Crisis Theory, Intervention and Counseling

Crisis Counseling:

Theory, Intervention and Practice

Four Steps

• Use open ended questions when learning survivor’s story
• Passive and Active listening (depending on the stage)
• Reflective Statements
• Inquire about past coping methods
• Identify personal resources (strengths)

• I get the feeling . . .
• I get the impression . . .
• I’m hearing that . . .
• It sounds to me like . . .
• I sense you’re . . .
• I’m wondering if . . .
• Tell me about it . . .
• I’d like to hear more . . .
• I’d be interested in understanding. . .
• How is it that . . .

“Situations for use include unexpected deaths of loved ones from natural causes, homicides, suicides, house and apartment fires, motor vehicle accidents in which someone has been seriously injured, child and adult drownings, domestic violence, sexual assaults, bomb threats, and gunshot wounds.” (Cacciatore, Carlson, Klimek, Michaelis & Steffan, 2011).

Application

• A person in crisis is the one who determines whether or not he or she is experiencing a crisis
• What is a crisis to one person may not be a crisis to another
• Everyone experiences stress, both good and bad, but each person reacts to stressful events differently
• Crisis intervention is short term, but research encourages counselors to refer people experiencing a crisis to local community resources for further assistance once the intervention is complete

• Asking multiple questions at once
• Questions that lead discussion off topic
• Why Questions
• Inflicting values or asking values questions
• Making Assumptions

• Cognitive Behavior Therapy
• Stress Inoculation Training
• survivors are taught a variety of different coping strategies such as progressive muscle relaxation, deep breathing, preparing for a stressor, and thought stopping
• Exposure Therapy
• use with caution
• Supportive Counseling
• normalizing survivor's reactions to a crisis
• most frequently used in rape crisis centers
• EMDR (Eye movement desensitization and reprocessing)
• Support Groups

Texas P.R.I.D.E.

“The mission of the Texas People Recovering In Spite of Devastating Events (P.R.I.D.E.) Crisis Counseling Program (CCP) is to assist individuals and communities in recovering from the effects of natural and human-caused disasters through community-based outreach and education.”

Abuse

Presenting Problems

Sexual Abuse

• Physical abuse
• Sexual abuse
• Emotional abuse
• Domestic violence
• Child abuse
• Exposure to violence

• Helplessness
• Mental confusion and disorganization
• Decision making and problem solving difficulties
• Intense anxiety
• Shock, denial and disbelief
• Anger, agitation and rage
• Lowered self esteem
• Fear
• Body or hand tremors
• Withdrawal from others
• Emotionally subdued, depressed
• Grief
• Apathy

• Rape Crisis Centers
• Acute vs. Non acute contacts
• more active and directive
• Assess degree of crisis
• Self Harm
• Suicidal
• Harm towards others
• Rape Crisis Hotline
• Repeat callers
• Anonymous
• Self-blame, guilt, shame
• Consider age, relationship to attacker, and possible need legal action

(Mitchell, 2010)

(Prins & Ruzek)

Crime-Related Violence

• Robbery
• Arson
• Shootings
• Murder
• Suicide
• Car accidents
• Any physical or emotional harm out of the control of the client

Core Components

Settings for Use

Nuts and Bolts

History

1920's: WWI aftermath and reintegration

1930's: Great Depression and

weather-based tragedy

1940's: Cocoanut Grove Club Fire and WWII

immigration and reintegration

1950's: Development of PTSD and

grief framework

• Crisis counseling is related to reestablishing homeostasis
• According to Caplan: “crisis is provoked when a person faces a problem for which he appears not to have an immediate solution and that is for a time insurmountable through the utilization of usual methods of problem solving” (Poal, 1990, p. 123)
• Coping is an overall objective of crisis intervention (Sandoval)

1960's: Crisis centers, suicide prevention centers and hotlines

1970's: Crisis field establishes solid techniques, focus shifts from community to individual experience

1980's-1990's: Expansion to fields of military,

schools, medical settings, emergency response, businesses and communities

2000's: Development of ACT based on

September 11th

(Mitchell, 2010)

Large-Scale Disasters

Main Goals of Crisis Counseling

Primary Founders

• Relief of symptoms
• Restoration to the optimal level of functioning that existed before the present crisis
• Understanding of the relevant precipitating events that contributed to the state of desquilibrium
• Identification of remedial measures that can be taken by the client or family that are available through community resources

• Erich Lindemann
• Psychologist at Boston Medical Center
• Grief and bereavement work
• Primary contributions to crisis perspectives and theory
• Symptoms coinciding with the expereince of loss and following grief
• Established the basic framework for defining symptomatology of a crisis
• Gerald Caplan
• Researcher at Harvard University
• PTSD and WWII immigration work
• Primary contributions to crisis perspectives and theory
• Gave definition to crisis
• Suggested that crisis is defined by the individual's perception of the surrounding events

• Natural disasters
• Fires
• Tsunamis
• Hurricanes
• Earthquakes
• Mass shootings
• Hostage situations
• Terrorist attacks

(Poal, 1990)

(Poal 1990)

Four Steps of Crisis Intervention

Secondary Contributors

Establishing Communication

• Establishing Communication (Education)
• Dealing with emotions (Offering support)
• Identifying the precipitating event(s)(Assessing the situation)
• Problem solving (Developing coping skills)

• Rappoport
• Defined three factors that create a crisis
• Defined three categories of crisis
• Defined four goals for crisis intervention
• Parad
• Characterized crisis to be individually perceived
• Defined characteristics of crisis
• Suggesting coping skills and tasks to aid in client adaptation
• Baldwin
• Defined seven categories of emotional crisis
• Included the presence of pre-existing psychopathology in defining crisis and emergencies
• Roberts
• ACT--Assess, Crisis, Trauma Treatment
• Seven stage crisis intervention model and ten step acute traumatic stress management protocol

Life Changes

(Poal, 1990)

• When speaking to the person in crisis, speak slowly and calmly
• Choose your words, tone, and manner with care.
• Communication is more effective if it is deliberate, methodical, and non-judgmental
• How you come across to the person in crisis will determine whether or not he or she will be receptive to you

(Vecchi 2009)

• Divorce
• Death
• Loss of resources
• Joblessness
• Homelessness
• Sudden illness or impairment
• Intervention by CPS/APS
• Situations that change daily life without the consent or control of the individual
• Role of the therapist: “This may consist of acting as a liaison between responding staff and the family; providing accurate, straightforward information to the family in a timely manner; allowing the family to process their thoughts or feelings on the basis of their perceptions of what occurred; ensuring that the family members' needs are met; and activating supports for the family.”

(Vecchi 2009)

Important Notes

(Cacciatore, Carlson, Klimek, Michaelis & Steffan, 2011)

What to Avoid

Evaluation

Dealing with Emotions

• Emotions are universal
• A person’s experiences are unique
• We all have felt similar emotions before, but that does not mean we know what a person is experiencing or feeling during a crisis

Intersections

Empirical Testing

(Vecchi 2009)

Crisis counseling is offered in from a variety of theoretical perspectives to a wide range of populations and their presenting problems

• Seek to establish culturally competent practice
• Recognize the importance of culture and respect diversity
• Maintain a current profile of the cultural composition of the community
• Recruit disaster workers who are representative of the community or service area
• Provide ongoing cultural competence training to disaster mental health staff
• Ensure that services are accessible, appropriate, and equitable;
• Recognize the role of help-seeking behaviors, customs and traditions, and natural support networks
• Involve community leaders and organizations representing diverse cultural groups as "cultural brokers"
• Ensure that services and information are culturally and linguistically competent
• Assess and evaluate the program's level of cultural competence

Limitations of the Model

• Greene, Norris, Rosen & Young: 'Tailoring disaster mental health services to diverse needs: an analysis of 36 crisis counseling projects'
• Aim: Test whether projects that reported taking actions to address diverse community needs were more successful in reaching all segments of the affected population

• “When early interventions take place in a group format, there is a potential for a contamination effect to occur” (Berkowitz, p. 299, 2003)
• Re-traumatization is possible if crisis counselor is not skilled
• Risk of pathologizing events for families and making them feel inadequate in overcoming a crisis (assuming certain events are a crisis for all)
• Short-term by nature, leaving little time and space for a well-developed working relationship
• Attachment between client and counselor can be unhealthy if client views counselor as their only help
• Biases and unpredictability as related to the social worker in the crisis response role

(Greene, Norris, Rosen, Young, 2010)

Crisis counseling is community and client-based, therefore testing must be specific to the community and client base.

Conflicts

Beliefs, rooted in culture, can affect a person's help-seeking behaviors

"Social workers need self-knowledge to be aware of how the experience of assisting those who have been traumatized or are in crisis is affecting them. Some calls can "hit close to home" because of personal experiences or losses. Being aware of their own sensitivities around certain issues can help workers maximize effectiveness by getting supervision or support and instituting self-care activities if necessary.”

• Examples:
• African-American culture
• Asian-American culture
• Pastoral counseling bias
• Connections to minority groups
• Connections to marginalized groups

Berkowitz, S. J. (2003). Children Exposed to Community Violence: The Rationale for Early Intervention. Clinical Child & Family Psychology Review, 6(4), 293-302.

Identifying Precipitating Events

"Another important factor is that recovery occurs in a community context. People coming together, mobilizing social support, and making meaning of the event are important aspects of recovery after a disaster. These social processes are shaped by culture. [Crisis] services should therefore support and work in consonance with culturally sanctioned processes for recovery.”

• The straw that broke the camel’s back, as it is sometimes referred
• Counselors have to understand what triggered a person’s crisis in order to best serve them
• Identifying and dealing with the emotions of a person in crisis corresponds with identifying the events that triggered his or her feelings

(Greene, Norris, Rosen, Young, 2010)

Problem Solving

References

Additional Therapy Models

Techniques

(Vecchi 2009)

• The process where the counselor or helping professional helps the person in crisis explore other alternatives and possible solutions to the crisis.
• Here the counselor can incorporate Solution Focused Therapy techniques
• “Part of effective problem-solving involves listening for distorted thinking on the part of the person in crisis. As a result of life experiences, individuals develop different patterns of thinking” (Vecchi, 2009, p. 58).
• Cognitive Behavior Therapy techniques will help work through the cognitive distortions

Work with Children

(Vecchi 2009)

(Prins & Ruzek)

• Children are resilient and often require less intervention
• Stability from the parent or caregiver is impactful
• Primary goals when working with children
• Making contact
• Providing safety
• Stabilizing affect
• Addressing needs and concerns
• Providing practical assistance
• Facilitate connections with social supports
• Facilitating coping
• Create linkages with needed collaborative services

• Berkowitz, S. J. (2003). Children Exposed to Community Violence: The Rationale for Early Intervention. Clinical Child & Family Psychology Review, 6(4), 293-302.
• Cacciatore, J., Carlson, B., Klimek, B., Michaelis, E., & Steffan, S. (2011). Crisis intervention by social workers in fire departments: an innovative role for social workers. Social Work,56(1), 81+.
• Greene, C. J., Norris, F. H., Rosen, C. S., & Young, H. E. (2010). Tailoring disaster mental health services to diverse needs: an analysis of 36 crisis counseling projects. Health and Social Work, 35(3), 211+.
• Mitchell, J. (2010). Important crisis intervention background and terminology. Critical incident stress management, 6(1), 6-8.
• Poal, P. (1990). Introduction to the theory and practice of crisis intervention. Quaderns de psicologia, 10(1), 121-140.
• Prins, A., & Ruzek, J. (n.d.). Techniques of Crisis Intervention. Support for Survivors. Retrieved November 24, 2012, from http://www.ok.ngb.army.mil/j1/sarc/sarc_documents/Reports_and_Articles/Techniques_Application.pdf
• Sandoval, J., Scott, A., & Padilla, I. (2009). Crisis counseling: An overview. Psychology In The Schools, 46(3), 246-256.
• Sullivan, M., Harris, E., Collado, C., & Chen, T. (2006). Noways tired: Perspectives of clinicians of color on culturally competent crisis intervention. Journal Of Clinical Psychology, 62(8), 987-999.
• Texas P.R.I.D.E. Crisis Counseling. (n.d.). Texas Departmet of State Health Services . Retrieved November 25, 2012, from www.dshs.state.tx.us/mhsa/pride/
• Vecchi, G. M. (2009). CONFLICT & CRISIS COMMUNICATION: Methods of Crisis Intervention and Stress Management. Annals Of The American Psychotherapy Association, 12(4), 54-63.

Guiding Principles of Texas P.R.I.D.E.

(Prins & Ruzek)

(Sandoval, J., Scott, A., & Padilla, I. 2009)

• Strengths-Based – CCP services promote resilience, empowerment, and recovery.
• Anonymous – Crisis counselors do not classify, label, or diagnose people; no records or case files are kept.
• Free – The services are provided without any cost to participants.
• Outreach Oriented – Crisis counselors deliver services in the communities rather than waiting for survivors to seek assistance from them.
• Conducted in Nontraditional Settings – Crisis counseling services may take place in homes, retail outlets, places of worship, or any setting requested by a survivor. These services do not take place in clinical/office settings.
• Designed to Strengthen Existing Community Support Systems – The CCP supplements, but does not replace, existing community systems.

http://www.dshs.state.tx.us/mhsa/pride/

Active Listening Techniques

(Prins & Ruzek)