HN499 Bachelor’s Capstone for Human Services Unit 5: Crisis Intervention Deborah 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: 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 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

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

Crisis and stress are NOT the same thing. Formula for Understanding the 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 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."

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?