Evaluation of Crisis Theory

Introduction

 Crisis theory and intervention have existed since the 1900s, and arguably before then. Since humans could recognize suicidal and behavioral changes in other humans due to various events, they have been implementing crisis theory even if there was no formal name. A crisis is a broad and subjective term used to describe a situation which affects an individual excruciatingly due to various life, environmental, and psychological stressors (James & Gilliland, 2013). Human behavior is primarily impacted by life events that they cannot control, and sometimes the event is so egregious, the individual can not understand it. Because of the subjectivity involved, interventions for crisis theory are derived from many other theoretical perspectives such as Ego Psychology, Behavior Theory, and Cognitive Theory. It is essential to recognize where they need came from, how the theory is applied, identifying successful use of the theory, and which individuals most benefit from this perspective.

Historical Origins of Crisis Theory

Social work, as a field, was derived from crisis intervention when the discovery was made that humans need a specific intervention when life stress wither became acute or compounded over time to create issues such as Post Traumatic Stress Disorder (PTSD).  Social workers were among the first to determine that the interventions for these times of distress needed to be treated differently than other disorders or diagnoses. Due to research by T.W. Salmon in World War I (WWI), and later Kardiner and Spiegel during World War II (WWII), three principles of crisis intervention were devised. These were immediacy, proximity, and expectancy (Mitchell, 1998). Crisis theory was emerging as the widely used theory we know now. During WWII and the great depression, these principles gained traction in mental health to aid in the adjustment of those displaced or impoverished due to those substantial events.  Furthermore, a need emerged to assist those in the armed forces that faced horrors unimaginable while serving their country (Walsh, 2013).

Eventually, Erich Lindemann and Gerald Caplan of Massachusetts General Hospital would formalize crisis theory in the 1940s and set the practice tenets we as social workers know so prevalently today (Roberts, 2000).  This event initiated the drive to theorize crisis which led to the Mental Health Centers Act of 1963.  With the policy’s implementation, asylum and psychiatric hospitals were converted to community health centers, and eventually community services boards, because of the new understanding that crisis can be acute, pervasive, and can lead to harmful mechanisms of coping (James & Gilliland, 2013).

The three most notable events to shape crisis intervention were the advent of Alcoholics Anonymous (AA), The National Organization for Women (NOW), and the Vietnam Veteran’s movements of the 1970s, according to James & Gilliland (2013).  Grassroots movements were shaped around a common theme: Needing help and intervention for specific critical incidences and not getting it.  The organizations’ goals were not shaped around crisis management, but they assisted in bringing issues, such as PTSD, to the attention of clinicians. The organizations’ assistance allowed for the creation of interventions such as Mobile Crisis Units, suicide prevention hotlines, and Critical Incident Stress Management Teams.

Major Tenets of Crisis Theory

When observing and assessing the behavior of an individual, there are many factors to take into consideration. Resiliency is the most common dynamic in determining how a person reacts to, and copes with, crisis and will be discussed further in the context of each crisis type. Primarily, there are three categories of crisis: Developmental, situational, and existential. Each is apparent by a unique identifier.

Developmental crises occur from naturally occurring milestones in life that may create stress due to transition.  The primary tenet behind this idea is housed in Erik Erikson’s psychosocial stages of development where life events directly correlate with expected normative stressors (Rosenberg, 1975). An example of this would be graduating college and preparing for adulthood, or giving birth to a first child. When these events occur, an individual with little resilience may face significant stress from calling into question their identity, that they may be unable to manage without clinical intervention and the ability to learn coping skills to manage that stress (Walsh, 2013). A person with higher levels of resiliency may, however, not react to the stress negatively at all because they have learned how to cope with higher levels of stress, become stoic in their identities, and not be challenged by such life events (Erikson, 1968).

Situational crises are perhaps the most common occurrences. The crisis are events that cannot be controlled, prepared for, or otherwise anticipated. It is for this reason that a multi-theoretical approach is necessary when managing a crisis. James & Gilliland (2013) assert that it is the unpredictability of these events that shape the outcomes due to a shift in values and beliefs after the traumatic event.  Because of the sudden and acute nature of these events, resiliency is of utmost importance to allow an individual to either grow, maintain equilibrium, or freeze. Though these patterns are evident in the other classifications of crisis, they are most prevalent in the situational crisis (Lewis & Roberts, 2001). Firstly, individuals with high levels of resiliency may grow based on the development of new strengths and coping skills acquired through therapy, intervention, or modeling. Most individuals experience an equilibrium period where they are not socially functional yet but have reverted to the way they were before the event. Despite the new knowledge and experience, most people can carry on and readjust without any significant changes or perpetual crisis states (Walsh, 2013). An individual with low levels of resiliency may freeze and never move past the trauma. The freeze state is unique; however, in that, it can occur even in those with high levels of resiliency if the nature of the trauma was severe enough. Examples of this may be aggravated by sexual assault, acts committed to, or by, service members during times of direct combat (Yeager & Roberts, 2005).

Lastly, existential crises are perhaps the most frustrating and challenging for persons to cope with and accept. The crises confront value and belief systems directly due to inner turmoil surrounding an event, decision, or responsibility.  An individual’s entire life narrative may have just been flipped upside down, leaving them scrambling to make sense of their identities (Erikson, 1968). Examples of this may be learning about a childhood adoption, or a marriage that held in high regard was saturated with affairs and turmoil, thus changing the view of marriage, or life itself, at that point. Regret tends to be a significant exacerbation of the crisis and is evident among those with lower rates of resiliency. They have been raised to believe one way, and life events force them to face options or choices different than that which they know or are capable of accepting at that time. Because of the significant paradigm shift seen with the crises, freezing and avoidance are often the response. An individual will deny the change and attempt to carry on as if they achieved equilibrium, and an event never occurred (Walsh, 2013).

Interventions

To allow the individual to move through the trauma, and regain appropriate social function after the event, interventions are typically indicated. Each person is unique in the way they respond to trauma and the following interventions, whether clinical or through natural supports. It is essential to quickly note that coping and adaptive skills are paramount to the process where a crisis is concerned.  According to Walsh (2013), there are two primary types of coping: biological and psychological (pp. 310-311). Biologically coping is a reflection by the body’s ability to manage stress without somatic expression when in a state of instability. This can look like emotional or gastrointestinal distress and sometimes even heart and blood pressure issues. Psychological coping, on the other hand, addresses the problem-solving approaches necessary to manage stressful situations and can be both positive and negative. A positive strategy may look like using natural and social supports to reinvest with feelings of attachment and safety to allow an individual to move forward into the growth stage.  A cynical strategy may be avoidance or even substance abuse in order to anesthetize themselves against pervasive thoughts of the event.

In order to determine the most appropriate strengths-based intervention, a thorough and timely assessment must take place. This allows the clinicians to determine best the strategy they will employ. It is at this time, a suicide assessment will take place, and a safety plan will be created if indicated (Lewis & Roberts, 2001). As mentioned earlier, crisis theory is not unique to itself, and it is comprised of other theories that may best suit the needs of the individual situation. For this paper, we will briefly examine Ego Psychology, Behavior Theory, and Cognitive Theory.

Interventions within the framework of ego psychology focus on motivating the client to resolve their crises by guiding them to self-reflection that allows them to be solution-focused. According to Walsh (2013), these interventions are sustainment, exploration/description/ventilation, and person-situation reflection. Sustainment focuses on relationships and how to achieve positive ones through appropriate development and education through the assistance of a clinician. Everly (2002) asserts that peers can also be useful for positive sustainment because of the empathy demonstrated within these groups, such as emergency responders, law enforcement, and military groups (pp. 89). Exploration, description, and ventilation examine the management of stress through the use of emotional articulation. The examination will teach the client how to look outside themselves in order to solve problems, rather than reflecting personally, and this will allow for cognitive distortions to occur. Lastly, person-situation reflection sets the stage for the client to face the current crisis by directing them to self-assess their direct role in the outcomes and solutions of the intervention (Walsh, 2013).

Sometimes individuals can get in their way to the point that the behaviors exhibited are the cause of the crisis. These individuals typically struggle with both positive and negative reinforcement and how to identify them and in times of crisis benefit from the use of behavior theory. The reinforcement of appropriate behaviors is critical to this theory. According to Walsh (2013), life skills, relaxation, coping skills, assertion, or desensitization training are necessary interventions for a clinician using behavior theory with a client in crisis because they are all highly structured, allowing the client to feel more in control.

In times of crisis, an individual can feel lost, or as we saw earlier, existentially stuck in a moment such as a breakup or a paradigm shift. These situations often happen violently or abruptly and elicit emotional reactions that the individual may not be able to control or understand at the moment fully. These reactions become assumptions that frequently lead to cognitive distortions that are emotional and not logic-based.  In these moments Cognitive theory is most widely implemented, though it is often used in conjunction with behavior theory to become cognitive-behavioral therapy (CBT), the most widely indicated intervention in critical situations (Dattilio & Freeman, 2007). Though these interventions are evidence-based, clinicians using crisis theory must be adept at testing for effectiveness.

Theory Effectiveness

 Theories evolve and change over time as new research is done to better aid the clinician in best practices, and this theory is no different. Though mostly unchanged, different thoughts on how to best implement crisis intervention have, as with any other theory, been subject to trends in the mental health field. The debate between the group and individual interventions has been a long-standing debate whose cycles are dependent on the most relevant data at the time (Roberts, 2005).  Because of the multi-theoretical approach instead of one practice model for a crisis, Walsh (2013) states that there is little direct research regarding crisis intervention and its effectiveness. This is not to say that it is ineffective, directly that the longitudinal data is challenging to come by despite the apparent success of crisis intervention through programs such as Critical Incident Stress Management (CISM), which are widely used as in intermediary between the crisis and individual intervention. CISM uses psychological first aid which includes eight tenets of effectiveness: “Contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping, and linkage with collaborative services” (James & Gilliland, 2013. pp. 20).

 According to Walsh (2013), success related to suicide prevention was found in 14 studies with an ending result of established best practices for protocols in suicide prevention centers. In another ten studies about psychiatric hospital outcomes, it was found that there was a decrease in hospitalizations over time and an increase in positively associated mental health through various psychological emergency services. Lastly, in various evaluation studies of programs about crisis intervention and intensive-in home services saw a decrease in out-of-home placements, affirming the effectiveness of these interventions despite the multi-theoretical approach. 

 Despite the success, there are critics of crisis theory, primarily about the fact that it pulls from many other theories. Some of the criticisms are founded from Erikson’s (1968) life stages and how rigid they are when a crisis itself is relativistic. Furthermore, cultural considerations are severely lacking in the literature surrounding crisis theory, which directly affects the cultural competency of clinicians that focus on crisis theory (James & Gilliland, 2013). Most crises center around the individual, according to the tenets of this theory which can negatively impact the effectiveness of this theory. If we dedicate all the focus to the individual, it becomes easy to dismiss the person’s natural supports in favor of what Walsh (2013) refers to as, “formal services” (pp. 329).

The client populations are most likely to respond best to work using this theory and precautions against using this theory with specific client populations. (No longer than two pages.)

 Using crisis intervention seems to be adequate for military populations, though there is evidence that sexual assault victims and those who are suicidal also benefit from this theory. Most clients who experience stressors beyond their capacity for coping. These are individuals who struggle with cognitive distortions due to critical levels of stress resulting from traumatic events.

 Because of the multi-theoretical approach, there are minimal precautions against this theory. When any approach can be used to manage an individual in crisis, any population can effectively benefit from crisis theory.

References

• Dattilio, F. M., & Freeman, A. (2007). Cognitive-behavioral strategies in crisis intervention (3rd ed.). New York: Guilford Press.
• Erikson, E. (1968). Identity: Youth and crisis. New York: W. W. Norton. (pp. 16, 38)
• Everly, G. S. (2002). Thoughts on peer (paraprofessional) support in the provision of mental health services. International Journal of Emergency Mental Health, 4(2), 89-90.
• Everly, G. S., & Mitchell, J. T. (1999). Critical incident stress management: A new era and standard of care in crisis intervention (2nd ed.). Ellicott City, MD: Chevron.
• James, R. K., & Gilliland, B. E. (2013). Crisis Intervention Strategies (7^th ed.). Pacific Grove, CA: Brooks/Cole.
• Lewis, S., & Roberts, A. R. (2001). Crisis Assessment Tools: The Good, the Bad, and the Available. Brief Treatment and Crisis Intervention, 1, 17–28.
• Mitchell, J. T. (1998). Critical incident stress management: A new era in crisis intervention. International Society for Traumatic Stress Studies: Stress Points. Retrieved from http://www.istss.org/education-research/traumatic-stresspoints/1998-fall/critical-incident-stress-management-a-new-era-in-c.aspx
• Roberts, A. R. (2000). An Overview of Crisis Theory and Crisis Intervention. In A.R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment, and research (2^nd ed.) (pp. 3-30). New York: Oxford University Press.
• Rosenberg, B. N. (1975). Planned short-term treatment in developmental crises. Social Casework, 56(4), 195-204.
• Walsh, J. F. (2013). Theories for direct social work practice (3rd ed.). Stamford, CT: Cengage Learning.
• Yeager, K. R., & Roberts, A. R. (2005). Differentiating Among Stress, Acute Stress Disorder, Acute Crisis Episodes, Trauma, and PTSD: Paradigm and Treatment Goals. In A. R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment, and research (pp. 90-119). New York: Oxford University Press.