Chapter 1 Basic Concepts of Crisis Intervention

Chapter 1 Basic Concepts of Crisis Intervention What is a Crisis? • A crisis is an event that may or may not be perceived as a disruption in life. A crisis does not necessarily lead to trauma. • Typically, a crisis is described using a trilogy definition; that is, there are three essential elements that must be present for an event to be considered a crisis: 1) a precipitating event 2) a perception of the event that leads to subjective distress 3) diminished functioning when the distress is not alleviated by customary coping mechanisms or other resources • When a crisis is perceived as disruptive to one’s life, the crisis may be experienced as a traumatic event. What is Stress? • In Western culture, stress is used to describe emotional phenomena ranging from feeling mild irritation and frustration to being frozen with fear. • The term stress was introduced into medical literature by Hans Selye to describe nonspecific responses of the human body to demands that are placed on it. • Selye distinguished between two types of stress: 1) distress (i.e., changes that are perceived negatively) 2) eustress (i.e., changes that are perceived positively) • Distress tends to cause more biological damage than eustress, the latter seeming to contribute to well-being. Crisis v s Stress ersu • The terms stress and crisis often have been used interchangeably in the literature, thus creating a bit of confusion. • Boss (2006) has attempted to distinguish between the two concepts, stating that stress is a continuous variable (i.e., stress may be measured by degree), whereas crisis is a dichotomous variable (i.e., there either is or is not a crisis). • It is helpful to think of a crisis as an event. There either is a crisis or there is not a crisis. • Stress may be thought of as a process that exists over time. Measuring Stress • Since stress can be measured by degree, a common and effective technique used in assessing stress levels and changes to stress is scaling (Erford, 2020). • Scaling can be used to monitor increases and decreases in stress (as well as just about any other symptom or variable such as depression, sadness, anger, etc.) and then to compare present distress to a baseline prior to the crisis event. • Ex: “On a scale of 0 to 10 (with 0 being none and 10 being the highest you ever experienced), how would you rate the level of anxiety you are feeling right now?” What is a Traumatic Event? • Just as the terms stress and crisis have been incorrectly used interchangeably, so too have the terms crisis and trauma. • A crisis is the event that, by itself, does not result in trauma. If a person perceives the crisis event in a way that affects daily functioning, the crisis event may become a traumatic experience. • Likewise, stress may or may not be experienced because of an event. Rather, it depends on the individual’s perception of the crisis. What is a Traumatic Event? • According to the DSM-5-TR, a traumatic event involves threatened or actual death or serious injury, or a threat to the well-being of oneself or to another person. • Examples include: – Natural disasters – Acts of terrorism – School and workplace shootings – Homicides – Sexual assaults – Exposure to these events as a first responder Responses to Trauma • People experiencing traumatic events respond with intense feelings of fear and helplessness. • Most people respond to trauma within a normal range of reactions to abnormal events, whereby the individual’s baseline is not disrupted to the point that it causes impairment or dysfunction. Others become significantly distressed and impaired, and a few develop illnesses such as acute stress disorder (A S D) and posttraumatic stress disorder (P T S D). – Hyperarousal, flashbacks, sleep disturbances, memory lapses, exaggerated negative beliefs • The risk for psychological disturbance tends to increase with the magnitude or intensity of the traumatic stressor and with the degree to which the event was human caused and intended to harm. Responses to Trauma • Reactions to traumatic events typically include physical, behavioral, cognitive, emotional, and spiritual responses, which tend to occur in stages but ultimately are temporary. – Physical responses may be experienced through symptoms such as palpitations, shortness of breath, nausea, muscle tension, headaches, and fatigue. – Behaviorally, individuals may experience sleep and dietary changes, social withdrawal, purposeful avoidance of or attention to reminders of the trauma, changes in relationships, and increased use of alcohol or other mood-altering substances. – Cognitive responses include rumination, preoccupation, forgetfulness, and difficulty concentrating. – Emotional responses include distress, anxiety, impatience, irritability, anger, and symptoms of depression. – Spiritual responses are centered on existential questions and attempts to find meaning in the traumatic event. What is Coping? • Coping is defined as any behavioral or cognitive action that is taken to manage stress. • How do you cope with stress? What is Coping? • Coping is defined as any behavioral or cognitive action that is taken to manage stress. • Responses to stress fall into three broad categories: – Problem-focused coping: taking direct behavioral actions to change or modify aspects of the environment that are thought to be the causes of stress. – Emotion-focused coping: reducing affective arousal so that the stressful situation may be tolerated; it generally involves cognitive processes that change the meaning of a stressor or create emotional distance from it. – Avoidance-focused coping: responses such as distraction or diversion are employed to avoid the stressor and the emotions that would be associated with it. What is Adaptation? • Adaptation, as an outcome of stress or crisis, is the degree to which functioning has changed over an extended period and may be measured by the fit between the individual or family system and the environment. • In some families, changes may have occurred in functional behaviors such as rules, roles, boundaries, and interpersonal communication patterns, resulting in families being better equipped to meet the challenges of future stressors. • Conversely, for some individuals and families, an imbalance continues between stress demands and the capability to meet those demands. What is Resilience? • Resilience may be defined as the dynamics that contribute to positive adaptation following exposure to experiences that have the potential to disrupt functioning (Masten & Obradovic, 2008). • Several fundamental adaptive systems seem to make a difference in human resilience. – Beginning in early childhood, adaptation and the likelihood of resilience seem to depend on the quality of relationships with attachment figures. – Social groups and networks provide resources such as information and support that are important in dealing with adversity. – Larger systems, such as religious and spiritual connections, provide attachment-like relationships and social support, as well as opportunities to practice self-regulation through prayer and meditation. • People who are resilient seem to be better at applying cognitive skills during times of high stress or threat of harm than those who are less well adapted. What is Crisis Intervention? • A unique strategy within the profession of counseling, distinguished from other forms of counseling by its purpose, setting, time, and intervention plan. • Whether working in an office or in the field, within established counseling relationships or new ones, the crisis counselor’s goal is the safety and stability of clients—that is, working toward restoring equilibrium. – Once equilibrium is restored, other forms of counseling may be initiated or resumed. Crisis Counseling v s Traditional Counseling ersu • Crisis work prioritizes stabilization and immediate assistance with the presenting distress. • Happens in the spur of the moment, in any setting where the client is. • Sessions can last minutes to hours • Termination is viewed differently and typically ends with a referral. • Does not typically include diagnosing clients. • Goal is usually to increase functioning • Happens in scheduled, predetermined setting • Sessions typically 45 or 60 minutes • Termination is a process over multiple sessions • Treatment may include providing a diagnosis Reframing Counseling for Crisis Work • It is important for counselors-in-training to view their work, in crisis intervention, with clients who experience a crisis as 1) conducting a thorough assessment of the person in crisis 2) providing stabilization 3) connecting the person to the next level of care for longerterm counseling, other noncounseling connections, or additional resources to address the crisis. • If a counselor tries to address long-term goals with a person in crisis, the assessment and treatment plan will not address the presenting problem. Trauma-Informed Care • Often the terms trauma-informed care (TIC) and crisis assessment are inappropriately used interchangeably. – Components of TIC may be integrated into the crisis assessment process, but TIC is not the same as crisis assessment and intervention. • Trauma-informed care assists an individual in restoring a sense of safety, power, and self-worth. • Essential elements of TIC include: – Trauma awareness – Emphasis on safety and trustworthiness • – Opportunity for choice, collaboration, and connection – Strengths-based skill building Roles in Crisis Intervention • Professional Counselor: – Helping them to gain insight into the ways crises affect their lives in a cognitive, behavioral, and emotional manner over a lengthy period – Providing specific treatment goals and objectives related to crisis – Monitoring and assessing the magnitude of severity of a crisis – Providing insight into co-occurring mental and emotional disorders and crisis (e.g., showing a client diagnosed with bipolar disorder how to cope with and monitor a crisis) – Providing specific crisis intervention strategies during a crisis and over time – Providing clients in crisis with resources and preventive measures – Assisting in alleviating symptoms associated with the crisis – Preparing clients to handle future crises Roles in Crisis Intervention • Psychiatrists – The key difference is that psychiatrists are medical doctors and can prescribe medication. • Psychologists – The role is identical to the professional counselor in this setting. • Social Workers – Although performing many of the same duties as counselors, social workers are well equipped to concentrate on the resource needs of their clients. Roles in Crisis Intervention • Paraprofessionals – Individuals within the mental health community with limited formal education and training in the professional mental health field, but they perform essential tasks for individuals in crisis such as: ▪ Manage resources that help facilitate stabilization (e.g., make sure clients keep all medical, financial, emotional, environmental, and social service appointments). ▪ Ensure clients are aware of appropriate resources that could be seen as preventive actions to crisis (e.g., make sure that a client has appropriate resources to pay the natural gas bill to have heat in the winter). ▪ Provide an outlet for clients to decrease isolation and talk to others (e.g., talk with individuals in crisis and provide assurance that someone cares for them and their situation). ▪ Participate in executing the modality and frequency aspects of the treatment plan—in other words, make the connections set out in the treatment plan. Roles in Crisis Intervention • Hotline workers – Are often the first point of contact for many individuals experiencing a crisis and may handle any number of crises resulting from suicidal and homicidal ideation, domestic violence, substance use, and sexual assault. – Crisis hotline workers perform essential tasks during a crisis situation: ▪ They assess the severity of the crisis situation and the lethality of the caller. ▪ They provide immediate crisis intervention to the caller in an attempt to deescalate the crisis. This is critical in a crisis situation because the caller does not have to make an appointment with a professional or wait to get help. Most hotlines are 24-hour services open 365 days a year. ▪ They provide resources to the caller that may help resolve the crisis. Impact of COVID-19 • Society has now adapted telehealth as an alternative to faceto-face counseling. – Although still not preferred by mental health professionals for many situations, including crisis assessments, the ability to receive some form of counseling via telehealth procedures is better than the absence of counseling. • In crisis situations, telehealth considerations should still be evaluated for effectiveness in high-risk situations, work with young children, stabilization of clients with serious mental illnesses, and in situations where individuals have limited privacy, such as clients at home who experience intimate partner violence. Approaches to Working with Clients in Crisis • Directive approaches include leading the person in crisis in a specific direction – For example, if someone is highly uncertain, spontaneous, or ambiguous and, at the same time, unable to get out of a crisis state, direction could provide immediate, though temporary, relief to feelings surrounding the crisis. – Another example, a person who presents with highly suicidal behaviors requires the crisis counselor to initiate an emergency involuntary hospitalization for the safety of the client. Approaches to Working with Clients in Crisis • Nondirective approaches allow the person in crisis to come up with the directives while the crisis counselor facilitates that process. – If the client can make rational decisions, even though in crisis, a nondirective approach may empower the client to make progress toward deescalation. – For example, asking clients who are recent flood victims what might be of most help to them right now allows them to respond with specifics, rather than the counselor determining what is needed. Approaches to Working with Clients in Crisis • A collaborative approach is a blend of directive and nondirective approaches, but with a flavor of togetherness: – Provides support and a sense of working together toward a common goal. – Collaboration can be particularly beneficial to clients who feel that they have too many choices, are aware of only options that have been ineffective in the past, or need some assistance in generating new options. Activity • Determine which statements are directive, nondirective, or collaborative • Discuss how each statement could be appropriate in specific circumstances • Situation: You arrive at the scene of a suicidal person holding a gun Activity • “Please put the gun down.” • “What would help you feel more comfortable about putting the gun down?” • “I want to help, but knowing you have that gun in your hand scares me. Can you put the gun down for me so I can help you more?” Activity • “You have generated some ideas on how you can stay safe, and they seem like good options.” • “I am happy to hear that you do not want to follow through on killing yourself. Can we continue to work together to see what resources are the best options and make a list so that when you start to have thoughts of wanting to kill yourself you can act on the best options first?” • “It sounds like you are thinking about killing yourself during most of the day and every day and have decided nothing else can take away your pain. I want to help you stay alive, and the only option I see to do that is for you to be admitted to the hospital.” Activity • “If I bring you the phone, would you call the police?” • “I’m going to call the police.” • “Do you think calling the police will help?” Pioneers in the Field of Crisis Intervention • Lindemann, a professor of psychiatry at Harvard Medical School and Massachusetts General Hospital, worked with patients dealing with grief following traumatic loss. – Outlined several common clinical features, including somatic distress, feelings of guilt, hostility, disorganization, behavioral changes, and preoccupation with images of the deceased – Referred to these symptoms as “acute grief” as a call for intervention – Lindemann suggested that helpers other than psychiatrists could be of assistance • Lindemann worked with his colleague Gerald Caplan to establish a community-wide mental health program in Cambridge, Massachusetts, known as the Wellesley Project. Pioneers in the Field of Crisis Intervention • By studying and working with individuals who had experienced loss through the fire or similar traumatic events, Caplan (1964) developed the concept of “preventive psychiatry,” which proposed that early intervention following a disaster or traumatic event can promote growth and well-being. • Beverley Raphael (2000) coined the term “psychological first aid.” – She advocated for attention that included comfort and consolation, immediate physical assistance, reunification with loved ones, an opportunity to express feelings, and support during the initial period following a traumatic event. – Described the need to consider Maslow’s hierarchy of needs and the importance of attending first to basic survival needs before attempting more traditional forms of counseling. Applied Crisis Theory • Four crisis domains: developmental, situational, existential, and ecosystemic (James & Gilliland, 2017): – Developmental crises are events that are expected to be experienced by most individuals during normal development. However, for some, the developmental crisis event could cause considerable trauma. ▪ E.g.: pregnancy, graduation, retirement, career transition, and aging – Situational crises are events that are often unexpected and involve some degree of a catastrophic, shocking, or random act. ▪ E.g.: terrorist attack, sexual assault, job loss, an accident, and a sudden illness – Existential crises may or may not involve religious faith or spirituality but are events that affect one’s sense of meaning, purpose, freedom, independence, forgiveness, shame, or other core beliefs. – Ecosystemic crises, which include natural or human-caused events, affect not only the individual but also any of the systems (e.g., families, schools, communities) connected with the crisis event. ▪ E.g.: hurricane, war Applied Crisis Theory • The crisis domain acts as a framework for understanding the individual’s perception of the event and its life effects. • It is important for the crisis counselor to understand the individual’s perception of the crisis before categorizing the crisis into one or more of the domains. – A crisis must be understood by how it is perceived by the individual affected by it. – Meet the client where they are at, don’t make assumptions. The Task Model of Crisis Assessment and Intervention Table 1.1 The Task Model of Crisis Assessment and Intervention (Jackson-Cherry, 2018) Level I : Four Essential Crisis Assessment Tasks Assessment Task 1: Address Safety, Stabilization, and Risk Assessment Task 2: Follow a Holistic Biopsychosocial-Spiritual Approach Assessment Task 3: Clarify the Problem(s) Assessment Task 4: Explore Coping Skills, Resources, and Supports Level II : Four Essential Crisis Intervention Tasks Intervention Task 1: Normalize and Educate Intervention Task 2: Explore Options Intervention Task 3: Develop a Plan and Obtain a Commitment Intervention Task 4: Prepare Documentation, Follow Up, and Provide Referrals Four Essential Crisis Assessment Tasks (1 of 4) • Assessment Task 1: Address Safety, Stabilization, and Risk – A thorough risk assessment should be the first step in the assessment and the main goal for the counselor. Risk should be assessed throughout crisis intervention as well. – Not assessing for risk in a crisis situation, or waiting until the end of a session to conduct such an assessment that is not thorough, is negligent. – Adhering to the standard of care is a primary focus of Assessment Task 1 and, if lethality is present, it should continue to be a focus in subsequent steps. – Often a person who is at risk may not initially report ideation or intentions of suicidal or homicidal behavior. – A client also must be stabilized enough to progress through the intervention tasks of this model and collaborate in the intervention plan. Four Essential Crisis Assessment Tasks (2 of 4) • Assessment Task 2: Follow a Holistic Biopsychosocial-Spiritual Approach – Crisis counselors should thoroughly assess a client for physical, medical, substance, psychological, social, spiritual, and other concerns. – If medical and other issues the client faces are not assessed, the diagnosis of the client may be incorrect, leading to an ineffective and inappropriate treatment plan or referral. – It is essential to assess the baseline functioning of the client during the present crisis and prior to the crisis. Later, the goal may be to formulate a plan that moves the person back to precrisis functioning or to develop a new baseline. – This task model follows an ABCDE assessment approach (affect, behaviors, cognitions, development, and environment). Four Essential Crisis Assessment Tasks (3 of 4) • Assessment Task 3: Clarify the Problem(s) – Although a client may present initially with a particular problem (which should be taken into consideration), the actual problem may not be known until a complete history is taken. – During this task, active listening, offering unconditional positive regard, and being nonjudgmental are essential. Empathically phrased yet challenging questions may be required to understand the actual crisis so that an effective action plan can be developed. Four Essential Crisis Assessment Tasks (4 of 4) • Assessment Task 4: Explore Coping Skills, Resources, and Supports – After clarification of the problem(s), crisis counselors explore the coping skills, resources, and supports that were available to the client when dealing with past crises and adjustments. – The client and counselor also discuss potential new resources, coping skills, and supports that the client may not be aware of or may not have used in the past. – Counselors assess these resources using a variety of research-based approaches, including resilience-based, positive psychology, hope-based, and wellness models. Four Essential Crisis Intervention Tasks (1 of 4) • Intervention Task 1: Normalize and Educate – A vital aspect of crisis intervention is to normalize a person’s response to the crisis. ▪ Often, clients experience normal reactions (e.g., fear, abandonment, hopelessness, loss of control) to an abnormal event. – Clients in crisis are feeling and thinking that things are out of control, they may be unable to control their feelings and thoughts as they typically do in other situations or do not like the feelings and thoughts they are experiencing. – Teaching clients that many of their feelings and thoughts are normal can remove much of the power the client perceives the crisis to have. Four Essential Crisis Intervention Tasks (2 of 4) • Intervention Task 2: Explore Options – The crisis counselor and client should collaboratively explore and evaluate all the options known to the client, as well as those developed by the counselor. – The intent is to work collaboratively in developing a plan for the safety of the person or others. ▪ In cases where the client is not able to commit to any plan involving safety, the counselor may have to move to a more directive approach. – The safety of the crisis counselor is as important as the safety of the client in crisis; therefore, if there is any sense of potential harm by the client, the crisis counselor should make personal safety a priority. Four Essential Crisis Intervention Tasks (3 of 4) • Intervention Task 3: Develop a Plan and Obtain a Commitment – The intervention plan is individualized and based on the comprehensive assessment of the client. – The counselor must consider the risk factors, biopsychosocial-spiritual elements; medical information; and coping skills, supports, and resources. – The plan should be documented as part of the discharge summary when referring the client to another mental health professional and used as a plan for follow-up. – Client commitment is essential for ownership and responsibility. Plans should have attainable and measurable goals to demonstrate progress. Four Essential Crisis Intervention Tasks (4 of 4) • Intervention Task 4: Prepare Documentation, Follow Up, and Provide Referrals – In a typical crisis, a client may be referred to another mental health professional in the community for continued or long-term care to meet client needs as specified in the intervention plan. – If the crisis occurred during a long-term case, documentation and follow-up must be made in a manner outlined in the plan. The ABC-X Model of Family Crisis The ABC-X Model of Family Crisis • Reuben Hill (1949, 1958) postulated the ABC-X model of family crisis. According to this theory, there is an interaction among a provoking stressor event (A), the family’s resources (B), and the meaning that the family attaches to the stressor event (C). The crisis (X), a state of acute disequilibrium and immobilization of the family system, is an outcome of this interaction. Activity • You are a counselor at a local mental health agency. You have just read the intake of a male client that you will see next week. His presenting problem is that he witnessed his brother being shot and killed. According to the A B CX Model, what might you consider in your assessment while working with this client? Activity • Complete Chapter 1 Quiz