Crisis intervention

Crisis intervention is an immediate and short-term psychological care aimed at assisting individuals in a crisis situation in order to restore equilibrium to their biopsychosocial functioning and to minimize the potential of long-term psychological trauma.^[1][2] Crisis can be defined as one's perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person's current resources and coping mechanisms.^[3]

Crisis situations can be in the form of natural disasters, severe physical injury, sudden death of a loved one, and specific emotional crises as a result of drastic transitions such as divorce, children leaving home, pregnancy, or family and school violence.^[4]

The priority of crisis intervention and counseling is to increase stabilization. Crisis interventions occur at the spur of the moment and in a variety of settings, as trauma can arise instantaneously. Crises are temporary, usually with short span, no longer than a month, although the effects may become long-lasting.^[5]

Crisis

An example of a crisis situation.

Crises can occur on a personal or societal level. Personal trauma is defined as an individual's experience of a situation or event in which he/she perceives to have exhausted his/her coping skill, self-esteem, social support, and power. These can be situations where a person is making suicidal threats, experiencing threat, witnessing homicide or suicide, or experiencing personal loss. While a person is experiencing a crisis on the individual level it is important for counselors to primarily assess safety. Counselors are encouraged to ask questions pertaining to social supports and networks, as well as give referrals for long term care.

Societal or mass trauma can occur in a number of settings and typically affects a large group or society such as school shoot-outs, terrorist attacks, and natural disasters. A counselor's primary concern when called to these types of crises is to assess people's awareness of resources. Individuals experiencing trauma in a large scale need to be aware of shelters that offer food and water and places that meet their basic necessities for survival.^[6]

Signs of crisis

Counselors are encouraged to be aware of the typical responses of those who have experienced a crisis or are currently struggling with a trauma. On the cognitive level, they may blame themselves or others for the trauma. Often, the person appears disoriented, becomes hypersensitive or confused, has poor concentration, uncertain, and poor troubleshooting capabilities. Physical responses to trauma include increased heart rate, tremors, dizziness, weakness, chills, headaches, vomiting, shock, fainting, sweating, and fatigue. Among the common emotional responses of people who experience crisis in their lives include apathy, depression, irritability, anxiety, panic, helplessness, hopelessness, anger, fear, guilt, and denial. When assessing behavior, some typical responses to crisis are difficulty eating and/or sleeping, conflicts with others, withdrawal and lack of interest in social activities.^[1]

Universal principles

There are five basic principles outlined for intervention for individuals dealing with personal and societal crisis:

• Prompt intervention – Since victims are initially at high risk for maladaptive coping or immobilization. providing intervention as quickly as possible is imperative. Resource mobilization should be immediately enacted in order to provide victims with the tools they need to return to some sort of order and normalcy, in addition to enable independent functioning.
• Facilitate comprehension – processing the situation or trauma is necessary in order for the sufferer to understand what the traumatic event was all about. This is done in order to help the victim gain a better understanding of what has occurred and allowing him or her to express feelings about the experience.
• Problem-solving – The counselor should assist the victim(s) in resolving the issue within the context of their situation and feelings. This is necessary for developing self-efficacy and self-reliance.
• Return to normalcy – counselor must help the victim get back to being able to function independently by actively facilitating problem solving, assisting him/her in developing appropriate strategies for addressing those concerns, and in helping putting those strategies into action. This is done in hopes of enabling the victim to become self-reliant.^[7]

General approach

A general approach of crisis intervention integrates numerous assessment tools and triage procedures. Roberts' 7-Stage Crisis Intervention Model, SAFER-R Model and Lerner and Shelton's 10-step acute stress & trauma management protocol creates one comprehensive model for responding to crisis that can be utilized in crisis situations.

The ACT (Assessment Crisis Intervention Trauma Treatment) model of crisis intervention developed by Roberts as a response to the September 11, 2001 tragedy outlines a three-stage framework.^[8] This tool is a guide and not to be followed rigidly.^[9]

The first step is the assessment stage; this is done by determining the needs of victims, other involved persons, survivors, their families, and grieving family members of possible victim(s) and making appropriate referrals when needed.

These are the three types of assessments that need to be conducted:^[10]

1. Triage assessment - an immediate assessment to determine lethality and determine appropriate referral to one of the following: emergency inpatient hospitalization, outpatient treatment facility or private therapist, or if no referral is needed;
2. Crisis assessment - consists of gathering information regarding the individual's crisis state, environment, and interpersonal relationships to be used in working towards resolving the current crisis. This step helps facilitate development of an effective and appropriate treatment plan.
3. Biosocial and cultural assessment - systematic assessment tools are used to ascertain the client's current levels of stress, situation, present problem, and severe crisis episode.^[11]

The goal of the crisis intervention stage of Roberts' ACT model is to resolve the client's present problems, stress, psychological trauma, and emotional conflicts. This is to be done with a minimum number of contacts, as crisis intervention is intended to be time-limited and goal-directed.

1. Intake and Assessing the person who is in Crisis/Suffering from the aftereffects of Crisis

Stage one of the seven step approach focuses on assessing lethality. The clinician is to plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment; this should be done promptly at the time of arrival. Once lethality is determined one should establish rapport with the victim(s) whom the clinician will be working with.

2. Exploring the Crisis Situation of the person

The next phase is to identify major problem(s), including what in their life has led to the crisis at hand. During this stage it is important that the client is given the control and power to discuss their story in his or her own words.

3. Understanding the Coping Style employed by the person

While he or she is describing the situation, the intervention specialist should develop a conceptualization of the client's "modal coping style", which will most likely need adjusting as more information unfolds. This is referred to as stage three.

4. Confronting Feelings, Exploring Emotions and Challenging the Maladaptive Coping Style

As a transition is made to stage four, feelings will become prevalent at this time, so dealing with those feelings will be an important aspect of the intervention. While managing the feelings, the counselor must allow the client(s) to express his or her story, and explore feelings and emotions through active listening and validation. Eventually, the counselor will have to work carefully to respond to the client using challenging responses in order to help him or her work past maladaptive beliefs and thoughts, and to think about other options.

5. Exploring Solutions and Educating the client in best practices of Coping

At step five, the victim and counselor should begin to collaboratively generate and explore alternatives for coping. Although this situation will be unlike any other experience before, the counselor should assist the individual in looking at what has worked in the past for other situations; this is typically the most difficult to achieve in crisis counseling.

6. Developing a concrete treatment plan/structure of activities and Reassuring the clients newly gained healthy perspective

Once a list has been generated, a shift can be made to step six: development of a treatment plan that serves to empower the client. The goal at this stage it to make the treatment plan as concrete as possible which could be followed by the client and implemented as an attempt to make meaning out of the crisis event. Having meaning of the situation is also an important part of this stage because it allows for gaining mastery.

7. Follow-Up

Step seven is for the intervention specialist to arrange for follow-up contact with the client to evaluate his or her post crisis condition in order to make certain resolution towards progressing. The follow-up plan may include "booster" sessions to explore treatment gains and potential problems.^[8]

SAFER-R Model

The SAFER-R Model is a much used model of intervention^[12] with Roberts 7 Stage Crisis Intervention Model. The model approaches crisis intervention as an instrument to help the client to achieve his or her baseline level of functioning from the state of crisis. This intervention model for responding to individuals in crisis consists of 5+1 stages.

They are:^[13]

1. Stabilize
2. Acknowledge
3. Facilitate understanding
4. Encourage adaptive coping
5. Restore functioning or,
6. Refer

Lerner and Shelton's 10 step acute stress & trauma management protocol^[14]

A comprehensive view of how to treat the trauma consists of ten stages outlined by Lerner and Shelton (2001). These 10 steps relate similar to the crisis intervention steps.

• The first step is to assess for danger/safety for self and others, this means for the victim, counselor, and others who may have been affected by the trauma.
• Then consider the physical and perceptual mechanisms of injury.
• Once injury is assessed the victim's level of responsiveness should be evaluated.
• If any medical needs are there, it should be addressed.
• The individual who witnessed or is experiencing a crisis, should be observed to identify his or her signs of traumatic stress.
• After the assessment of the situation is completed the counselor should introduce his or her self, state their title and role, and connect with the individual by building rapport.
• A good rapport building allows for a more fluid approach in grounding the individual, this can be done by allowing the client/person to tell their story.
• The interventionist provides support through active and empathetic listening,
• Normalize, validate, and educate the individuals emotions, stress and adaptive coping styles.
• Finally, the intervention specialist is to bring the person to the present, describe future events, and provide referrals as needed.

After the crisis situation has been assessed and crisis interventions have been applied, the aim is at eliminating stress symptoms, thus treating the traumatic experience.

Non-violent approach

Non-violent approach in crisis intervention for agitation management involves better understanding of Proxemics (Personal space of a person) and Kinesics (Nonverbal communication through postures).^[15] It helps to reduce anxiety, escalations and disruptions in agitated incidents and reduces use of restraints by 25%.^[16]

Criticisms

When using crisis intervention methods for the disabled individual, every effort should first be made to first find other, preventative methods, such as giving adequate physical, occupational and speech therapy, and communication aides including sign language and Augmentative Communication systems, behavior and other plans, in order to first help the handicapped individual to be able to express their needs and function better. Too often, crisis intervention methods including restraining holds are used without first giving the disabled more and better therapies or educational assistance. Often school districts, for example, may use crisis prevention holds and "Interventions" against disabled children without first giving services and supports (at least 75% of cases of restraint and seclusion reported to the Department of Education involved disabled children in the 2011-12 school year.) Also, school districts fail to inform parents about their disabled child's "intervention" with restraint or seclusion, thereby providing little, if any, opportunity for the family to help the disabled child recover. Congress is trying to curtail the use of restraint and seclusion by school districts, having proposed legislation "Keeping All Students Safe Act" which had bi-partisan support but the bill has repeatedly died in committee. It will be re-introduced in 2015 by Senator Chris Murphy (CT). Critical incident debriefing is a widespread approach to counseling those in a state of crisis. This technique is done in a group setting 24–72 hours after the event occurred, and is typically a one-time meeting that lasts 3–4 hours, but can be done over numerous sessions if needed. Debriefing is a process by which facilitators describe various symptoms related PTSD and other anxiety disorders that individuals are likely to experience due to exposure to a trauma. As a group they process negative emotions surrounding the traumatic event. Each member is encouraged continued participation in treatment so that symptoms do not become exacerbated.^[17]

Critical incident debriefing has been criticized by many for its effectiveness on reducing harm in crisis situations. Some studies show that those exposed to debriefing are actually more likely to show symptoms of PTSD at a 13-month follow-up than those who are not exposed to the debriefing. Most recipients of debriefing reported that they found the intervention helpful. Based on symptoms found in those who received no treatment at all, some critics state that reported improvement is considered a misattribution, and that the progress would naturally occur without any treatment.^[18]

References

• Greenstone, J.L. & Leviton, Sharon. (1993, 2002,2011). Elements of crisis intervention: Crises and how to respond to them, Third Edition. Pacific Grove, CA: Brooks/Cole Publishing Company, Thomson Learning.
• Greenstone, J.L. (2005). The elements of police hostage and crisis negotiations: Critical incidents and how to respond to them. Binghamton, New York: The Haworth Press, Inc.
• Greenstone, J.L.(2008). The Elements of disaster Psychology: Managing psychosocial trauma – An integrated approach to force protection and acute care. Springfield, Illinois: Charles C. Thomas, Publishers.
• Greenstone, J.L. & Leviton, Sharon (1981). Hotline: Crisis intervention directory. New York: Facts on File.
• Greenstone, J.L. & Leviton, Sharon (1982). Crisis intervention: Handbook for interveners. Dubuque: Kendall-Hunt.
• Greenstone, J.L.& Leviton, Sharon. (1983). Crisis intervention. In Raymond Corsini (ED) Encyclopedia of Psychology. New York: John Wiley and Sons.

External links

• Responding to persons with mental illness can screening checklists aid law enforcement
• Crisis internvetion teams responding to mental illness crisis calls

Journals of crisis intervention research:

• Crisis: The Journal of Crisis Intervention and Suicide Prevention