Crisis Counseling

There are many definitions of what constitutes a crisis sufficient to bring a person to counseling. Richard K. James and Burl E. Gilliland defined a crisis as the perception of an event or situation as intolerable and one that exceeds the immediately available resources and coping mechanisms of the person. Unless the person obtains relief, the crisis has the potential to cause severe affective, cognitive, and behavioral malfunctioning. Crisis is both universal and idiosyncratic. No matter how resilient one is, if the duration and intensity of the crisis is severe enough, no one is immune from breaking down. Crisis is also idiosyncratic because what one person may successfully overcome, another may not, even though the circumstances are virtually the same.

For most people, crises are time limited, lasting from 6 to 8 weeks. At the end of this time, people should regain a sense of equilibrium. However, this does not mean the fallout from the crisis is resolved. It simply means people should recover the capacity to function on a day-to-day basis. If resolution of the crisis does not continue or is impeded, the problems stemming from the crisis can become pervasive. The problems will change from an acute state to a chronic state wherein the individual is constantly at risk to fall back into a continuous cycle of crisis. If this happens, the person will be in a transcrisis state.

History of Crisis Counseling

It has only been within the past 60 years that crisis intervention has grown into a field of its own with specific theories and techniques. Groundbreaking work by Erich Lindemann with the survivors of the Boston Cocoanut Grove fire of 1942 and Gerald Caplan’s extension of that work forms much of the foundation for crisis intervention. Two historical events in the 1970s hallmark the birth and evolution of crisis intervention as a clinical specialty. The first was the Vietnam War and the perplexing psychological trauma that veterans carried out of it. The second was the women’s movement that exposed domestic violence in its many forms. It became clear that no one is immune from the severe emotional distress and psychological disequilibrium that could result from exposure to traumatic events.

There are numerous factors that stand out as influencing the growth of crisis intervention as a clinical subspecialty.

  1. Suicide. The possibility of dealing with suicidal clients is ever present and is prevalent in all age and racial/ethnic groups. The resulting development of early research on the causes of suicide and suicide intervention techniques by Edwin Shneidman has been one of the seedbeds from which the fertile field of crisis intervention has grown.
  2. Crisis lines. The advent of telephone crisis and hotlines and, recently, the Internet, has made mental health services available to vast numbers of people who would otherwise be unable or unwilling to avail themselves of mental health services. The ease of access, constant availability, lack of cost, and anonymity of the caller have made the crisis line the most used form of crisis intervention in the world.
  3. Interpersonal violence. The discovery that more unreported or underreported interpersonal violence takes place than what was previously thought has brought this large crisis population to the attention of counselors. Interpersonal violence has far-reaching effects for the survivors that occur long past the original incident itself and form the basis for what may be called transcrisis states.
  4. Substance abuse and drug addiction. The rise of substance abuse and the smorgasbord of both prescription and illicit drugs are a fertile breeding ground for personal, interpersonal, and community crisis.
  5. Posttraumatic stress disorder. In the last four decades, posttraumatic stress disorder (PTSD) has become identified as a major mental health problem. In a world where natural disasters and human-made traumatic events occur on an everyday basis, counselors have realized that those events leave a long and wide wake of residual stress.
  6. The mentally ill on the streets. With the advent of psychotropic drugs in the 1960s, it was believed that a significant turning point had occurred in the world of mental illness. It was felt that the antipsychotic drugs would allow the large, residential, state mental hospitals to be replaced with less-restrictive community mental health clinics and halfway houses. Unfortunately, this has not happened. The negative side effects of antipsychotic medication and the lack of adequate supervision have influenced the chronically mentally ill to stop taking their medication. Psychotic symptoms quickly resurface and are further compounded when individuals use alcohol or illicit street drugs. These “dual diagnosis” clients may then have very severe and violent psychotic breaks with reality. They also may become a large part of the homeless population. As a result, police departments have become unwilling participants in the community mental health business as they attempt to contain these mentally ill individuals. Indeed, one of the largest groups of professionally trained crisis interventionists is specially trained police officers who operate on Crisis Intervention Teams.

Theories of Crisis Intervention

Crisis intervention theory is in its infancy. To date, emphasis has been on helping people recover from crisis situations rather than on theory development. However, a number of experts in the field have recognized this shortcoming and are beginning to build theoretical models for understanding crisis intervention. Their research focuses on including and using contextual issues that influence individuals’ reactions in crises. These researchers are integrating ideas from systems, adaptional, interpersonal, and ecological approaches to understand crisis intervention.

Systems crisis theory is based on the interrelationships among people and events and how they reciprocally interact with one another when a crisis occurs. The crisis of addiction, its compounding effect on the family of the addict, and the family’s enabling tactics to keep the system in maladaptive homeostasis is a classic example of systems theory in operation. Crisis intervention usually means disrupting and breaking down the old system by directly confronting the behaviors that sustain it.

Adaptional theory operates on the premise that a crisis is sustained through maladaptive behaviors. Just as maladaptive behaviors are learned, they may be unlearned and new, more constructive behaviors that are more reinforcing to the individual may replace them. The battered wife who finally leaves the abusive relationship for a shelter, completes her education, and becomes financially and emotionally independent from her abusive and controlling spouse is an example of adaptional theory at work.

Interpersonal theory is based on the belief that as long as people believe that their reference of self-evaluation is placed in others, they cannot escape the crisis. By establishing or reestablishing the locus of self-evaluation within themselves, people are able to gain or regain control of their lives and take appropriate action to overcome the crisis. The grief-stricken parents of a dead child who condemn God, or the doctors, remain stuck in their grief and cannot marshal their own intrapersonal resources to overcome the traumatic event. Regaining personal control is one of the major central axes on which crisis intervention revolves.

Ecological theory reaches beyond closed systems such as the family, school, or job site into the environment at large. Urie Bronfenbrenner’s model for human development forms the cornerstone for this influence. Ecological theory deals with the multifaceted impact of large-scale natural and human-made disasters such as hurricanes, earthquakes, bombings, and nuclear reactor meltdowns, as well as the effects these events have not only for the people themselves, but also across the environment. Ecological theory calls for crisis intervention on a massive scale in a multitude of ways that deal with the psychological and physical needs of the survivors along with repair of the environment itself.

Typologies of Crises

Crises can be categorized into four types. Although these overlap, each has unique characteristics setting it apart from the others. An understanding of these characteristics can increase counselors’ abilities to provide the appropriate intervention.

Developmental crises occur when events in the normal flux and flow of human growth are disrupted by a dramatic shift that precipitates an abnormal response. Graduation from college, marriage, a first child, job change, or retirement are all key developmental benchmarks that call for dramatic shifts in how a person operates and may occasion a crisis event. Cultural variances may play a large part in whether these developmental issues are seen as crises or not.

Situational crises occur when an uncommon event occurs that the individual has no way of forecasting or controlling. Automobile accidents, rapes, shootings, sudden illnesses, the unexpected death of a child or spouse, job loss, and divorce are all examples of unforeseen, sudden, and intense traumatic events that are far out of the realm of normal functioning. These crises generally do not have a cultural component. The crisis of being a victim of a violent crime is a crisis regardless of the culture.

Existential crises are those inner conflicts that accompany the important human issues of joy, happiness, love, responsibility, goal orientation, and self-concept. Existential crises occur when individuals suddenly realize that some important intrapersonal aspect of their lives will never be fulfilled. Finding out that a major league baseball career is beyond one’s skills after a great collegiate career, never taking a risk or having an adventure before being bedridden with arthritis, and a death bed review of one’s life as meaningless are examples of crises of self-purpose and self-worth.

Systemic crises ripple out into large segments of the population and the environment itself. Natural disasters such as Hurricane Katrina and the Indonesian tsunami wreak havoc on all parts of the ecological system across wide geographic areas. They result in death and injury, as well as the loss of basic human necessities such as food and shelter. Infrastructure services are destroyed, and the means of employment are lost because the businesses where people worked are no longer in existence. Natural and human-made disasters such as the Oklahoma City Federal Building bombing, the September 11 attacks, and school massacres not only affect the immediate victims but also psychologically impact people throughout the world via extensive media coverage. As a result, the kinds of psychological intervention applied to these crisis domains tend to be very different from those used in the normal course of psychotherapy.

Basic Crisis Intervention

Crisis intervention targets temporary affective, behavioral, and cognitive distortions generated by traumatic events and helps people recognize and correct their perceptions, feelings, and behaviors to approximate more normal precrisis functioning. Crisis intervention is based on an equilibrium/disequilibrium paradigm that has four stages: (1) disturbed equilibrium from the trauma, (2) brief therapy targeted at the trauma and disequilibrium, (3) the client’s working though the trauma, and (4) and restoration of equilibrium.

Crisis Intervention Models

There are numerous crisis intervention models now available to the counselor. Probably the most common is the equilibrium/disequilibrium model that views people as in a state of disequilibrium in comparison to their precrisis coping ability. Its aim is to use previous client coping mechanisms or new counselor-generated coping mechanisms to help clients regain equilibrium and bring maladaptive responses under control. It is most often used in early intervention when the person is out of control, disoriented, emotionally distraught, and unable to function.

A specific adaption that is representative of this model for crisis intervention is a six-step model proposed by Richard James and Burl Gilliland. In this model, the steps do not necessarily function as discrete entities. Rather, some of the steps may be transposed or they may be integrated as a smoothly flowing process. Overarching the six steps is a constant and dynamic triage assessment of affective, behavioral, and cognitive functioning as proposed by Rick Myer. This continuous assessment allows counselors to evaluate the clients’ past and present situational crises in regard to their ability to cope, response to personal threat, amount of lethality, degree of mobility, and type and amount of direct action needed by the counselor. The six-step model may be loosely divided into two major categories of Exploration and Acting. In the first three steps of Exploration (i.e., defining the problem, determining safety needs, and providing immediate physical and psychological support), the emphasis of the counselor will be on exploration and assessing by attending, empathizing, and being nonjudgmental, caring, respectful, and genuine. However, counselors may also become confrontive, directive, assertive, and guiding when clear threats to the client’s or others’ safety emerges. In the second three steps (i.e., examining alternatives, making plans, and obtaining commitment), the emphasis of the counselor will be on acting by becoming involved in the intervention at a nondirective, collaborative, or directive level according to the assessed needs of the client and the availability of environmental supports and coping mechanisms. It is likely that the second three steps will have a higher degree of counselor involvement, responsibility, information giving, guidance, and directiveness than would normally be seen in a typical counseling encounter.

Crisis Counseling Skills

To deal with both crisis and transcrisis states calls for a variety of skills from the counselor that do not fit neatly into what might be expected of a more traditional therapist. Unlike traditional, long-term therapy, the creation of a cure or the movement of a client to more self-actualized behavior is not an end goal. The immediate and overriding objective of the crisis worker is to contain the situation, stabilize the client, stop the escalation of emotional disequilibrium and disorganization, and, it is hoped, return the client to as close to precrisis functioning as possible. Such intervention will typically be on a very time-limited basis that may be measured in minutes, hours, or days, rather than weeks, months, or years. After stabilization, the client may be referred, if needed, to long-term therapy where systemic change and increased functioning are the goals.

The ability to use accurate listening and responding skills; assess, synthesize, diagnose, explore alternatives; and plan and solve problems are all as important in crisis intervention as they would be in traditional therapy. However, the crisis worker will typically have little time, support, or resources to do these activities. Because of rapidly changing conditions and the volatile atmosphere that surrounds a crisis, the worker will have to be exceedingly adaptive. At times, when clients are clearly out of control, crisis intervention is much more directive and closed ended than traditional therapy. It is likely that owning or “I” statements that use assertion, positive reinforcement, limit setting, and here-and-now responses are used much more than in typical counseling. The same may be said of closed questions that ask clients for “Yes” or “No” responses to determine their degree of physical mobility, psychological equilibrium, personal safety, and potential lethality towards themselves or others.

References:

  1. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.
  2. Figley, C.R. (Ed.). (1985). Trauma and its wake: The study of post-trauma stress disorder. New York: Brunner/Mazel.
  3. Finklehor, D. (1984). Child sexual abuse: New theory and research. New York: Free Press.
  4. Fujimura, L. E., Weis, D. M., & Cochran, J. R. (1985). Suicide: Dynamics and implications for counseling. Journal of Counseling and Development, 63, 612-615.
  5. James, R. K., & Gilliland, B. E. (2004). Crisis intervention strategies (5th ed.). Pacific Grove, CA: Brooks/Cole.
  6. Myer. R. A. (2002). Triage assessment for crisis intervention. Pacific Grove, CA: Brooks/Cole/Wadsworth.
  7. Ochberg, F. M. (Ed.). (1988). Post-traumatic therapy and victims of violence. New York: Brunner/Mazel.

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