as civilians in the Police Service
Pairing police officers with mental health workers to go on patrol calls
Specially trained mental health police officers
All of these approaches involve combining front-line policing with mental health support to ensure that sensitivity is respected. Emergency services may also respond to mental health issues where individuals are psychotic or otherwise struggling with a connection to reality, which can put these staff in danger.
Initial Detention / Court Hearings
After an individual has been arrested, the next interception point of the sequential intercept model is initial detention and hearings post-arrest. Individuals may be diverted at this point to programs for non-violent, low level crime (such as petty theft or trespassing) based on the symptoms of their mental illness.
Diverting this individual to mental health treatment can avoid exacerbating their mental health issues. Additionally the court may “employ mental health workers to assess individuals after arrest in the jail or the courthouse and advise the court about the possible presence of mental illness and options for assessment and treatment, which could include diversion alternatives or treatment as a condition of probation.”
Jail / Court
Individuals who have mental illnesses and get involved in the criminal justice system are likely to spend a significantly longer jail term than individuals with the same charges who do not have mental illnesses. (Hoke, 2015) For this reason, the third intercept point is the jail or court system, where many individuals with mental illness are managed.
One important opportunity is the establishment of Mental Health Courts set up specifically for people with diagnosed mental illnesses relevant to their crimes.
After an individual has exited the court system (if on probation) or jail (if sentenced to serve time), it is time for them to re-enter society. Transition points like this are times where an individual may be feeling the least supported and at greatest risk of suicide (Pease, Billera & Gerard, 2016) or of reoffending. (Caudill & Trulson, 2016) Discharge planning is common in hospitals but not in jail, which can make continuing care difficult for clients who are released from jail.
One potential model for solving this noted by Munetz & Griffin is the APIC (Assess, Plan, Identify, and Coordinate) Model by Osher, Steadman & Barr (2003). This plan “highlights the importance of collaboration among multi-sectoral community partners to ensure that the community is committed to the transition process.” (Evidence Exchange Network, 2014)
The final intercept in the Sequential Intercept Model is community corrections, which is probation or parole. Since mental health treatment is often a condition of staying out of jail, these individuals represent an excellent opportunity to help those in the criminal justice system continue to access care, despite the adversarial nature of the parole/probation relationship.
Caudill, J. W., & Trulson, C. R. (2016). The hazards of premature release: Recidivism outcomes of blended-sentenced juvenile homicide offenders. Journal Of Criminal Justice, 46219-227. doi:10.1016/j.jcrimjus.2016.05.009
All mental health professionals in the US and Canada have an ethical duty to warn, the requirement to warn someone who is at risk of harm of that harm. This leads clinicians to conduct homicide risk assessments to determine the level of danger to others.
In therapy or crisis intervention, the clinician is required to breach a client’s confidentiality in order to make notifications for both homicide risk and suicide. The homicide notification was codified in Tarasoff v. Regents of the University of California (1976), a famous case where a psychologist was held liable after failure to take adequate steps to protect a woman that a client had confessed the desire to kill, when he did.
Borum & Reddy (2001) enumerated a variety of steps to performing a homicide risk assessment in a Tarasoff-style risk assessment, which is differentiated from a more long-term risk assessment by a focus on on clinical judgement than on an examination of actuarial risk factors. The ACTION steps below are used to perform the assessment.
To start, it’s important to clarify the difference between making a threat, and posing a threat. Someone who says they wish to hurt someone may not pose intent or take action that demonstrates an actual risk. Preparatory behaviours help guide the risk assessment, and include selecting a target, choosing the method, time and place of violence, acquiring means, and so on.
The goals of the Tarasoff homicide risk assessment will be:
Is the client headed towards a violent act?
How fast is the client moving towards that act, and do opportunities exist for intervention?
ACTION Steps for Tarasoff Homicide Risk Assessment
Attitudes in support of violence
Is the client demonstrating any antisocial attitudes or beliefs? If the client is at risk of harming their partner, do they hold misogynistic or patriarchal beliefs? The goal here is to determine whether the client believes that violence is a justified or normal response to this situation. The more justified the client believes he or she is, the higher the risk of violence.
Borum & Reddy also identify other factors to explore under attitudes:
Hostile attribution bias
Expectations about success of violence
Whether the client feels it will accomplish their goal
Capacity to carry out threat
Does the client have access to the means, and the intellectual capacity to carry out a criminal, violent act? They also need access to the target and opportunity. Stalking often precedes violent acts (Meloy, 2002) and this can lead to an individual learning about the target’s schedule and whereabouts.
Thresholds crossed in progression of behaviour
Any presence of lawbreaking indicates a “willingness and ability to engage in antisocial behavior to accomplish one’s objective.” Additionally, any kind of plan and preparatory behaviours to achieve this plan should be explored.
Intent to act vs. threats alone
It’s important to clarify the difference between an actual intent to act versus simple threats. On the distress line, we clarify with callers who make violent comments whether they actually intend to harm the person they’re speaking about, or whether their comments are a result of frustration.
Questioning the client helps suss out their intent, in addition to any preparatory behaviours, alternative plans to accomplish their aim (that may or may not involve violence.) A client who believes there is no other way to meet their goals are more likely to turn to violence.
Other’s knowledge of the client
Knowing how others respond to the client’s planned actions will help assess their potential for action. If many people around them respond negatively to their plan they may be less likely to follow through. On the opposite side, if their supports provide little resistance this can increase risk. The client’s self-report can also help inform their attitudes.
Non-compliance with strategies to reduce risk
Is the client willing and interested in reducing their chance of committing a violent act? If they have previously breached legal requirements like parole or court orders, or demonstrate a willingness to do so in the future, this raises their risk.
Appreciating the gravity of their mental health status and desire for treatment may also be important.
Borum, R. & Reddy, M. (2001) Assessing violence risk in tarasoff situations: A fact-based model of inquiry. Behavioral Sciences and the Law. 19:375-385. doi: 10.1002/bsl.447
Meloy, J. (2002). “Stalking and violence.” In J. Boon and L. Sheridan (eds.) Stalking and psychosexual obsession: Psychological perspectives for prevention, polcing, and treatment. West Sussex, UK: John Wiley & Sons, Ltd
Tarasoff v. Regents of the University of California, 131 Cal. Rptr. 14 (Cal. 1976)
One issue that comes up very commonly in the “men’s issues” movement is an alleged bias in the Family Court system. Some men maintain that women are awarded custody, alimony/spousal support and/or child support more often and in higher amounts than themselves for no good reason.
A Bias in the Law?
The Department of Justice, in their 2002 report “Putting Children First” noted their opinion that there was no bias on the part of the legislation itself, while also conceding “while the law may be gender neutral, in a majority of cases the mother is a sole custodian or, in a joint custody arrangement, she is the primary caregiver with the father having the role of an access parent.”
This report goes on to state “There is no reason to believe that this gender differentiation is a result of systemic bias in the Canadian courts. It is more likely that in the vast majority of cases the parties have themselves agreed on this arrangement. The social realities or parents’ perceptions regarding parenting roles may be responsible.”
As the “tender years” doctrine (which stated that mothers should be the sole breadwinners) has fallen out of favour in place of the “best interests of the child” doctrine, at least on paper, one can assume that there is no de jure bias in the laws as written. As judges still have control over awards, however, bias may still exist.
Prevalence of Sole Mother Custody
The most common point brought up is that women are often chosen as the custodial parent when a relationship dissolves. The research seems to indicate that this is true.
A research report by Le Bourdais, Juby & Marcil-Gratton (1999) notes the following breakdown of custody:
81 percent sole mother
7 percent sole father
13 percent shared custody
This suggests that while the majority of the time the woman is awarded custody, there is no information provided about the way that custody was determined. For that information, we turn to the National Longitudinal Survey of Children and Youth (NLSCY).
The NLSCY, recorded in a Department of Justice report (2000) notes that in 1995, slightly more than half of relationships (52%) where custody was established did not involve a court order. This may suggest that men are choosing to give up custody voluntarily. The same report, however, also notes that in cases where a court order did exist, almost 80% of the time a court order was established, the mother was granted sole custody.
The large mother sole custody number drops slightly (but still substantially) when the child gets older, with 80.6% of mothers of children 0-5 being given sole custody, while only 74% of mothers of children 6-11 did.
Another interesting element from this survey is that contact with fathers drops the longer the relationship has been broken up. I won’t speculate on the reasons for this.
Two questions that I don’t believe have existing data to answer them include whether men apply for custody less often, and whether men win custody more often when they apply for it.
One argument is that men are counselled by family lawyer they are unlikely to win if they do apply, and secondly that only those with so-called “slam dunk” cases will even bother. This could explain some of the disparities claimed in other countries where men who ask for custody are more likely to win than women — but where men simply don’t contest custody.
Alimony / Spousal Support and Child Support
Alimony or spousal support is money that is paid to a spouse (an ex-husband or ex-wife) after a divorce. It is usually time-limited, and designed to compensate the spouse who gave up earning power during the marriage (often to raise children.)
Kelly (2013), using data from the 2011 General Social Survey noted that 96% of spousal and child support awards in Canada were paid by the father to the mother. This is interesting when you consider that according to the US Bureau of Labour Statistics (2013), 38% of women outearned their husbands. Similar numbers are reported in Canada (Sussman & Bonnell, 2006) and England. (Ben-Galim & Thompson, 2013)
Despite men being eligible for spousal support, it is awarded less often. It’s unclear from the research whether this is the result of men not applying for alimony or spousal support – or whether judges, who have significant discretion over awards, are choosing not to give it to men.
Ben-Galim, D., Thompson, S. (2013) Who’s Breadwinning? Working Mothers and the New Face of Family Support. Institute for Public Policy Research.
Labor Force Statistics from the Current Population Survey. Bureau of Labour Statistics. (2013) Accessed electronically on Nov 2, 2015 from http://www.bls.gov/cps/wives_earn_more.htm
Selected Statistics on Canadian Families and Family Law: Second Edition. (2000) Department of Justice. Accessed electronically on Nov 2, 2015 from http://www.justice.gc.ca/eng/rp-pr/fl-lf/famil/stat2000/index.html
Final Federal-Provincial-Territorial Report on Custody and Access and Child Support: .Putting Children First. (2002) Department of Justice. Accessed electronically from http://justice.gc.ca/eng/rp-pr/fl-lf/famil/flc2002/pdf/flc2002.pdf.
Kelly, M.B. (2013) Payment patterns of child and spousal support. Juristat. Accessed electronically on Nov 2 2015 from http://www.statcan.gc.ca/pub/85-002-x/2013001/article/11780-eng.htm.
Le Bourdais, C., Juby, H., Marcil-Gratton, N. Keeping Contact with Children: Assessing the Father/Child Post-separation Relationship from the Male Perspective (1999) Department of Justice. Accessed electronically on October 21 from http://www.justice.gc.ca/eng/rp-pr/fl-lf/divorce/2000_3/pdf/2000_3.pdf.
Sussman, D., Bonnell, S. (2006) Wives as primary breadwinners. Perspectives on Labour and Income. 7(8)
As a volunteer or paid helpline worker, we all endeavour to improve our work on the lines. Whether you have 100 or 1000 hours on your helpline there will always be things you can learn and strategies that you can apply to better connect with callers.
Listed below are a few strategies you can implement immediately and over your next few shifts to improve your work on the lines.
More Accurate Reflections
WHAT ARE THEY: Reflections, as you may recall, are restatements of what a caller has said with a focus on their feelings and emotional state.
EXAMPLE: If someone tells you there dog has just passed away, a paraphrase (which focuses on content rather than emotion) might be “You had to put your dog down”, while a reflection, which focuses on the emotional message behind the words may be “You’re feeling very alone.” (Or another emotion they’ve displayed depending on the context.)
HOW TO IMPROVE: Improving your reflections starts with learning more emotional words. Keeping a list of emotional words (which is perhaps a bit too big) can help you learn to use words like chaotic, shocked, neglected and empty more often than common emotional reflections like “frustrated” and “stuck” which we may rely on unintentionally when we can’t think of anything.
Additionally, there has been some support (e.g. Naar & Suarez, 2011) for the idea that dropping the “stems” may improve how people feel about reflections. Stems are things like, “It sounds like. . .”, “What I’m hearing is . . .” and so on. Since I haven’t seen any definitive research examining this I’ll leave it up to you. While stems help demonstrate to others that you’re using empathy, they may leave the caller feeling a bit alienated and “therapized.”
More Effective Suicide Risk Assessments
WHAT IS IT: Suicide risk assessment, of course, is assessing a person’s danger level and likelihood of attempting suicide in the near future. It is certainly a scary topic for both the caller and the helpline worker who is responding. Unfortunately, a lack of confidence and sometimes cause workers to simply shy away from the subject entirely, which can cause them undue anxiety and prevent workers from being the most effective.
Improving your suicide risk assessment skill will increase your ability to work with callers safely and make you a more confident helpline worker.
EXAMPLE: A caller tells you that they’re feeling stressed out and when they get like this they sometimes “have bad thoughts.”
HOW TO IMPROVE: The first step is to assess exactly where your knowledge of suicide risk is. Using a tool like the Suicide Intervention Response Inventory can help you learn where you make mistakes and what part of suicide risk you need to improve on.
Mishara (2011), noted that a lot of Centres certified by the American Association of Suicidology (who should be required to ask clients about suicide on every call) actually only asked less than 50% of the time. His research determined that the failure to ask clients about suicide meant they missed suicide attempts in progress (who later identified during the call they were attempting on the line) and likely missed other suicidal clients who may go on later to attempt.
Learn Strategies for Specific Crisis Situations
WHAT IS IT: Specific crisis situations sometimes call for specific, directive information. Beyond connecting individuals with appropriate referrals, gaining an understanding of domestic violence, financial issues, child custody concerns or the emotions surrounding breakups can improve.
EXAMPLE: A 30 year old caller with $20,000 in personal debt calls in and tells you that he has just lost his job.
HOW TO IMPROVE: The Distress Centres of Ontario (DCO) offers a website called Learning Forums for participating organizations, these are 30-60 minute videos that volunteers can watch taught by experts. If you don’t have access to this kind of resource, you can still learn helpful strategies from websites like YouTube.
Listed below are some YouTube videos on topics relevant to helpline work:
While it is well known that adolescents can struggle through turbulent periods of mental health, although very rarely do we consider the suicide risk of younger children. In fact, in Canada the coroner can’t declare a suicide of anyone aged 9 or under (Statistics Canada, 2014) these deaths are likely classified accidents.
The suicide rate in children has remained relatively steady in the period between 2007 and 2011, the most recent year that Statistics Canada data is available. (Statistics Canada, 2014) The suicide rate in children and young adults aged 10-19 was a low of 5.89% of the total suicide rate in 2010 and a high of 6.29% in 2008.
Because children and young adults are often relatively healthy, suicide is the second leading cause of death for Canadians aged 1-24 at 20% of deaths, behind accidents at 35% (Statistics Canada, 2011). It is suspected that the suicide rate is in fact under-reported, because most provinces require the coroner to rule out all other causes of death first (Casey & Hunter, 2011), leaving a number of likely suicides classified as accidents.
Because children’s health and welfare is the responsibility of their parents, it is often easier for parents to access supports than for other populations. Parents can take their children to their family physician, the ER/local hospital or to agencies focused on children’s and youth mental health.
Girls and women tend to have a higher rate of suicide attempts, than boys and men, often two to three times higher (Statistics Canada, 2012) however men die much more often. (Statistics Canada, 2014) This is due to their choice of suicide method; while women tend to favour poisoning, which is often non-lethal, men tend to favour hanging or – especially in the United States – firearms, which are more lethal.
This trend is changing however, the rate of hanging in women has increased by several percent in recent years. (Statistics Canada, 2012)
Most youth suicides happen at night and in the home, where access to the suicide method is available (Miller & Eckert, 2009) with the lethality of the suicide attempt roughly corresponding with the intent to die (Berman et. al., 2006) For instance, a youth with a stronger intention to die is more likely to use hanging or firearms than a youth with less intent.
Deficits in the mental health system have been identified (e.g. by Renaud, 2014) that focus on continuity of care, with individuals at risk or dying by suicide often not receiving the services they needed and under-diagnosis of mental health issues in youth.
Rudd et. al (2006) identifies a number of warning signs, which, distinct from the risk factors identified below, substantially increase likelihood of immediate suicidal behaviour. They include:
Rage, anger, seeking revenge
Engaging in reckless/risky behaviour
Increased alcohol use
Withdrawing from peers and family
Anxiety or agitation
Large change in sleep pattern (insomnia or hypersomnia)
Dramatic mood changes
No reason to live; sense of purposelessness
Children are highest risk to suicide in the period transitioning out of hospitalization, so it should be used with caution. (Huey et al., 2004) If less intensive methods are available to stabilize the child they are preferred.
While bullying is commonly discussed in the media, a review of 94 youth suicides in Toronto showed bullying was an identified factor in the death in only 6.4% of cases, while conflict with parents, romantic and academic problems and criminal or legal problems accounted for a combined 59.5% of suicides. (Sinyor, Schaffer & Cheung, 2014)
A note on medication: While research had demonstrated that use of anti-depressants increased suicide risk in children and young adults, leading to a “black box” warning on anti-depressant medication, subsequent research showed that the resulting controversy led to under-prescribing of anti-depressants to children who actually needed them, raising the overall youth suicide rate. (BMJ, 2014)
Interpersonal conflict and loss Lethal and disciplinary problems
Depression and hopelessness (Dube, Bhargava & Sood, 2014)
Previous suicide attempts
Social isolation and rejection (Frederick, Kirst & Erickson, 2012)
Limited access to mental health facilities
Low self-esteem (Wilburn & Smith, 2005)
Poor family environment
Impulsiveness is a commonly cited factor in youth suicide (Witte, et. al., 2008), and while some suicides may be legitimately impulsive it’s important to rule out that an individual may have had undetected suicidal ideation or other long-standing risk factors before sudden warning signs or suicide attempts emerge.
An additional risk factor to consider is suicide contagion. There have been documented cluster suicides where the glorification and glamorization of one youth (or celebrity’s) suicide encourages others to do the same.
Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). “Adolescent suicide: Assessment and intervention” Washington, DC: American Psychological Association.
BMJ. (2014) “Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study” doi: http://dx.doi.org/10.1136/bmj.g3596
Bridge, J.A., Goldstein, T.R., & Brent, D.A. (2006) Adolescent suicide and suicidal behaviour. Journal of Child Psychology and Psychiatry. 47(3/4): 372-394
Casey, L., Hunter, P. (2011) “Suicide may be substantially underreported in Ontario” Toronto Star. Retrieved electronically from http://www.thestar.com/news/gta/2011/12/02/suicide_may_be_substantially_underreported_in_ontario.html on February 9, on February 9, 2015
Dube, S., Bhargava, D., Sood, P. (2014) “Comparative Study on Mental Health Among Youth” International Journal of Multidisciplinary Approach and Studies. 1(5).
Frederick, T.J., Kirst, M., & Erickson, P.G. (2012) “Suicide attempts and suicidal ideation among street-involved youth in Toronto” Advances in Mental Health. 11(1):8-17
Huey, S.J., Jr., Henggeler, S.W., Rowland, M.D., Halliday-Boykins, C.A., Cunningham, P.B., Pickrel, S.G., et al. (2004). “Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies.” Journal of the American Academy of Child and Adolescent Psychiatry, 43, 183–190.
Miller, D., Eckert, T. (2009) “Youth Suicidal Behavior: An Introduction and Overview” School Psychology Review. 38(2):153-167
Renaud, J., Seguin, M., Lesage, A., Marquette, C., Choo, B., Turecki, G. (2014) Canadian Journal of Psychiatry. 59(10):523-530
Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M., Mandrusiak, M., et al. (2006). “Warning signs for suicide: Theory, research, and clinical applications” Suicide and Life-Threatening Behavior, 36, 255–262
Sinyor, M., Schaffer, A., Cheung, A.H. (2014) “An Observational Study of Bullying As a Contributing Factor of Youth Suicide in Toronto” Canadian Journal of Psychiatry. 59(12):632-638
Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.
Statistics Canada. (2012) “Suicide rates: an overview” Retrieved electronically from http://www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm on February 9, from February 9, 2015
Statistics Canada. (2011) “Percentage distribution for the 5 leading causes of death in Canada, 2011” from CANSIM, table 102-0561. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on February 9, 2015.
Wilburn, V.R., Smith, D.E. (2005) “Stress, Self-Esteem and Suicidal Ideation in Late Adolescents” Adolescence. 40(157).
Walsh, E., Eggert, L.L. (2007) “Suicide risk and protective factors among youth experiencing school difficulties” International Journal of Mental Health Nursing. 16:349-359
Witte, T.K., Merrill, K.A., Stellrecht, N.E., Bernert, R.A., Hollar, D.L., Schatschneider C., Joiner T.E. Jr. (2008) “’Impulsive’ youth suicide attempters are not necessarily all that impulsive.” Journal of Affective Disorders. 107(1-3):107-16