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We live in an era in which crisis-inducing events and acute crisis episodes are prevalent. Each year, millions of people are confronted with crisis-inducing events that they cannot resolve on their own, and they often turn for help to crisis units of community mental health centers, psychiatric screening units, outpatient clinics, hospital emergency rooms, college counseling centers, family counseling agencies, and domestic violence programs (Roberts, 2005).
Crisis clinicians must respond quickly to the challenges posed by clients presenting in a crisis state. Critical decisions need to be made on behalf of the client. Clinicians need to be aware that some clients in crisis are making one last heroic effort to seek help and hence may be highly motivated to try something different. Thus, a time of crisis seems to be an opportunity to maximize the crisis clinician’s ability to intervene effectively as long as he or she is focused in the here and now, willing to rapidly assess the client’s problem and resources, suggest goals and alternative coping methods, develop a working alliance, and build upon the client’s strengths. At the start it is critically important to establish rapport while assessing lethality and determining the precipitating events/situations. It is then important to identify the primary presenting problem and mutually agree on short-term goals and tasks. By its nature, crisis intervention involves identifying failed coping skills and then helping the client to replace them with adaptive coping skills. It is imperative that all mental health clinicians-counseling psychologists, mental health counselors, clinical psychologists, psychiatrists, psychiatric nurses, social workers, and crisis hotline workers-be well versed and knowledgeable in the principles and practices of crisis intervention. Several million individuals encounter crisis-inducing events annually, and crisis intervention seems to be the emerging therapeutic method of choice for most individuals.
Crisis Intervention: The Need for a Model A ”crisis” has been de¬ned as An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping mechanisms. Crisis also refers to ”an upset in the steady state.” It often has ¬ve components: a hazardous or traumatic event, a vulnerable or unbalanced state, a precipitating factor, an active crisis state based on the person’s perception, and the resolution of the crisis. (Roberts, 2005, p. 778) Given such a de¬nition, it is necessary that crisis workers have in mind a framework or blueprint to guide them in responding. In short, a crisis intervention model is needed, and one is needed for a host of reasons, such as the ones given as follows. When confronted by a person in crisis, clinicians need to address that person’s distress, impairment, and instability by operating in a logical and orderly process (Greenstone & Leviton, 2002). The profetional, often with limited clinical experience, is less likely to exacerbate the crisis with well-intentioned but haphazard responding when trained to work within the framework of a systematic crisis intervention model. A inclusive intervention allows the novice as well as the experienced clinician to be mindful of maintaining the ¬ne line that allows for a response that is active and directive enough but does not take problem ownership away from the client. Finally, a intervention should suggest steps for how the crisis worker can intentionally meet the client where he or she is at, assess level of risk, mobilize client resources, and move strategically to stabilize the crisis and improve functioning.
Crisis intervention is no longer regarded as a passing fad or as an emerging discipline. It has now evolved into a specialty mental health ¬eld that stands on its own. Based on a solid theoretical foundation and a praxis that is born out of over 50 years of empirical and experiential grounding, crisis intervention has become a multidimensional and ¬‚exible intervention method.
However, the primary focus of crisis literature has been on giving aid and support, which is understandable given that the first concern in the aftermath of a crisis is always to provide assistance (McFarlane, 2000), not to conduct systematic research (Raphael, Wilson, Meldrum, & McFarlane, 1996). Experts in crisis intervention have focused on practical issues such as developing intervention models that manage postcrisis reactions (Paten, Violanti, & Dunning, 2000), with little attention being given to the development of theory (Slaikeu, 1990). Slaikeu stated that crisis theories are more like a cluster of assumptions, rather than principles based on research that explain or predict the effect of crises on individuals. Ursano et al. (1996) agreed, stating that clinical observations and implications derived from mediators of traumatic stress have guided interventions, rather than theory. Although these efforts have increased the understanding of the nature of crises, a need exists to mold these assumptions and observations into theory.
The field of crisis intervention is predicated upon the existence of the phenomenon of psychological crisis. Because crisis intervention is the natural corollary of the psychological crisis, this review begins with a definition of the crisis phenomenon.
Definition of crisis
“Crisis occurs when people encounter an obstacle in achieving the important objectives of life. This obstacle and cannot be overcome by means of customary methods used dealing with difficulties. This results in a state of disorganization and confusion, in which made numerous unsuccessful attempts of solutions.
Moreover, the crisis resulted from the problems on the road practically important in achieving objectives, obstacles where people feel that they are not able to overcome through the usual choices and behavior”. (1964)
by CARKHUFFA and Berenson
“Crises are crises so that the affected people do not know any ways of dealing
themselves with the situation” (1977)
“Crises of this personal difficulties or situations that deprive people of ability and
prevent conscious control of his life” (1984)
“Crisis is a state of disorganization in which man is confronted with the destruction of important objectives of life or profound impairment of their life cycle and methods of dealing with stressful factors. The term crisis typically refers to a sense of fear, shock and experienced difficulties in connection with the disorder, and not to the same disorder” (1985)
“Crisis develops in clear stages:
a) the situation is critical, which controls whether the normal mechanisms for dealing
deal with difficult enough;
b) the mounting tension and disorganization accompanying this situation excess capacity
it affected people to cope with difficulties;
c) the situation requires reaching for the extra resources (ex. professional
d) may prove necessary referral to a specialist who will help in removal of
serious personality disorder ” (1995)
“The crisis is transitional state of internal imbalance, caused by critical
event or life events. This condition requires significant changes and decisions.” (1999)
The Chinese word for crisis presents a good depiction of the components of a crisis. The word crisis in Chinese is formed with the characters for danger and opportunity. A crisis presents an obstacle, trauma, or threat, but it also presents an opportunity for either growth or decline.
Crisis is self-defined , because crisis is any situation for which a person does not have adequate coping skills. Therefore, What is a crisis for one person may not be a crisis for another person. In mental health terms, a crisis refers not necessarily to a traumatic situation or event, but to a person’s reaction to an event. One person might be deeply affected by an event, while another individual suffers little or no ill effects. Crises may range from seemingly minor situations, such as not being prepared for class, to major life changes, such as death or divorce. Crisis is environmentally based. What is now a crisis may not have been a crisis before or would not be a crisis in a different setting.
Basic Crisis Theory: Since Lindemann’s (1944, 1956) seminal contribution of a basic crisis theory stemming from his work in loss and grief, the development of crisis theory has advanced considerably. Lindemann identified crises as having: (1) a period of disequilibrium; (2) a process of working through the problems; and (3) an eventual restoration of equilibrium. Together with the contributions of Caplan (1964), this work evolved to eventually include crisis intervention for psychological reactions to traumatic experiences and expanded the mental health field’s knowledge base in applying basic crisis theory to other types of crises experienced by people.
In addition to recognizing that a crisis is accompanied by temporary disequilibrium, crisis theorists identify the potential for human growth from the crisis experience and the belief that resolution may lead to positive and constructive outcomes such as enhanced coping abilities. Thus, the duality contained in a crisis is the co-existence of danger and opportunity (Gilliland & James, 1997). One part of the crisis state is a person’s increased vulnerability and reduced defensiveness. This creates an openness in people for trying different methods of problem-solving and leads to change characterizing life crises (Kendricks, 1985).
Expanded Crisis Theory: While expanded crisis theory, as we understand it today, merges key constructs from systems, adaptation, psychoanalytic and interpersonal theories (Gilliland & James, 1997), the advent of systemic thinking heralded a new way of viewing crisis states. By shifting away from focusing exclusively on the individual in crisis to understanding their state within interpersonal/familial relationships and life events, entry points and avenues for intervention significantly increase. Systems theory promotes the notion that traditional cause and effect formulations have a tendency to overlook the complex and difficult to understand symptomlogy often observed in people in crisis. Especially with younger populations, crisis assessments should occur only within the familial and social context of the child in crisis.
More recently the ecological perspective is gaining popularity as it evolves and develops into models of crisis intervention. From this perspective, crises are believed to be best viewed in the person’s total environmental context, including political and socio-economic contexts. Thus, in the United States, mobile crisis teams primarily responding to adult populations use an ecological model. Issues of poverty, homelessness, chronicity, marginalization and pervasive disenfranchisement characterize the client population served (Cohen, 1990).
Ecocsystem Theory: Most recently an ecosystem theory of crisis is evolving to explain not only the individual in crisis, but to understand those affected by crisis and the ecological impact on communities. For example, the devastating rate of suicide and attempted suicide in Inuit youth reverberates through their communities on multiple levels. Ecosystem theory also deals with larger scale crises from environmental disasters (e.g. oil spills) to human disasters (e.g. Columbine school shootings).
Applied Crisis Theory: Applied crisis theory encompasses the following three domains:
Developmental crises which are events in the normal flow of human growth and development whereby a dramatic change produces maladaptive responses; Events such as birth, which is a crisis both for the mother and the infant, the onset of puberty and adolescence, marriage, the menopause, and so on as we progress through the biological stages of life, are known as developmental crises, These differ from “situational crisis” in that they necessarily occur at a given point in development and everyone has to pass through them. This goes along with Erikson’s theory of personality development, in that personality continues to develop through life, changing radically as a function of how an individual deals with each stage of development.
There are several causes of developmental crisis. One cause is a deficit in skills that can keep a person from achieving developmental tasks or turn a predictable transition into a crisis. For example, if a parent does not have the skills to be a parent, having a baby could become a crisis situation. Developmental crisis can also occur when the individual is not prepared for milestone events, such as menopause, widowhood, etc. Another cause is when one of life’s developmental transition is perceived by the individual as being out of phase with society’s expectations. Examples of this could be leaving home, choosing a partner, marrying, having kids, and retiring.
Situational crises which emerge with the occurrence of uncommon and extraordinary events which the individual has no way of predicting or controlling; Traumatic events which might or might not happen at a given time. These could either be major catastrophes such as earthquakes, floods, etc., which could affect a whole section of society. In other words – occurs in response to a sudden unexpected event in a person’s life. The critical life events revolve around experiences of grief and loss. like loss of a job, divorce, abortion, death of a love one, severe physical or mental illness, or any other sudden tragic event.
One characteristic of situational crises is their sudden onset and unpredictability. While a struggle with developmental issues usually builds over time, situational crises strike from nowhere all at once. Unexpectedness is another factor of situational crises. People generally believe “it won’t happen to me,” and are blind-sided when it does happen to them. Emergency quality is another characteristic of situational crises. When a situational crisis hits, it needs to be dealt with immediately. Situational crises also impact the entire community. These events usually affect large numbers of people simultaneously, requiring intervention with large groups in a relatively short period of time. The last characteristic of situational crises is the presence of both danger and opportunity. Reorganization must eventually begin. This reorganization has the potential for the individual to emerge on either a higher or lower level of functioning.
Existential crises which refer to inner conflicts and anxieties that relate to human issues of purpose, responsibility and autonomy (e.g., middle life crisis).
It is a stage of development at which an individual questions the very foundations of their life: whether their life has any meaning, purpose or value. An existential crisis is often provoked by a significant event in the person’s life – marriage, separation, major loss, the death of a loved one; a life-threatening experience; psycho-active drug use; adult children leaving home; reaching a personally-significant age (turning 30, turning 40, etc.), etc. Usually, it provokes the sufferer’s introspection about personal mortality, thus revealing the psychological repression of said awareness
Each person and situation is unique and should be responded to as such. Therefore, it is useful to understand the crisis from one or more of these domains in order to understand the complexities of the individual’s situation and to intervene in more effective ways. One would also tend to see a younger population with developmental and/or situational crises (Gilliland & James, 1997).
Due to the duration of the crisis, we may distinguish
– Acute crises
– Chronic crises
Stages of a Crisis
In order to articulate the elements of a responsive mobile crisis service a conceptual framework of the stages of crisis is presented. There is agreement in the literature that most crisis interventions should last about one to six weeks (Caplan, 1964; Kendricks, 1985). This suggested time frame is based on identifiable stages of a crisis. Frequently cited in the literature (Gilliland & James, 1997; Smith, 1978) is Caplan’s four stages of crisis:
Phase I – The person has an increase in anxiety in response to a traumatic event; if the coping mechanisms work, there’s no crisis; if coping mechanisms do not work (are ineffective) a crisis occurs.
Phase II – In the second phase anxiety continues to increase.
Phase III – Anxiety continues to increase & the person asks for help. (If the person has been emotionally isolated before the trauma they probably will not have adequate support & a crisis will surely occur).
Phase IV – Is the active crisis – here the persons inner resources & supports are inadequate. The person has a short attention span, ruminates (goes on about it), & wonders what they did or how they could have avoided the trauma. Their behavior is impulsive & unproductive. Relationships with others suffer, they view others in terms of how can they help to solve the problem. The person feels like they are losing their mind, this is frightening – Be sure to teach them that when the anxiety decreases that thinking will be clearer.
While others have proposed slightly varying stages, there are commonalties in understanding that crises are time-limited, have a beginning, middle and end, and that intervention early in a crisis can produce stabilization and a return to the pre-crisis state. No intervention, or inadequate intervention, can result in chronic patterns of behavior that result in transcrisis states (Gilliland & James, 1997).
Transcrisis: the original crisis event becomes submerged into the unconscious and
re-emerges when anxiety is re-experienced. A woman who experienced rape will
re-experience problems with being sexually intimate with a man and experience problems in intimate relationships.
Crisis stages can be distinguished from mental disorders in that the person in crisis can be described as having normal and functional mental health before and after the crisis. Additionally crisis tend to be of limited duration and after the crisis is over, the client’s turmoil will frequently subside. There however persons who can stay in crisis state for month or years. Such individual is described as being In transcrisis state. It’s also possible for transcris state to lead to the development of anxiety and other tipes of mental disorder (ex.PTSD).
Crisis intervention is the form of psychological help, that is focused on therapeutic contact, concentrated on the problem, that caused the crisis, limited in time, when the person is confronted with the crisis and has to solve it. That kind of help lets us reduce the crisis response and minimize functional impairment. (Badura-Madej, 1999)
Crisis intervention is emergency first aid for mental health (Ehly, 1986). Crisis intervention involves three components: 1) the crisis, the perception of an unmanageable situation; 2) the individual or group in crisis; and 3) the helper, or mental health worker who provides aid. Crisis intervention requires that the person experiencing crisis receive timely and skillful support to help cope with his/her situation before future physical or emotional deterioration occurs.
Crisis intervention provides the opportunity and mechanisms for change to those who are experiencing psychological disequilibrium, who are feeling overwhelmed by their current situation, who have exhausted their skills for coping, and who are experiencing personal discomfort. Crisis intervention is a process by which a crisis worker identifies, assesses, and intervenes with the individual in crisis so as to restore balance and reduce the effects of the crisis in his/her life. The individual is then connected with a resource network to reinforce the change.
HISTORY Crisis Intervention
Origins of crisis intervention, should be found in the topics related to the suicide prevention, the development of environmental psychiatry, as well as a vocation to life services dealing with emergency psychotherapeutic assistance for victims of traumatic events, such as: war or natural disasters (Badura-Madej, 1999).
The roots of crisis intervention come from the pioneering work of two community psychiatrists-Erich Lindemann and Gerald Caplan in the mid-1940s, 1950s, and 1960s. We have come a far cry from its inception in the 1950s and 1960s. Speci¬cally, in 1943 and 1944 community psychiatrist, Dr. Erich Lindemann at Massachusetts General Hospital conceptualized crisis theory based on his work with many acute and grief stricken survivors and relatives of the 493 dead victims of Boston’s worst nightclub ¬re at the Coconut Grove. Gerald Caplan, a psychiatry professor at Massachusetts General Hospital and the Harvard School of Public Health, expanded Lindemann’s (1944) pioneering work. Caplan (1961, 1964) was the ¬rst clinician to describe and document the four stages of a crisis reaction: initial rise of tension from the emotionally hazardous crisis precipitating event, increased disruption of daily living because the individual is stuck and cannot resolve the crisis quickly, tension rapidly increases as the individual fails to resolve the crisis through emergency problem-solving methods, and the person goes into a depression or mental collapse or may partially resolve the crisis by using new coping methods. A number of crisis intervention practice models have been promulgated over the years (e.g., Collins & Collins, 2005; Greenstone & Leviton, 2002; Jones, 1968; Roberts & Grau, 1970).
The goals of crisis intervention are relatively limited, relate to the immediate crisis situation and are the following:
Reduction in disequilibriurn or relief of symptoms of crisis
Restoration to precrisis level of functioning
Some understanding of the relevant precipitating events
Identification of remedial measures which the client can take or make available through community resources.
Connecting the current situation with past life experiences and conflicts
Initiating new modes of thinking, perceiving feeling and developing new adaptive and coping responses which are useful beyond the immediate crisis situation, leading to an emancipated maturation and empowerment.
While there is no one single model of crisis intervention (Jacobson, Strickler, & Mosley, 1968), there is common agreement on the general principles to be employed by EMH practitioners to alleviate the acute distress of victims, to restore independent functioning and to prevent or mitigate the aftermath of psychological trauma and PTSD (Butcher, 1980; Everly & Mitchell, 1999; Flannery, 1998; Raphael, 1986; Robinson & Mitchell, 1995; Sandoval, 1985; Wollman, 1993).
1. Intervene immediately. By definition, crises are emotionally hazardous situations that place victims at high risk for maladaptive coping or even for being immobilized. The presence onsite of EMH personnel as quickly as possible is paramount.
2. Stabilize. One important immediate goal is the stabilization of the victims or the victim community actively mobilizing resources and support networks to restore some semblance of order and routine. Such a mobilization provides the needed tools for victims to begin to function independently.
3. Facilitate understanding. Another important step in restoring victims to pre-crisis level of functioning is to facilitate their understanding of what has occurred. This is accomplished by gathering the facts about what has occurred, listening to the victims recount events, encouraging the expression of difficult emotions, and helping them understand the impact of the critical event.
4. Focus on problem-solving. Actively assisting victims to use available resources to regain control is an important strategy for EMH personnel. Assisting the victim in solving problems within the context of what the victim feels is possible enhances independent functioning.
5. Encourage self-reliance. Akin to active problem-solving is the emphasis on restoring self-reliance in victims as an additional means to restore independent
functioning and to address the aftermath of traumatic events. Victims should be assisted in assessing the problems at hand, in developing practical strategies to address those problems, and in fielding those strategies to restore a more normal
The practice of crisis intervention, typically consist of the following (Badura – Madej, 1999):
Providing emotional support to facilitate the reaction to emotion;
Confronted with the reality and countering tendencies to deny and distorted to form at the moment the most important problem to solution;
Assess the current ways of coping in terms of their adaptive nature;
Referring to good coping strategies or creating new strategies;
A plan of assistance.
Characteristics of a crisis intervention (Badura-Madej, 1999):
– Assistance as soon as possible after the critical event, preferably at the time, when the existing ways of coping are exhausted with crisis, and new constructive behaviors yet not created – to provide the support reduces the risk run adaptive ways of coping;
– Focus on the situation and the current problem associated with the crisis (the “here and now “), taking into account the individual history of man (analysis of this story helps to understand the nature and depth of the crisis reaction)
– Emotional support, often also material support (accommodation, shelter, food,
drinking, etc.) to ensure a sense of security to the person in crisis;
– A large intensity of contacts (depending on the situation) – and sometimes even daily;
– Time limit (6 – 10 meetings)
– flexibility in assisting interactions – from the directive operation, client collaboration, to the non-directive action;
– Mobilizing the natural support system for people in crisis, cooperation with other institutions, providing possible support from institutions to holistic approach to people in crisis (eg, OPS, police, etc.).
Crisis Intervention Models
(Gilliland and James, 2005)
Practice and intervention literature indicate the usefulness of certain general theoretical models for the construction of concrete measures for persons in crisis. Belkin (1984) proposes a classification includes equilibrium model, cognitive model and psycho-social model of transformation (Gilliland and James, 2005).
Equilibrium model indicates a basic fact of the continuum balance – imbalance,
which differentiates functioning non-crisis and crisis. Persons in crisis, experiencing
state of disorganization, lack of balance of basic psychological functions, are not able to effectively use their customary ways of coping and methods of solving problems.
The aim of the intervention from the point of view of equilibrium model is to assist the client in regained pre-crisis equilibrium. therefore the use of this approach is the most
justified in the initial stages of intervention, when a person has no sense of control over himself and course of events is confused and unable to take adequate
decisions and appropriate action. Until the client does not recover even though part of the capacity to coping, the main effort should be directed to stabilize the condition of the person. Only then it is possible to use his abilities to cope, and other internal and external resources to solve a crisis problem. Equilibrium model considered
is the “cleanest” model of crisis intervention (Caplan, 1961; for: Gilliland and James, 2005).
The cognitive model of crisis intervention is based on the premise that crisis are rooted in faulty thinking about the event or situations that surround the crisis – not in the events themselves or the facts about events or situations (Ellis, 1962). The goal of this model is to help people become aware of and change their views and beliefs about crisis events or situations.
The basic tenet of the cognitive model is that people can gain control of crisis in their lives by changing their thinking, especially by recognizing and disputing the irrational and self-defeating parts of their cognitions and by retaining and focusing on the rational and self-enhancing elements of their thinking.
The messages that people in crisis send themselves become very negative and twisted, in contrast to the reality of the situation. Dilemmas that are constant and grinding wear people out, pushing their internal state of perception more and more toward negative self-talk until their cognitive sets are so negative that no amount of preaching can convince them anything positive will ever come from the situation.
Crisis intervention in this model can be compared to work on rewriting your own “program” by the client, which on a positive Coupling back and repeat the exercise in self-assessment of the new situation, be able to change emotions and behavior in a more positive and constructive. Cognitive model can be used in practice when the client has already regained some sufficient level of psychological stability, allowing where appropriate perception, drawing conclusions, making decisions and experimenting with new behaviors.
Basic concepts of this approach are fond in the rational-emotive work of Ellis (1982), the cognitive-behavioral approach of Meichenbaum (1977), and the cognitive system of Beck (1976).
Psychosocial transition model
Psychosocial transition model is another useful approach to intervention in
crisis. This model is based on the assumption that man is the result of the interaction between the genetic equipment, and the learning process, setting the social environment. Both people and their environment and social influence processes are subject to constant change. Therefore, crises may be related to both internal and external (psychosocial, social and environmental) difficulties.
The purpose of crisis intervention, as seen from this perspective, is to help, cooperation with client in an adequate assessment of both internal and external circumstances influencing the emergence of the crisis, as well as assist in the selection of effective alternatives to the (client’s) existing, inefficient behavior, inappropriate attitudes and inefficiencies how to use the resources of the environment in which I live. To obtain a stand-alone control over his private life customers can be needed for obtaining adequate internal mechanisms to deal with difficulties, as well as social support and environmental resources.
The Psychosocial transition model does not perceive crisis simply an interal state of affairs that resides totally within the individual. It reaches outside the individual and askes what system need to be changed. Systems such as family, peer group, work environment, religious community are examples who can also support or interfere with the psychological ada
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