Family-based Crisis Intervention with Suicidal

Adolescents in the Emergency Room: A Pilot

Study
Elizabeth A. Wharff, Katherine M. Ginnis, and Abigail M. Ross

The prevailing model of care for psychiatric patients in the emergency room (ER) is eval-
uation and disposition, with little or no treatment provided. This article describes the
results of a puot study of a famuy-based crisis intervention (FBCI) for suicidal adolescents
and their families in a large, urban pédiatrie ER. FBCI is an intervention designed to
sufficiently stabilize patients within a single ER visit so that they can return home safely
with their families. Of the 100 suicidal adolescents and their families in the sample, 67
met eligibility criteria for FBCI. Demographic and clinical characteristics and disposition
outcomes from the sample were compared with those obtained retrospectively from a
matched comparison group (N= 150). Statistical analyses compared group inpatient ad-
mission rates and disposition outcomes. Patients in the puot cohort were significandy less
likely to be hospitalized than were those in the comparison group (36 percent versus 55
percent). Only two ofthe patients in the FBCI cohort were hospitalized immediately after
receiving the intervention during their ER visit. FBCI with suicidal adolescents and their
families during a single ER visit is feasible and safely limits the need for inpatient psychiat-
ric hospitalization, thereby avoiding disruption offamily, academic, and social activities
and increasing use of less intrusive and more cost-effective psychiatric treatment.

KEYWORDS; crisis intervention;family intervention; suicidal adolescents; suicide

A
s the adolescent suicide rate has been in-
creasing over the last several decades
(Centén for Disease Control and Preven-
tion, 1998, 2007a, 2007b, 2008; Office of Disease
Prevention and Health Promotion, 2000), there
has been a parallel increase (as high as 59 percent)
in pédiatrie emergency room (ER) usage rates by
adolescents in need of mental health evaluations
in the United States (Breslow, Erickson, & Cava-
naugh, 2000; EUison, Hughes, & White, 1989;
Hughes, 1993; Page, 2000; Sills & Bland, 2002;
Stewart, Spicer, & Babl, 2006). Suicidality in ado-
lescents has been the most significant factor in the
majority of ER visits for behavioral health con-
cerns (Stewart et al., 2006) and the most common
presenting problem for adolescents subsequently
admitted to an inpatient psychiatric unit (Brooker,
Ricketts, Bennett, & Lemme, 2007).
Although the number of psychiatric ER visits
has increased substantiaUy (Bruffaerts, Sabbe, &
Demyttenaere, 2004; Hughes, 1993; Larkin,
Claassen, Emond, PeUetier, & Camargo, 2005),
child mental health service avaUabUity has not
kept pace, resulting in longer ER wait times and
stays for patients (American CoUege of Emergency
Physicians, 2008), Ekely contributing to a phe-
nomenon termed psychiatric "boarding" (Man-
sbach, Wharff, Austin, Ginnis, & Woods, 2003)
that has gained notoriety in the popular press
(Holmberg, 2007; Katz, 2006; Kowalczyk, 2007;
Trafford, 2000). Boarding describes a patient who
is in psychiatric crisis and requires inpatient hospi-
talization but for whom there is no available inpa-
tient psychiatric bed (Mansbach et al., 2003). In a
recent survey of ER medical directon, over 70
percent reported boarding psychiatric patients as a
routine practice, with nearly 40 percent doing so
a minimum of once a week (American CoUege of
Emergency Physicians, 2008).
In current practice, the standard of care in
emergency psychiatry is evaluation and disposition
with little or no treatment provided at the time of
presentation (Bruffaerts, Sabbe, & Demyttenaere,
2008). Psychiatric ER protocol is a noteworthy
deviation from triage practice in standard emer-
gency care, in which the most acute patients are

doi: 10.1093/SW/SWS017 O 2012 National Association of Social Wo-kers 133

 prioritized and receive the most rapid and inten-
sive care. Historically, there has been little focus
on psychiatric treatment within the emergency
setting, often due to time pressures to move pa-
tients through the ER and the prevailing treat-
ment philosophy that psychiatric treatment of
suicidal patients requires admission to a locked in-
patient facility.
A number of studies evaluating specialized in-
terventions occurring within the context of the
ER have yielded significant increases in after-care
treatment compliance among psychiatric patients
(Rotheram-Borus et al., 1996; Spooren, Van
Heeringen, & Jannes, 1998) and reductions in de-
pressive symptomology (R.otheram-Borus, Piacen-
tini, Cantwell, BeUn, & Song, 2000) and suicide
attempts (Huey et al., 2004). None, however, have
piloted or evaluated a single-session intervendon
that occurs exclusively within the ER.
Though limited data on the cost-effectiveness of
alternatives to inpatient hospitalization are avail-
able (Lamb, 2009; Shepperd et al., 2009),
community-based interventions like multisystemic
therapy (MST) show promising results; specifically,
in a randomized controlled trial of 116 adolescents
meeting criteria for inpatient hospitalization re-
ceiving either home-based MST or inpatient
hospitalization, higher levels of patient satisfaction,
improvement in family functioning, and reduc-
tions in externalizing symptoms were reported in
the MST group than in the group receiving
inpatient hospitalization (Henggeler et al., 1999).
Because the ER is frequently a critical point of
contact for suicidal adolescents to receive access to
services, we developed a farrdly-based crisis inter-
vention (FBCI) for use exclusively in the ER,
with the explicit goal of decreasing acute symp-
toms and sending more suicidal adolescents home
safely with their families.
FBCI is based on the assumptions that an inpa-
tient hospitalization is not necessarily the most
helpful level of psychiatric care for adolescents
with suicidal ideation/behavior, that families and
caregivers are able to provide support to an adoles-
cent fanuly member if given both an opportunity
and effecdve tools to use, and that a family that
learns to support an adolescent while he or she is in
crisis wül be empowered to provide ongoing
support once the acute psychiatric crisis subsides.
Based on an integradon of cognidve-behavioral skill
building, psychoeducadon, therapeudc readiness.
134
and safety planning, FBCI uses nonjudgmental
collaboradon (Madsen, 1999) to stabilize padents
and provide psychiatric intervention in the ER for
both the adolescent and the family, thereby de-
creasing a patient's level ofriskand increasing the
capacity of the family to maintain the patient at
home with appropriate therapeutic supports.
This two-part puot study explored (1) the
safety and feasibility of FBCI in a population of
adolescents presenting with suicidal complaints in
a large urban pédiatrie ER and (2) disposition
outcomes between the pilot sample and a com-
parison sample obtained retrospectively during the
identical calendar period immediately preceding
the FBCI study period. It was hypothesized that
FBCI during an ER visit would prove both feasi-
ble and safe and that rates of inpatient psychiatric
hospitalization in the sample of patients presendng
during the FBCI study period would be lower
than those in the retrospective cohort sample.
METHOD
Study Design
This puot study was conducted in the Boston
Children's Hospital ER, in which approximately
1,000 patients in psychiatric crisis are seen annually.
Nearly 40 percent of these patients present
•with chief complaints of depression or suicidal
ideation/behavior. During an 18-month period
(January 1, 2001, through June 30, 2002), 100
suicidal adolescents and their families were re-
cruited to participate in the pilot study of FBCI
when presenting to the ER. The sample was ob-
tained consecutively. Padents were excluded
when they met at least one of the following
five criteria: (1) not currently living with a fanuly,
(2) presenting to the ER unaccompanied by a
family member, (3) intoxicated/sedated at the
time of ER presentation, (4) presenting with cog-
nitive limitations that prohibited FBCI participa-
tion (that is, severe psychosis or significant
developmental delay), and (5) presenting during
an overnight shift (11:00 P.M. through 8:00 A.M.,
Monday through Friday) or during weekend
hours (5:00 P.M. Friday through 8:00 A.M.
Monday), because FBCI-trained staff were not
available to administer the intervention during
these ER shifts. Informed consent and assent were
obtained from all patients and families prior to
patients receiving both a standard psychiatric
Social Work VOLUME 57, NUMBER 2 APRIL 2012
evaluation and FBCI. After finishing the standard
psychiatric evaluation with the chUd and famUy,
the social worker used her best chnical judgment
to make the decision about whether the patient
could benefit from FBCI. If the evaluating social
worker had any uncertainty about whether the
patient was appropriate for FBCI, a supervisor was
avaUable for consultation.
A pUot design was selected because the entire
ER psychiatry staff was trained in the interven-
tion protocol, rendering random assignment of
famihes to standard or specialized ER care im-
possible. Prior to commencing the study, aU ER
psychiatry social work staff members were trained
in FBCI protocol by the creators of the inter-
vention. FBCI staff were required to attend
weekly meetings to review cases with the crea-
tors of the intervention. Fidelity to the interven-
tion was measured using a checklist requiring
completion of each of the four core essential
components of FBCI. Interrater rehabUity was
established prior to study start. FBCI staff met
weekly during the 18-month pUot study period
to maintain interrater reHabUity. The safety of
FBCI was measured by the number of FBCI
patients who reported incidence of a suicide
attempt or completion during the three-month
foUow-up period. FeasibUity was measured by
our abUity to adequately train ER staff in FBCI
protocol and implement the single-session inter-
vention within the context of a busy ER. Fideh-
ty to the intervention was measured using a
checklist requiring completion of each of the
four core essential components of FBCI. Demo-
graphic and clinical characteristics and disposition
data from the pUot sample were then compared
with data obtained retrospectively from a cohort
of suicidal adolescents presenting consecutively
to the ER during the previous 18-month calen-
dar period (fanuary 1, 1999, through June 30,
2000). The Boston ChUdren's Hospital institu-
tional review board approved the pUot study.
Recruitment and Consent for the Pilot
Study
AU patients and famUies presenting to the ER
during the study period received standard emer-
gency care, or treatment as usual (TAU). This
process began with a medical examination by an
ER physician. Once medical clearance was ob-
tained and a psychiatric consultation was
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER
requested, participants were approached by a psy-
chiatry research assistant to obtain informed
consent/assent. Once consent was obtained, the
patient and famUy were asked to complete some
brief psychometric measures—the ChUdren's
Depression Inventory (CDI) (Kovacs, 1982), the
Hopelessness Scale for ChUdren (HSC) (Spirito,
WUhams, Stark, & Hart, 1988) and the FamUy
Adaptability and Cohesion Evaluation Scale II
(FACES II) (Olson, Portner, & Lavee, 1982)—to
assess depression, hopelessness, and flexibUity of
famUy system, respectively. AU psychometric mea-
sures used have demonstrated strong reliabUity
and vahdity (Kazdin, Rogers, Sc Colbus, 1986;
Kovacs, 1992; Olson et al., 1983). Famihes were
also asked to complete a comprehensive famUy
self-report form, which coUected demographic
and historical information. Patients and families
were not excluded if the famUy or adolescent did
not complete the assessment forms. AU forms
were avaUable in Spanish and English. Interpreters
were avaUable for famUies whose first language
was other than English or Spanish. The Study
Flow is depicted in Figure 1.
Determination of Inclusion for FBCI
On completion of the standard emergency psy-
chiatry evaluation with the adolescent and family,
the evaluating chnician, either a licensed master's-
or doctoral-level social worker, reviewed the case
with the attending psychiatrist to determine the
appropriate level of psychiatric care. FamUies were
offered FBCI only if the evaluating social worker,
attending psychiatrist, and famUy were in agree-
ment that FBCI might enable the adolescent to
return home safely. The decision to offer FBCI
was based on both the acuity of the adolescent's
suicidality and the capacity for galvanizing envi-
ronmental supports avaUable to and within the
famUy system. If the evaluating social worker, at-
tending psychiatrist, and famUy concurred that
FBCI might help the adolescent return home
safely with his or her famUy, the social worker
then proceeded with FBCI. Adolescents who
were not offered FBCI were hospitalized at an in-
patient psychiatric facUity.
FBCI
The thoretical underpinnings of this single-session
ER intervention come from cognitive-behavioral,
narrative, and family systems therapies, with an
135
 Figure 1: Study Flow Chart

Patient presents to ER with Exclusion Critetia:

suicidality and is medically cleared • Not currently living
with a family
• Presenting to ER
unaccompanied by a
• Study team obtains informed family member
consent and administers CDI, HSC, • Intoxicated/
and FACES II sedated at the time of
• Clinician performs standard ER presentation
psychiatric evaluation and • Severe cognitive
determines FBCI eligibility limitations that
prohibited FBCI
participation
Exclusion
• Presenting during an
Criteria:
ovemight/ weekend
Acuity of
shift
suicidality

Patient is ::iot FBCI Patient is FBCI eligible

eligible: Disposition of (n = 67)
inpatient tospitalization
(« = 33)

Clinician does FBCI in

ER: Meets with patient
and family both
individually and together

Clinician consults with

attending psychiatrist,
adolescent, and family to
determine whether the
patient can retum home
safely

Patient is hospitalized (n = Patient returns home safely

2) (« = 65)

Note: ER = emergency room; CDI = ChildreiTs Depressio • Inventory; HSC = Hopelessness Scale for Children; FACES II = family Adaptability and Cohesion Evaluation Scale II;
FBCI = family.based crisis intervention.

overaU approach of nonjudgmental collaboration, the whole family together, attempting to con-
as described by Madsen (1999;. First, the social struct a single, unified perception of the problem
worker holds separate meetings with the adoles- using the same narrative approach. We refer to
cent and family to assess the sequence of events unified perception of the problem as the "joint
and differing perceptions leading to the suicidal crisis narrative." During the meeting, the social
problem. During these meetings, the social worker assesses family roles and the potential flex-
worker uses a narrative approach to help each ibUity and adaptabiUty of the family system, using
party tell his or her story. The social worker also cUnical interventions to both facilitate and
explores what each party feels would be necessary improve communication among family members.
for the adolescent to retum home safely with his The social worker uses cognitive—behavioral ther-
or her family. Next, the social worker meets with apeutic approaches, including relaxation.

136 Social Work VOLUME 57, NUMBER 2 APRIL 2012

problem-solving, and cognitive reframing tech-
niques to shift negative atttibutions. The social
worker also works with the chud and family to
problem solve around any specific dilemmas as
needed. In the family meeting, the social worker
tties to help the family and adolescent work to-
gether to improve intrafamilial communication, to
safety plan, and to effect additional changes that
will enable the adolescent to feel safe at home.
The goal of FBCI is to effect changes that wOl
reduce the acute symptoms that brought the ado-
lescent to the ER and increase the family's aware-
ness of the problem and sense of efficacy to help
their chud, thereby avoiding inpatient admissions
and further disruptions of the adolescent's hfe.
After completing FBCI, the social worker again
consults with the supervising psychiattist to
review the case and obtain consensus that the
patient is able to return home safely. Patients are
discharged home only when the patient, family,
attending psychiattist, and assessing social worker
agree that this is the best disposition for the
adolescent.
Follow-up Assessments
Five follow-up assessments were completed by a
study clinician via telephone at one-day, one-
week, two-week, one-month, and three-month
intervals from the date of the ER visit. Follow-up
assessments served the dual purpose of obtaining
information about the patient's level of function-
ing and facilitating acquisition of additional sup-
portive services as needed. Follow-up assessments
were completed only for those adolescents and
families who were discharged home after their
ER visit. Data on incidence of subsequent psychi-
attic evaluations and inpatient hospitalizations
were also collected at these five follow-up
intervals.
Retrospective Comparison Group
Demographic and clinical charactetistics and dis-
position outcomes of patients in the pilot sample
were compared retrospectively with adolescents
{N= 150) who presented consecutively to the
same ER with complaints of suicidal behavior/
ideation duting the corresponding 18-month cal-
endar petiod immediately preceding the puot
study petiod Qanuary 1, 1999, through June 30,
2000). Retrospective cohort patients met the
same inclusion and exclusion ctitetia as those in
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER
the pilot sample. Standard psychiattic assessment
information—including demographic informa-
tion. Diagnostic and Statistical Manual of Mental Dis-
orders (4th ed.) {DSM-IV) (Ametican Psychiattic
Association, 1994) diagnoses, and disposition de-
tennination—that pertained to each patient in the
retrospective compatison group was obtained
through a medical record review.
Statistical Analyses
Frequency disttibutions and means were calculat-
ed for demographic data in both the puot and
retrospective cohort compatison samples (see
Table 1). Mean CDI, HSC, and FACES II adapt-
ability and cohesion scores were computed for the
sample using a dichotomous disposition outcome
(inpatient hospitahzation/aU others) as the depen-
dent vatiable (see Table 2). Between-groups dif-
ferences in mean CDI, HSC, and FACES II
scores were examined using independent sample
Í tests (see Table 2).
Chi-square analyses were used to examine dif-
ferences in demographic vatiables and disposition
outcomes between the pilot and retrospective
cohort samples. Disposition outcomes were cate-
gotized by level of support (inpatient, intensive
outpatient, and outpatient services). Analyses of
disposition outcome rates between the pilot and
retrospective cohort samples are reported in
Table 3.
RESULTS
Demographics
The pilot sample included 100 adolescents ages
13 to 18 years presenting to a large urban ER
with symptoms of suicidality. A total of 144 suici-
dal adolescents presented to the ER duting the
FBCI study petiod, 44 of whom were excluded
from participating in the study due to aforemen-
tioned exclusion ctitetia, lack of available research
assistants, or lack of available FBCI-trained staff.
Among the 100 adolescents participating in the
pilot study, 76.0 percent were female. Mean
patient age was 15.6 {SD= 1.5) years. Sixty-five
percent of patients self-identified as white, 16
percent self-identified as black, 11 percent self-
identified as Hispanic/Latino, 3 percent self-
identified as biracial, 2 percent self-identified as
Asian, and 3 percent self-identified as being of
another race. Demographic data obtained
137
 Table 1: Demographics of Intervention and Comparison Groups
iiteryention'(/V= 100) Comparison (/V={150) ¡
Variable
Gender
Female 76 76.0 111 74.0
Male 24 24.0 39 26.0
Race/ethnicity
Asian 2 2.0 4 2.7
Black 16 16.0 26 17.3
Hispanic/Latino 11 11.0 15 11.0
White 65 65.0 97 64.7
Biracial 3 3.0 2 1.3
Other 3 3.0 6 4.0
Living arrangement
Parents 96 96.0 139 92.7
Other relative 4 4.0 11 7.3
Foster care 0 0.0 1 0.7
Primary language
English 89 89.0 138 92.0
Spanish 7 7.0 11 7.3
Other 4 4.0 1 0.7
Legal custody
Parents 96 96.0 140 93.3
DSS/DCF 1 1.0 5 3.3
Other relative 2 2.0 1 0.7
Other 1 1.0 0 0.0
Primary DSM-IVxás I diagnosis
Total depressive disorders 76 76.0 105 70.0
Bipolar disorder 5 5.0 10 6.7
Other mood disorders 1 1.0 2 1.3
Anxiety disorders/PTSD 8 8.0 10 6.6
Other' II 11.0 23 15.3
Notes: The average age in years was 15.60 (SD=1.4S) for the intervention group and 15.50 {SD=1.47) for the comparison group. DSS = Department of Social Sen/ices; DCF =
Department of Children and Families; DSM-IV= Diagnostic and Statistical Manual of Mental Disorder (4th ed.); PTSD = posttraumatic stress disorder.
'Includes eating disorder, psychosis, substance abuse behavioral disorders, attention-deficit/hyperactivity disorder, and somatoform disorders.

Table 2: Pilot Sample CDI, FACES II, and Table 3: FBCI and Comparison Group
HSC Scores Disposition Outcomes, in Percentages
Disposition FBCI Comparison
Total CDI Inpatient 34 31.56 9.863 <.OO1 Outcome (/V=100) (W=150)
All others 61 23.26 9.83 Inpatient 35" 55
Patient cohesion Inpatient 31 47.19 12.38 .876 Intensive outpatient 21" 5
All others 59 47.63 12.925 Outpatient 43 37
Family cohesion Inpatient 33 54.73 8.596 .490 Other 0 3
Note: FBCI = family.based crisis intervention.
All others 60 56.02 8.54 "Reduction in hospitaiization rate: p<.0001.
Patient ''increase in intensive outpatient referrai: p < .001.
adaptability Inpatienc 32 38.66 9.46 .364
All others 54 40.56 9.07
Family retrospectively from the comparison sample (150
adaptability Inpatient 32 44.72 7.10 .952 suicidal adolescents presenting consecutively to
All others 58 44.81 6.32
the ER during the corresponding previous
Hopelessness Inpatient 27 11.15 4.36 .001
18-month calendar period) are presented in
All others 60 7.52 4.44
Notes: W=100. CDI = Children's Depression Inventory; HSC = Hopelessness Scale for
Table 1. Patients in the comparison sample did
Children; FACES II = Family Adaptability and Cohesion Evaluation Scale II. not differ significantly in age, race and ethnicity,

138 Social Work VOLUME 57, NUMBER 2 APRJL 2012

living arrangements, primary language, legal
custody status, caregiver relationship status,
primary DSM-IV diagnosis, or reported family
history of depression from their counterparts in
the pilot study. Exclusionary criteria were
matched between samples.
On compledon of the initial psychiatric evalua-
tion, 67 percent of adolescents (n = 67) were eligi-
ble to receive FBCI. The remaining 33 percent
(n = 33) who did not receive FBCI were hospital-
ized due to the acuity of their suicidality. Of the
67 patients who received FBCI, 97.0 percent
{n = 65) were not hospitalized. Only two padents
who received FBCI were hospitalized after their
ER visit. These patients were unable to engage in
safety planning during FBCI and thus required
hospitalization. Statistically significant differences
in depressive symptom severity occurred between
patients who were admitted to an inpatient unit
and those who were not. Mean CDI scores for
34 patients with an inpatient disposition (31.50
[SD = 69.86]) were significantly greater than the
mean CDI scores for 60 patients who did not
(23.26 [5D = 9.83]). CDI scores were not avail-
able for two patients who were ineligible for
FBCI and for three who received the intervention
and were discharged home. Similarly, mean HSC
scores were higher among patients who were hos-
pitalized (n = 27 [p = .001]). HSC scores v/ere not
available for eight patients deemed ineligible for
FBCI and for five patients who received FBCI
and were discharged home.
Neither CDI nor HSC scores differed signifi-
cantly between patients receiving an inpatient
hospitalization and those receiving intensive out-
patient treatment. Differences in patient and
family FACES II cohesion or adaptability subscales
did not approach significance for any disposition
category (see Table 2).
Suicidal adolescents and families who presented
to the ER during the FBCI pilot period v/ere sig-
nificantly less likely to be admitted to an inpatient
psychiatry unit than were members of the
matched sample who presented during the com-
parison period. Sixty-five percent of suicidal pa-
tients presenting during the study period were
discharged home, whereas only 44.7 percent of
the comparison cohort (n = 67) were discharged
home. Adolescents and their families presenting
to the ER during the pilot study period v/ere sig-
nificandy more likely to receive a referral to
WHARPF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER
intensive outpatient services (acute day treatment
programs and intensive home-based therapies) at
discharge fi'om the ER (21.0 percent [n = 21]
venus 5.3 percent [n = 8], p<.001) than were
their TAU counterparts in the retrospective
cohort (see Table 3).
Of the 65 patients and families who received
foUow-up assessments at five separate intervals as
a component of the intervention protocol, 43
(66.1 percent) were reached at one day, 44 (67.7
percent) were reached at one week, 42 (64.6
percent) were reached at two weeks, 44
(67.7 percent) were reached at one month, and 36
(55.4 percent) were reached at three months. A
total of 55 patients (84.6 percent) were reached at
least once during the foUow-up period. Pearson
chi-square tests revealed no significant differences
between patients reached at foUow-up and those
unable to be reached in age, gender, primary axis I
diagnosis, CDI or HSC scores, or insurance cate-
gories. No patients reported incidence of attempt-
ed or completed suicide during the three-month
foUow-up period.
None of the patients for whom data was
coUected at the one-day foUow-up required an
inpatient hospitalization. At the three-month
foUow-up, seven patients reported requiring an
inpatient hospitalization since the initial ER visit
(12.7 percent), only two (3.6 percent) of whom
were hospitalized because of suicidal complaints.
Other reasons for hospitalization included transi-
tion between partial hospitalization placements,
decompensadon due to schizophrenia, self-injurious
behavior (nonsuicidal), and psychiatric evaluadon
required prior to entering child protecdve custody.
DISCUSSION
Considering the increasing rates and high costs of
adolescent psychiatric hospitalization and an in-
creasingly overburdened health-care system, inves-
tigations evaluating the efficacy of therapeutic
interventions occurring within the ER are essen-
tial. To date, FBCI is the only standardized single-
session crisis intervention for suicidal adolescents
evident in the literature that has been designed for
and pUoted within the ER to demonstrate feasi-
bility, acceptabUity, and significant reductions in
inpatient hospitalization rates relative to a demo-
graphicaUy matched, retrospectively obtained
comparison sample.
139
 Avoidance of inpatient psychiatric admission for
suicidal adolescents has several benefits for the in-
dividual adolescent, the family^ and the mental
health system. Although the sodetal stigma associ-
ated with mental health problems has been
reduced somewhat, the stereotypical view of ado-
lescent inpatient psychiatric care depicted in
popular literature and films continues to prevail.
An inpatient admission may negatively affect an
individual or family's beliefs about recovery
(Hellzen & Lilja, 2008), the capacity to be safe in
the world, or the family's ability to provide a safe
and supportive environment for their chud. Con-
venely, community-based supports may allow a
chud to refrain from developir.g a "dependency
upon the hospital environment or from being
stigmatized" (Shepperd et al, 2009, p. 3). An
ER-based crisis intervention provides the adoles-
cent and family with the message that, despite the
suicidal ideation/behavior with, which they pre-
sented, there are skills that famlies can learn that
will enable the adolescent to alleviate his or her
distress and thus remain at home. The family feels
empowered to be the coordinator of and partici-
pant in their child's care, comparable to the foun-
dational empowerment model used by the
community intensive therapy team in the United
Kingdom (Darwish, Salmon, Ahi^a, & Steed, 2006).
roCI provides psychoeducation to promote en-
gagement in therapy and (¡mraiy understanding of
treatment. In addition to the tangible parts of the in-
tervention, FBCI provides hope for a family that
arrived at the ER overwheln^ed, anxious, and
worried for a child's survival. During the study, sev-
eral families expressed relief and gmdtude for the care
that they received in the ER and noted during
follow-ups that family communication and function-
ing in home and school domains had improved.
The absence of significant differences between
family adaptability or cohesion TACES II scores)
and hospitalization in the intervention group was
an unexpected finding. Even the most seemingly
inflexible and uncommunicati'^e families could
engage with a skilled clinician to participate in
psychiatric treatment of their child. Using Parad's
(1965) crisis theory approach, v e posit that even
the most rigid family system is open to change
during a crisis. FBCI allows cHricians to take ad-
vantage of this opportunity, thereby avoiding un-
necessary psychiatric hospitalization.
140
The significant increase in referrals for intensive
outpatient treatment in the puot sample indicates
that these adolescents were clearly in need of in-
tensive mental health support; however, FBCI
enabled chnicians to join with families to provide
them with the tools needed to care for their chil-
dren safely at home, allowing this intensive treat-
ment to occur outside the hospital. As previously
noted, FBCI incorporates cognitive therapeutic
techniques to reframe negative attributions. A
recent study of a 12-session cognitive-behavioral
treatment for suicide prevention that also includes
cognitive refcaming as a key component has dem-
onstrated feasibility in a population of suicidal ad-
olescents (Stanley et al., 2009), providing further
empirical support for cognitive-behavioral treat-
ment techniques for suicidahty specifically. FBCI
could be a part of a growing number of more
cost-effective alternatives to inpatient hospitaliza-
tion—such as multisystemic therapy (Henggeler &
Borduin, 1990; Henggeler et al., 1997; Huey
et al., 2004; Schoenwald, Ward, Henggeler, &
Rowland, 2000) and rapid-response outpatient
models (Greenfield, Larson, Hechtman, Rous-
seau, & Platt, 2002)—that have been shown to be
as feasible as inpatient hospitalization for treating
suicidality in adolescents presenting to the ER.
The absence of significant differences in HSC and
CDI scores between those receiving dispositions
of an inpatient hospitalization and intensive out-
patient services within the puot study group indi-
cates that safety can be estabhshed at home for
even severely depressed adolescents.
The follow-up component of the FBCI proto-
col also yielded promising results. Of the 55 pa-
tients (85.9 percent) reached during the
three-month follow-up period, none required an
immediate inpatient hospitalization (within one
week). Remarkably, only two FBCI patients (3.6
percent) reached during the three-month
foUow-up period required an inpatient hospitali-
zation due to suicidal ideation or behavior.
The medical system uses a model of stabihza-
tion in the ER whenever possible and admission
only when necessary. FBCI and other crisis inter-
vention protocols could help the mental health
system move to a similar model in which inpatient
admission is no longer the default position.
Current trends indicate that the majority of ado-
lescents presenting with suicidal ideation/behavior
Social Work VOLUME 57, NUMBER 2 APRIL 2012
are admitted to psychiatric inpatient facilities
(Brooker et al., 2007). Inpatient hospitaUzation is
much more costly than other alternatives that
have been sho^wn to be as effective in reducing
suicidal ideation/behavior in adolescents (Gould,
Greenberg, Velting, & Shaffer, 2003; Henggeler
et al., 2003).
This change in mindset is critical for the system to
appropriately respond to and care for patients along
the continuum of care. Patients who can go home
with intensive outpatient follo^w-up do not board in
the ER, where they •wül receive minimal psychiatric
treatment. Instead, they go home with outpatient
services in place, allowing them to engage in treat-
ment more quickly than they would if they were
sitting in the ER awaiting an inpatient bed.
LIMITATIONS
There were several limitations to this study.
Though random assignment to FBCI or TAU
conditions would have been preferable, FBCI
involved changing clinicians' practice within the
ER; it was not possible to randomly assign famiUes
to treatment and control groups. The closest avail-
able approximation to a control group was a retro-
spectively obtained sample from the most recent
corresponding 18-month calendar period prior to
cUnician training in FBCI. The retrospective com-
parison component of the study also prohibited
acquisition of data on the frequency of ER visits in
the TAU group; thus, ER recidivism rates could
not be analyzed comparatively between the two
samples. The foUo^w-up duration of three months
is also a Umitation. Though alternatives to inpa-
tient hospitalization have been shown to be more
effective in extemaUzing symptom reduction and
improvement in family functioning than inpatient
hospitalization (Henggeler et al., 1999; Schoen-
wald et al., 2000), research indicates that these
gains may be relatively short-lived (Henggeler
et al., 2003). We hypothesize that FBCI may
reduce ER recidivism and hospitaUzation rates.
Studies of pédiatrie emergency psychiatry services
indicate that multiple presentations account for 19
percent to 36 percent of ER visits and that ap-
proximately 50 percent of repeat •visits occur
within one month of the pre^vious presentation.
Though data were unavailable on foUow-up hos-
pitalizations for the comparison group, rates of
repeat ER presentations were much lower in the
FBCI sample than in other samples. Currently, we
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER
are conducting a randomized cUnical trial that ex-
amines the efficacy of FBCI, long-term gains, and
effects of FBCI on ER recidi^vism rates. Although
we did place foUow-up phone caUs to aU study
participants, no famiUes required assistance in ac-
cessing additional services at any of the foUow-up
time points; however, other services (beyond
those recommended as part of the discharge plan)
were not controUed for in this study. Future
studies should control for additional service use
and variability.
CDI, HSC, and FACES II scores were not col-
lected posttreatment or during foUow-up and,
therefore, could not be analyzed. No psychomet-
ric measures were obtained for the TAU group at
any time point, as there was no practical way to
proceed because of the nature of the population
presenting to the ER and human subjects issues.
In addition, frequency and dose of each of the
four core components of FBCI were not coUected
as part of this study. Future studies exploring the
efficacy and effectiveness of FBCI should incorpo-
rate the frequency and dose of each of these core
components.
CONCLUSIONS
Patients who received FBCI were significantly less
Ukely to be hospitaUzed than were their compari-
son cohort counterparts. Suicidal adolescents pre-
senting in crisis to the ER were able to be sent
home safely with appropriate therapeutic supports.
This puot study demonstrates that a single-visit
model of crisis intervention for suicidal adoles-
cents and their famiUes deUvered in the ER can
sufficiently stabilize an adolescent and family
system, regardless of cohesion and adaptabiUty
levels, to enable a safe discharge home.
It is essential to begin to use a model of crisis
intervention for suicidal adolescents and their
families to provide reUef from their acute symp-
toms with the least amount of family disruption.
Empirical e^vidence has yet to document the supe-
riority of inpatient care in effectively reducing
rates of suicidal ideation, nonlethal attempts, or
completed suicides among adolescents (Gould
et al, 2003). FBCI benefits the adolescent and
family and simultaneously alleviates an overbur-
dened mental health system by limiting use of
scant inpatient resources, keeping them available
for those who truly need them. FBCI is a stan-
dardized protocol that could be used by crisis
141
clinicians across contexts to provide this kind of
intervention, and it may be a cost-effective and
advantageous alternative to inpatient hospitaliza-
tion for both patients and providers.
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Elizabeth A. Wharff, PhD, MSW, is director, Katherine

M. Ginnis, MSW, MPH, is associate director, and
Abigail Ross, MSW, MPH, is a research social worker,
Emergency Psychiatry Service, Department of Psychiatry,
Boston Children's Hospital. Funding for this pilot study was
provided by the George Harrington Trust. The authors are
grateful to the adolescents and their families who participated in
the study and to the ER social workers who piloted family-
based crisis intervention (FBCI) with them, including Ariel
Botta, Elizabeth Colton Notine, Christina Feith, Lara Kay,

WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the FR 143
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