HN499 Bachelor’s Capstone for Human

Services

Unit 5: Crisis InterventionDeborah Smith

Prepared by Cathy Moore

Crisis Intervention… “emotional first aid” (Rosenbluh, 1981)

Emotional equivalent of physical first aid Must be applied skillfully and timely [within 2 to

3 weeks after event leading to crisis] Act immediately to stop the emotional bleeding;

attempt to Relieve anxiety Prevent further disorientation Ensure that suffers do not harm themselves

or cause harm to others Is to emergency room medicine what a

medical practice is to psychotherapy practice

Crisis defined… “an obstacle that is, for a time,

insurmountable by the use of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many abortive attempts at a solution are made … an upset in the steady state of the individual.” -- Gerald Caplan, 1961 [father of modern crisis intervention theory]

A Crisis can occur when any event leads a person to look for an immediate solution to an acute situation.

If a solution to the event is found, no matter how reasonable or not, there is not a crisis.

If a solution is not found, a Crisis state ensues.

Stress-Producing Situations may lead to

Crisis: Changes in family

dynamics or structure – separation, divorce, blended family, gaining new family member

Economic changes Community changes Significant life events Natural disasters Entry to school/college Being arrested Physical illness

Change in job/career Acute episodes of

mental disorder Sexual difficulties Auto accident – with

or without injury Death of loved one Major illness of family

member Actual or impending

loss of something significant in one’s life

A Crisis Leads to Decrease or Change in Functioning *[Different people indicate crisis in

different ways]; i.e. cry, explode, verbalize, withdrawal, depression

Emotional/psychological Feel sad, angry, miserable

Cognitive Thinking is confused, ‘fuzzy’

Behavior Risk-taking, non-ordinary

EMOTIONAL Signs & Symptoms of Psychological Reactions to

Crisis Shock Denial Insecurity Fatigue uncertainty Fear Helplessness Depression Panic Despair

Frustration Inadequacy Anger Feeling out of control Numbness Grief Outrage Irritability Survivor guilt

COGNITIVE Signs & Symptoms of Psychological Reactions to Crisis

Confusion Poor attention span Poor concentration Flashbacks

Loss of trust Difficulties in decision

making Nightmares

BEHAVIORAL Signs & Symptoms of Psychological Reactions to

Crisis

Withdrawal Angry outbursts Change in appetite Increased fatigue Excessive use of sick

leave Alcohol or drug abuse Frequent visits to

physician for nonspecific complaints

Spending sprees

Anger remarks to God Loss of desire to attend

religious services Crying Preoccupation with

crisis to exclusion of other areas of life

Diminished job/college performance

Hysterical reactions

Formula for Understandingthe Process of Crisis Formation:

A Triology Definition

• Precipitating Event Occurs • Perception of Event Leads to Subjective

Distress leads to Impairment in Functioning• Coping Skills Fail to Improve Functioning

Crisis and stress are NOT the same thing.

Cognitive Key is the most Crucial part of understanding

Crisis: Perception

Cognitive Key: ‘the meaning a person gives to the event’

Role of Crisis worker is to ‘unlock’ or ‘reframe’ person’s perception of event = increase functioning

The most difficult part of a crisis to diagnose The most easily and quickly altered by counselor Goal of CI is to help restore functioning level,

never to change the precipitating event.

Crisis as Danger and Opportunity

Opportunity:1. With help / Counseling / Intervention, the

individual survives the crisis with increased coping skills, emotional growth, and resources which prepare him for future stressors.

Danger:2. Without Help, the individual may return to a

lowered level of functioning by use of the ego defense mechanisms or remain nonfunctional via suicide, homicide, or psychosis.

With same event, some are thrown into crisis and others

are not…Why?

Material Resources: money, shelter, transportation, food, clothing

Personal Resources: ego strength, personality traits, physical well-being, intelligence and education

Social Resources: friends, family, school mates, co-workers, church, clubs

TYPES OF CRISES Developmental: normal, expected,

transitional phases as people move from one stage of life to another. People often unable to cope with evolving needs of family members

Situational: uncommon, extraordinary events. No way of forecasting or controlling them, emergency quality

THE ABC MODEL OF CRISIS INTERVENTION

A: Developing strong rapport Basic attending skills CI worker perceived by client as empathic, present,

nonjudgmental, genuine B: Identifying the nature of the crisis and altering perceptions

Most important phase of CI model Using skills in Phase A, identify precipitating event,

perspective, subjective distress, current and previous functioning

Provide new ways for client to think about, perceive, process the situation

C: Offering coping skills Encourage & listen to client’s ideas for coping before

offering CI worker’s ideas Plan for Follow-up of some type

A: DEVELOPING AND MAINTAINING RAPPORT

Foundation of CI – Rapport, trust, open “People don’t care what you know, until

they know how much you care.” Purpose: ‘to develop rapport’ - invites

client to talk, bring calm to situation, allow client talk about facts & express feelings, allows counselor to hear, empathize, respect.

Gain clear understanding of internal experience of crisis as client sees it.

Open-ended Questioning Most effective way to invite client to talk Allow for exploration of what the client just

said Begin with “how” and “what” Attach the question with something the

client just said Don’t ask “why” questions: tends to create

defensiveness Avoid “have you” questions, they are

usually forms of hidden advice

Closed-ended Questions Questions such as “do you”, “does it”, and

“are you” lead to answers such as “yes” and “no” which go nowhere. Change them into what and how questions.

Be specific and direct. Avoid “would you mind”, “could you tell me

more”. Direct the client about what to explore

A: SUMMARIZATION Purpose: help client pull together his/her

thoughts This helps move the interview along and

into other areas, such as the C section. Useful when the counselor is not sure

where to lead the client. Includes emotions, facts, cognitions

disclosed throughout the entire session

Note…. Developing rapport is ongoing Must develop rapport at the

beginning – establish trust But also must continue to foster

rapport throughout to maintain trust and encourage a more successful interaction.

B: IDENTIFYING THE PROBLEM

Counselors need to identify the nature of the crisis: precipitating events cognitions about these events emotional distress how the client is functioning

socially, academically, occupationally, and behaviorally since the crisis.

Identifying Precipitating Event

Important to learn what is going on with client “What brings you here today” “What prompted you to call for an appt?

Learn how client has been trying to cope since event happened: difficulty has brought them here

Identify client’s perception about event –what it means to him/her now

Review formula for understanding Crisis Formation

ETHICAL ISSUES Counselor must assess directly or

indirectly for the following: suicide child abuse elder and disabled adult abuse danger to others medical or organic illness, substance

abuse Examples p. 84-85

Therapeutic Interaction Statements

Validation & Support Educational Empowering Reframing

Therapeutic Interaction Statements: Validation &

Support these make clients feel that their

point of view and subjective experiencing is valid and that the counselor empathizes with their plight.

Counselor lets clients know that their feelings are normal and difficult.

Say things that friends/family probably wouldn’t say

Validation & Support Statements

NOT “It’s okay.” or “Don’t worry.” or “Forget about it.”

“I know that you feel like everything is falling apart right now, but many people have gone through the same situation and have survived. You have every reason to believe you can survive too.”

Therapeutic Interaction Statements: Educational

counselor offers factual information based on counselor knowledge about various aspects of the client’s crisis.

This helps normalize the experience or corrects false ideas the client might hold.

Educational Statements

Based on facts and research (things you could learn from annotated bibliography types of resources)

“30% of women live in abusive situations.”

63% of rape victims are raped by someone they know – a partner or an acquaintance.”

Therapeutic Interaction Statements: Empowering

these comments help the client feel more powerful and in control.

Counselor points out choices available and how client can overcome feelings of helplessness.

Empowering Statements “You did not have a choice in being

raped, but you do have a choice of what you do now. You have the choice to call the police, go to court, tell a friend, or not do any of these things. You alone control that decision. Let’s talk about your feelings and thoughts on each of those choices.”

Therapeutic Interaction Statements: Reframing

helps the client view the situation from a slightly different point of view using the client’s frame of reference.

Sometimes a positive perspective is changed into a negative one, sometimes a negative perspective is changed into a positive one.

Probably one of the strongest healing skills available

Reframing Statements First understand the client’s frame

of reference (can’t “reframe” if you don’t know the “frame”) – ask open ended questions.

"The art of reframing is to maintain the conflict in all its richness but to help people look at it in a more open-minded and hopeful way."

Initial frame Reframe I am in a tunnel and I can’t see a way out.

Every tunnel has an entrance and exit.

I am too anxious to study. You need to be anxious enough to concentrate.

I know I will never be confident. Being confident starts with having insights about our limits.

When he/she looks at me like that he/she hates me.

People cover up their hurt by putting a scowl on their faces.

He hits me because I do stupid things and deserve it.

People who hit are insecure and trying to control other people through violence. No one deserves that.

I am never going to get over this pain. You can choose to let go of hurtful feelings.

Examples of Reframing Statements

C: COPING Have client explore their own attempts at coping

and think of what they would like to do now. Counselor then offers alternative coping ideas

such as referrals to support groups, 12 step groups, long term, family, or marital therapy, shelters or other agencies, physicians & lawyers

Sometimes counselors might recommend that clients journal, or read books, view films or participate in assertive training or stress management courses.

Discussion… Why is it so important to provide

crisis intervention before moving on to more in-depth intervention?

What unique challenges might professionals face when working with people in crisis that they might not face when working with other clients?