Question

The Crisis Intervention Model

Chapter 9

Karen S. Knox and Albert R. Roberts

LEARNING OBJECTIVES

After reading this chapter, the reader will be able to

•gain knowledge about both the historical development of crisis intervention theories and models, and how recent research has contributed to evidence-based practice in crisis intervention;

•understand the different levels and stages of crisis and how these may impact clients;

•identify appropriate direct practice knowledge and skills for effective crisis assessment and treatment planning;

•apply the Assessment, Crisis Intervention, and Trauma Treatment (ACT) Model and Seven-Stage Crisis Intervention Model in direct practice with clients;

•integrate crisis intervention skills within a generalist-eclectic framework when working with individuals, families, and groups; and

•critically analyze the strengths and limitations of crisis intervention.

OVERVIEW OF CRISIS INTERVENTION

Case Examples of Crisis Incidents and Reactions

Case Study 9.1: Sexual Assault

Alice was walking to her car after getting off work when she was attacked from behind. She was abducted and driven to an isolated area where her assailant raped her repeatedly over several hours before leaving her there and driving away in her car. During the attacks, the rapist held his knife against her throat and threatened to kill her if she reported him to the police. She was able to get help from a passerby after he left, and was transported to the hospital where she received medical treatment and a sexual assault examination, and the crimes were reported to law enforcement. Alice feared for her life that night and is still scared that her attacker may find her and hurt her again, since he got her home address from her driver’s license when he stole her purse. The victim services crisis counselor with the police department provided crisis intervention services on the scene, while Alice was at the hospital, and during the initial criminal investigation. A week after the rape, Alice called and disclosed that she was unable to concentrate at work and is afraid of being at home alone. She was also having intrusive thoughts about the rape and terrifying nightmares. The victim services crisis counselor explained to Alice that these are typical reactions for sexual assault survivors, discussed safety plan options for her to initiate so that she could decrease her anxiety and fears at home and work, and encouraged Alice to follow up with the referral to the rape crisis center for individual and group counseling services.

Case Study 9.2: Sudden Death

Jeff went to work as usual on the military base where he is a lab technician at the hospital. Later that afternoon, a gunman came onto the floor where Jeff’s lab is and opened fire, killing a doctor and injuring several of his coworkers. Jeff hid in a closet while the gunman went from room to room shooting other victims. He could hear their screams and was frozen—unable to respond even though he knew others were trying to help the wounded. Even after the military police captured and arrested the gunman, he could not leave his hiding place until one of the rescuers found him. Jeff is traumatized by the fear he experienced and sounds he heard during the attack. He is feeling relief at not being hurt, but also feels guilty for not helping his friends and not trying to stop the gunman, and is ashamed that he hid while others were being shot. Jeff has not returned to work yet, and has been anxious and irritable about what to say to his friends and how his coworkers will treat him. The survivors of the critical shooting incident have been referred to the social worker at the employee assistance program (EAP). Since there are numerous employees who are in need of crisis counseling, the social worker will need to assess and plan interventions at both the individual and group levels of treatment.

Case Study 9.3: Natural Disaster

Ted and his family were asleep when the tornado warnings sounded and had just gotten into their bathroom for shelter when their house seemed to explode. After the tornado hit their neighborhood, Ted and his family emerged unhurt from what remained of their home to discover most of their neighborhood was gone. When their neighbors started to gather to assess the damage and try to find other survivors, Ted suffered a heart attack and his wife had to perform cardiopulmonary resuscitation on him. Emergency responders transported Ted to the nearest medical facility where he is still hospitalized. His wife and children are at the hospital waiting to hear from other family members in the area; they have no belongings, no place to stay, or transportation. Ted’s wife, Amy, seems to be in shock, and the children are afraid that the tornado will come back again. The hospital social worker first attempts to find them some clean clothes and food while they are waiting to find out more from the physician about Ted’s condition and medical needs. Other crisis intervention and triage services are also being set up by the community crisis management team first responders and disaster relief organizations at the hospital and disaster sites to assist survivors with basic needs services.

These case examples highlight some of the different types of crises and reactions of survivors in the aftermath of trauma. Some crisis situations are personal or family incidents, while others can be triggered by a sudden, community-wide traumatic event, such as a natural disaster, terrorist attack, or industrial accident. Survivors, family members, significant others, and witnesses of traumatic incidents usually experience a series of physiological and psychological reactions. Some common symptoms and reactions include intense fears, heightened anxiety, hypervigilance, startle reactions, intrusive thoughts, flashbacks, despair, hopelessness, irritability, terror, sleep disturbances, shock, guilt, numbness, extreme distrust of others, and shattered assumptions that they and the community where they reside are not safe. These symptoms are evidenced in the diagnosis of acute stress, and one of the goals of crisis counseling is to provide immediate interventions to help prevent or minimize these reactions from developing further into posttraumatic stress disorder (PTSD).

Understanding of Human Problems

The crisis intervention model holds that individuals will experience stressful events and crises as a natural part of life development. Using systems theory, stress is evoked when disequilibrium and anxiety occur as a result of the crisis or traumatic event, and when the individual’s coping skills and resources do not adequately resolve the immediate crisis reactions and consequences. This perspective does not view the individual in crisis as pathological or mentally ill, since all human beings experience and deal with challenges presented during crises and trauma as a normal part of the human condition.

Crisis theory supports the perspective that all human beings have strengths and abilities to deal effectively with problems in living, and that crises are opportunities for individuals to utilize and build on those strengths to develop appropriate coping abilities that address the consequences of the crisis. Crisis theory espouses that the individual’s motivation for change is stronger during or immediately after a crisis due to the anxiety and disequilibrium, and the individual is most receptive to helping professionals and resources to ameliorate the stressful conditions as soon as possible after the crisis. Therefore, while the social worker may need to be more directive during crisis intervention than in other treatment models, the individual is encouraged to be active and present oriented in order to gain some measure of control and stability when dealing with a crisis. Using a strengths-based approach gives survivors hope and motivation that they can meet and deal with the challenges they face as a consequence of the crisis.

Conception of Therapeutic Intervention

Persons experiencing traumatic events usually benefit from rapid assessment and crisis intervention. Crisis counseling shares many principles and strategies with brief, time-limited, task-centered, and solution-focused practice models. Crisis intervention is one of the action-oriented models that is present focused, with the target(s) for intervention being specific to the hazardous event, situation, or problem that precipitated the state of crisis. Therefore, this model focuses on problems in the here and now, and addresses past history and psychopathology only as they are relevant to any current conditions of the crisis. Crisis theory postulates that intervention is time limited to a period of 4 to 6 weeks with the goal of mobilizing needed support, resources, and the adaptive coping skills of the client to resolve or minimize the disequilibrium experienced by the precipitating event. Once the client has returned to a pre-crisis level of functioning and homeostasis, any further supportive or supplemental services are usually referred out to appropriate community agencies and service providers.

In Jeff’s case example, he would receive crisis intervention and counseling services from professionals at different agencies and programs over a period of time. Crisis counselors employed in law enforcement or at the military hospital would work with him and the survivors and witnesses of the shooting incident on the scene and through the initial reporting and criminal and military investigations. Hospital emergency department social workers would provide crisis stabilization during the medical examination and treatment, and make referrals for continued hospitalization needs or discharge planning. The counselor at the EAP program would typically provide time-limited individual and group treatment, and then provide referrals for any long-term counseling services if needed. If Jeff has to testify or is involved in any court proceedings against the offender, victim-witness advocates would provide both crisis and supportive counseling services, as it is common that PTSD symptoms and traumatic memories can be triggered during this time. They would also explain the legal proceedings and protocols for survivors and witnesses, assist in trial preparation and testimony, and inform clients about other benefits such as victims compensation funds that provide financial aid for medical and counseling expenses related to the criminal offense.

While some clients stabilize and return to a level of adequate functioning within the 4- to 6-week time frame, some survivors of trauma will have longer term treatment needs. Time frames for crisis intervention vary depending on several factors, including the agency’s mission and services, the client’s needs and resources, and the type of crisis or trauma. Crisis intervention can be as brief as one client contact, which is typical with 24-hour suicide prevention or crisis hotlines. Some crisis situations may require several contacts over a few days of brief treatment, whereas others may provide ongoing and follow-up services for up to 10 to 12 weeks. Additional crisis intervention services may be needed in the future. An example of a one-contact case is Ted and his family, as crisis intervention services would be immediately provided to his wife and children at the hospital by the emergency department social worker for his medical emergency. However, the family is also in need of continuing medical services and basic needs services due to the tornado, and disaster relief organizations and personnel at the local and federal levels would be available for any crisis interventions and ongoing needs. This case example illustrates both the micro- and macrolevels of crisis preparedness and interagency cooperation that are necessary with large-scale crisis situations.

The immediacy and action orientation of crisis intervention require a high level of activity and skills on the part of the social worker. They also require a mutual contracting process between the client and the social worker, but the time frame for assessment and contracting must be brief by necessity. People experiencing trauma and crisis need immediate relief and assistance, and the helping process must be adapted to meet those needs as efficiently and effectively as possible. Therefore, some of the tools and techniques used in the assessment and contracting phases, such as intake forms, social history gathering, engagement of the client, and intervention planning, must be used in ways or formats that facilitate a rapid response. The assessment, contracting, and intervention stages may need to be completed and implemented on the very first client contact. Clients in an active state of crisis are more amenable to the helping process, since their usual coping strategies and resources are inadequate to deal with the crisis, and this can facilitate completion of these tasks in a brief time frame.

In the case example of Alice, the sexual assault investigation and medical needs must be assessed and intervention initiated immediately. Crisis intervention counseling would be implemented by the police social worker simultaneously during the first contact with Alice. The rape examination and police investigation could take several hours, depending on the response time by law enforcement and medical professionals. The police crisis team and hospital social worker would provide crisis intervention services until the client has stabilized and received follow-up contacts by another collateral provider of crisis services, such as a rape crisis center counselor or volunteer. Examples of interventions provided by the police crisis team and hospital social worker would include assisting with the criminal investigation, explaining medical procedures and treatments for the sexual assault, and notification of family or significant others who can provide support and resources. Other services include immediate crisis counseling and assisting with basic needs, such as providing a change of clothes, since what the survivor was wearing will be taken into evidence. Safety issues would be addressed since sexual assault victims may not feel safe at home, if the rape occurred there, or fear that the offender could return or find the person there. Safety planning, support systems, transportation after discharge, and referrals for follow-up contacts to address other immediate concerns or needs would also be provided on the first contact with Alice.

During a crisis, social workers must be knowledgeable about the appropriate strategies, resources, and other collateral services to initiate timely interventions and meet the goals of treatment. Specialized knowledge about specific types of crises, traumatic incidents, or client populations is necessary for effective intervention planning. For example, crisis intervention with victims of family violence requires education and training on the dynamics and cycle of battering and abuse, familiarity with the community agencies providing services to this client population, and knowledge about any legal options available to victims. Similarly, social workers dealing with bereavement and loss in hospice settings need to be knowledgeable about the grief process, medical terminology, specific health problems or conditions, and support services for family survivors. Due to the diversity of crisis situations and events, the basic models and skills of crisis intervention must be supplemented by continued professional education and experience with specialized client populations or types of trauma encountered in practice.

Another characteristic of crisis intervention models is the use of tasks as a primary change effort. Concrete, basic needs services such as emergency safety, medical needs, food, clothing, and shelter are the first priority in crisis intervention. Mobilizing needed resources may require more direct activity by the social worker in advocating, networking, and brokering for clients who may not have the knowledge, skills, or capacity to follow through with referrals and collateral contacts during the time of active crisis.

Of course, the emotional and psychological traumas experienced by the client and significant others are important considerations for crisis intervention. Ventilation of feelings and a complex range of emotional reactions to crises are typical; however, initially the crisis worker should focus on techniques to calm the trauma survivor and reduce any physiological and emotional responses to the crisis since research on memory consolidation and physiological reactions has found that this reduces the development of posttraumatic stress symptoms (Dyregrov & Regel, 2012; James et al., 2016; Krans et al., 2013). Skills of reflective communication, active listening, and establishing rapport are essential to this process, as are interventions that target and reduce physiological reactions, such as deep breathing, presenting a calm demeanor, using a low tone of voice, slowing down communication flow, and being mindful of body space.

HISTORICAL DEVELOPMENT

Although crisis intervention has developed into a cohesive treatment model only in the past 50 years, human beings have been dealing with crises since antiquity. In ancient Greece, the word crisis came from two root words—one meaning “decision” and the other meaning “turning point.” Similarly, the two symbols in the Chinese language for crisis represent danger and opportunity. These definitions imply that crisis can be both a time for growth and impetus for change, as well as an obstacle and risk for harm and unhealthy reactions (Roberts, 2000).

Historically, family and religious systems helped people in crisis. The roots of crisis intervention developed in the 1940s and 1950s from several sources, including physicians, psychologists, psychiatrists, sociologists, social workers, and the military. Multidisciplinary teams involving these disciplines in various settings, such as public health agencies, hospitals, family counseling centers, and disaster response programs, did much of the work.

One of the pioneers in crisis intervention was Dr. Eric Lindemann, who was associated with the Harvard School of Public Health and Massachusetts General Hospital. His pioneering study on loss and bereavement with 101 survivors and family members of the victims of the Coconut Grove nightclub fire in Boston was one of the first efforts to develop a more systematic way of helping people in crisis (Lindemann, 1944). From his research, theories of the grief process and typical reactions to crisis were developed. He also concluded that the duration and severity of grief reactions appeared to be dependent on the success with which the bereaved person mourns and grieves the loss and changes, and readjusts to life without the deceased loved one (Roberts, 2005b; Yeager & Roberts, 2015a).

Other developments in psychiatry in the 1940s and 1950s contributed to the knowledge and research base of crisis intervention. From ego psychology, Erikson’s (1950) stages of human development included key psychosocial crises that had to be resolved over the course of life. He postulated that crisis and major life transitions are normal in human and social development, and can help individuals develop coping skills to successfully resolve both maturational and situational crises.

Suicide prevention services were another type of community-based mental health program that developed to respond to those in crisis. Much of the pioneering work was done at the Los Angeles Suicide Prevention Center in the late 1950s and 1960s (Dublin, 1963; Farberow & Schneidman, 1961; Schneidman et al., 1970). As the suicide prevention movement developed, the Center for Studies of Suicide Prevention (now defunct) was established in 1966, and by 1972, almost 200 such programs had been established across the country (Roberts, 2005b).

The Victim Witness Assistance Act of 1982 and the Victims of Crime Act of 1984 established federal funding and state block grants for crisis intervention programs and victim advocacy services in the criminal justice system. These comprehensive programs are located at police departments, prosecutors’ offices, and nonprofit agencies. Victim advocates focus on helping crime victims and family members with court-related advocacy, medical and mental health issues, and financial assistance (Roberts, 1990). States and local communities have been able to develop family violence, sexual assault, and victim services programs as a result of this federal assistance. As a result, thousands of statewide, county, and city victim service and domestic violence programs expanded to help individuals resolve particular crime-related problems and crises (Roberts, 1990, 1997).

The nature of crisis intervention changed dramatically after the Oklahoma City Federal Building bombing on April 19, 1995, and the terrorist attacks on the World Trade Center and the Pentagon on September 11, 2001. We live in an era in which sudden, unpredictable crises and traumatic events are brought into our homes by the media (Roberts, 2005b). Millions of people were affected, either directly or indirectly, by the flooding, widespread destruction of property, and evacuation of thousands of people from hurricanes Katrina and Rita in 2005, which were a wake-up call for all communities and crisis professionals to expand and coordinate interagency crisis response teams, programs, and resources.

RESEARCH AND EVALUATION

Research studies evaluating the effectiveness of crisis responses to these disasters and terrorist attacks served as guideposts for more effective macro- and microlevel crisis intervention planning (Castellano, 2003; Dass-Brailsford & Hage Thomley, 2015; Dziegielewski & Sumner, 2002; Henry, 2015; Kaul & Welzant, 2005; Underwood & Kalafat, 2002). The suddenness and severity of these national disasters and terrorist attacks that affected large numbers of people prove that it is imperative that all emergency services personnel and crisis workers be trained to respond immediately at both levels of practice.

The effectiveness of crisis intervention programs in various community-based social service, law enforcement, and mental health agencies has been another focus of research and program evaluation (Dziegielewski & Jacinto, 2015; Roberts & Everly, 2006; Vincent et al., 2015). Over the years, a proliferation of journal articles and books dealing specifically with crisis intervention models, skills, and intervention strategies for particular client groups, including youth-focused and school-based programs (Jimerson et al., 2005; Knox & Roberts, 2005, 2015; Kubiak et al., 2019), working with sexual assault and incest survivors (Edmond et al., 2004; Knox & Roberts, 2015; Schrag & Edmond, 2018), substance abuse (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018; Yeager, 2002), family violence (Knox & Garcia Biggs, 2007; Paul, 2019), and crisis intervention in health and mental health settings (Couvillon et al., 2019; Ginnis et al., 2015; Kim & Kim, 2017; Registered Nurses’ Association of Ontario, 2017; Wheeler et al., 2015; Yeager & Roberts, 2015a).

Research on best practices in crisis intervention provides evidence that school-based crisis intervention programs are effective in reducing symptoms of PTSD (Rolfsnes & Idsoe, 2011). Studies also report the effectiveness of crisis intervention programs for psychiatric emergencies with suicidal adolescents and other mental health crises in hospital emergency departments and for reduced rehospitalizations for persons with dementia (Dion et al., 2010; Johnson et al., 2012; Wharff et al., 2012). There is a need for more LGBTQA-specific crisis services considering that these youth are more than twice as likely to attempt suicide than their peers (Goldbach et al., 2019). Best practices for intervention with sexual harassment and assault and PTSD in military social work are also a recent focus due to the growing numbers and needs for current military members and other combat veterans from previous wars (Bell & Reardon, 2011; Yarvis, 2011).

The recent development of models for community-based crisis intervention teams (CITs) that are based on the Memphis Model aims to deal more effectively with mental health crises that involve law enforcement (Kasick & Bowling, 2015; Kubiak et al., 2017; Pelfrey & Young, 2019; Watson et al., 2017). The CIT model is multidisciplinary and includes members from law enforcement, social work, mental health, and emergency medical services to provide more comprehensive and effective crisis intervention services. The emphasis on mental health education and training for law enforcement officers, along with coordination of community resources, has shown effectiveness in changing officers’ perceptions and interactions with persons experiencing mental health crises, and increasing utilization of mental health and social services resources (Kubiak et al., 2017; Pelfrey & Young, 2019).

More recent research focuses on neurobiological functions that are important treatment considerations during crisis intervention, especially to minimize or prevent the development of PTSD symptoms. Research indicates that during the 6-hour time frame post-crisis incident, interventions that disrupt the memory consolidation process can reduce flashbacks and intrusive memories of the event (James et al., 2016; Sundermann et al., 2013; Tabrizi & Jansson, 2016). Therefore, it is more beneficial to work on basic needs and use a solutions-focused approach at the beginning of crisis intervention to minimize memory consolidation, instead of focusing on the details or memories of the crisis incident that would promote memory acquisition, consolidation, and storage.

A critical process in memory consolidation is high activation of physiological, emotional, and psychological responses (Dyregrov & Regel, 2012). Crisis interventions that reduce arousal, anxiety, and fear responses, including deep breathing, low arousal communication, and other calming or stabilizing strategies, such as normalization and psychoeducation, are most useful immediately after the crisis event. Crisis survivors who are injured and need medical treatment and pain control benefit from pharmacological strategies, since using pain medication or cortisol has been found effective in reducing trauma memories and the development of PTSD symptoms (Bryant et al., 2009; Dyregrov & Regel, 2012; Holbrook et al., 2010; Yehuda & Golier, 2009). Another area of research indicates that sleep promotes the memory consolidation process, thus it is also recommended that trauma survivors not sleep during the 6-hour time frame post-crisis (Dyregrov & Regel, 2012; Wagner et al., 2006).

THEORETICAL BASE AND CENTRAL CONSTRUCTS

The major tenets of crisis intervention derived originally from psychodynamic theory, particularly ego psychology, and ecological systems theory. Central ideas borrowed from ego psychology include life developmental stages, psychosocial crises, coping skills, and defense mechanisms. From the ecological systems theory, concepts such as homeostasis, disequilibrium, and interdependence are basic principles of crisis intervention.

Cognitive behavioral models share many characteristics with the basic assumptions and techniques of crisis intervention. These are action-oriented models, with a present focus and time-limited treatment. The cognitive behavioral principle that an individual’s perceptions and cognitions affect their beliefs, feelings, and behaviors in an interactive way is essential to crisis theory. The critical incident or precipitating event has to be perceived as a crisis by the client. Individuals involved in the same crisis situation may have very different perceptions, feelings, reactions, and coping skills (Datillo & Freeman, 2010; Roberts, 2005b; Yeager & Roberts, 2015a). Cognitive behavioral models that are currently being used and have been found to be effective with survivors of trauma and those with PTSD are trauma-focused cognitive behavioral treatment (CBT; Blankenship, 2017; Rubin et al., 2017), cognitive processing (Dickstein et al., 2013; Regehr et al., 2013; Suris et al., 2013), and prolonged exposure (Goodson et al., 2013; Regehr et al., 2013).

Another cognitive behavioral model that has been used in crisis intervention is eye movement desensitization and reprocessing (EMDR), which was developed in the mid-1990s by Shapiro (2017). This model is also time limited, and espouses that if trauma can produce immediate symptoms, then healing can also be accomplished in the same time frame by using this model’s techniques. This approach has been widely researched and used effectively with clients who suffer from PTSD such as military combat veterans (Yarvis, 2011), natural disasters (Konut et al., 2006), and terrorism (Silver et al., 2005); sexual assault survivors (Edmond et al., 2004; Regehr et al., 2013); and other trauma victims, including children and adolescents (Farkas et al., 2010; Greyber et al., 2012; Lewey et al., 2018; Soloman et al., 2009).

The solution-focused model has been used in crisis intervention with diverse client populations and is particularly suited to managed-care policies that have institutionalized time-limited treatment in most public sector agencies, such as mental health clinics, medical or hospital settings, EAPs, and health maintenance organizations (Greene & Lee, 2015; Kondrat & Teater, 2012). Solution-focused therapy has also been recommended for survivors of sexual assault and their partners (Tambling, 2012), those suffering from substance abuse and addictions (Yeager & Gregoire, 2015), and adolescents in crisis (Hopson & Kim, 2004).

Crisis intervention theories and models have evolved to incorporate a wide variety of techniques and skills from many different theoretical approaches. This is consistent with a generalist-eclectic approach and is critical when working with diverse client populations in various crisis situations and settings. However, the basic principles and assumptions of crisis theory provide a foundation knowledge base from which more specialized strategies and techniques can be learned and developed. Two other important concepts in crisis intervention—levels of crises and stages in crisis—are discussed next.

Levels of Crises

A classification paradigm developed by Burgess and Roberts (2005; Yeager et al., 2015) for assessing emotional stress and acute crisis episodes identifies seven main levels of crises along a stress–crisis continuum. While each crisis and each individual’s subjective experience of a crisis are unique, this stress–crisis continuum can be used in assessment and intervention planning to determine the level of care and most effective treatment modalities. It is important to note that the type of crisis services and the need for more intensive intervention may be necessary as the level of crisis increases along the continuum.

Level 1: Somatic Distress

This level of crisis results from biomedical causes and less severe psychiatric symptoms that cause stress and disequilibrium in the individual’s life. Other situational problems, such as health/medical conditions, relationship conflicts, work-related stressors, and chemical dependency issues would be included.

Level 2: Transitional Stress Crisis

This involves stressful events that are an expected part of life span development. These crises are normal life tasks or activities that can be very stressful, such as premature birth, divorce, and relocation. The individual may have little or no control over the situation and is unable to cope effectively.

Level 3: Traumatic Stress Crisis

These situations are unexpected and outside the individual’s locus of control. These crises can be life-threatening and overwhelming. They include combat, suicide, sexual assault, and other types of crime victimization.

Level 4: Family Crisis

This relates to developmental tasks and issues associated with interpersonal and family relationships that are unresolved and harmful psychologically, emotionally, and physically to those involved. Examples of this level of crisis are child abuse, family violence, and homelessness.

Level 5: Serious Mental Illness

This stems from a preexisting psychopathology, such as schizophrenia, dementia, or major depression, that can cause severe difficulties in adaptation for both the affected individual and the family support system.

Level 6: Psychiatric Emergencies

These are situations in which general functioning has been severely impaired, such as the acute onset of a major mental illness, a drug overdose, or suicidal attempts. The individual has a loss of personal control, and there is a threat or actual harm to self and/or others.

Level 7: Catastrophic Crisis

This level involves two or more level 1 to 3 traumatic crises in combination with level 4, 5, or 6 stressors. The nature, duration, and intensity of these stressful crisis situations and events and personal losses can be extremely difficult to accept and resolve. An example of this level of crisis is losing all family members in a suicide/murder or disaster.

Stages of Crisis

The stages of crisis are similar to those of the grief process. These stages do not always follow a linear process—individuals can skip stages, get stuck in a stage, or move back and forth through successive stages. Although there are many theoretical frameworks for crisis intervention, most of them include the following four stages:

Stage 1: Outcry

This stage includes the initial reactions after the crisis event(s), which are reflexive, emotional, and behavioral in nature. These reactions can vary greatly and can include panic, fainting, screaming, shock, anger, defensiveness, moaning, flat affect, crying, hysteria, and hyperventilation, depending on the situation and the individual.

Stage 2: Denial or Intrusiveness

Outcry can lead to denial, which is the blocking of the impacts of the crisis through emotional numbing, dissociation, cognitive distortion, or minimizing. Outcry can also lead to intrusiveness, which includes the involuntary flooding of thoughts and feelings about the crisis event or trauma, such as flashbacks, nightmares, automatic thoughts, and preoccupation with what has happened.

Stage 3: Working Through

This stage is the recovery or healing process in which the thoughts, feelings, and images of the crisis are expressed, acknowledged, explored, and reprocessed through adaptive, healthy coping skills and strategies. Otherwise, the individual may experience blockage or stagnation and develop unhealthy defense mechanisms to avoid working through the impacts, issues, and emotions associated with the crisis.

Stage 4: Completion or Resolution

This final stage may take months or years to achieve, and some individuals may never complete the process. The individual’s recovery leads to integration of the crisis event, reorganization of their life, and adaptation and resolution of the trauma in positive meanings of growth, change, or service to others in crisis. Many crisis survivors reach out to support and help others who suffer similar traumas through volunteer work and service organizations. For example, Compassionate Friends offers support groups and counseling services to parents and family who have lost a child through death.

PHASES OF HELPING

The phases of helping in various models of crisis intervention are similar to each other and utilize many of the same assessment and intervention strategies (Datillo & Freeman, 2010; Everly & Lating, 2013; Greenstone & Leviton, 2011; James & Gilliland, 2017; Kanel, 2019; Roberts & Yeager, 2009). This chapter focuses on the Assessment, Crisis Intervention, and Trauma Treatment (ACT) model (Roberts, 2005a; Yeager & Roberts, 2015a) and the seven-stage crisis intervention model (Roberts, 2005a; Yeager & Roberts, 2015b).

The Assessment, Crisis Intervention, and Trauma Treatment Model

The ACT model is a conceptual, three-stage framework and intervention model that integrates various assessment and triage protocols with the primary crisis intervention strategies. The ACT model can be used with a broad range of crises and can facilitate the psychosocial/lethality assessment and helping process for effective crisis intervention across diverse types of clients and trauma situations. It is the only model that focuses explicitly on the need to assess lethality, particularly when clients present because of a life-threatening, dangerous, or violence-precipitating crisis.

The A in the ACT model refers to triage, crisis, lethality, and trauma assessment and referral to appropriate community resources. The primary goal in conducting an assessment is to gather information that can be helpful in resolving the crisis. The assessment process should provide a step-by-step method of exploring, identifying, describing, measuring, and diagnosing health and mental health concerns, environmental conditions, strengths, resilience and protective factors, lifestyle factors, and current level of functioning. Appropriate triage and trauma assessment is critical to effective crisis intervention and treatment planning.

The C in the ACT model refers to the crisis intervention treatment plan and services that are provided on the scene, through short-term treatment or by referral to other community agencies. Types of services in this phase would include immediate crisis intervention, the delivery of basic needs and disaster relief, and referral to appropriate community social services, medical facilities, and mental health agencies.

The T in the ACT model refers to the need for follow-up services and referrals to address any symptoms of PTSD and continuing traumatic stress reactions. Stress management for first responders is also addressed in this phase to deal effectively with their traumatic stress reactions and to implement recovery strategies.

Seven-Stage Crisis Intervention Model

The seven-stage crisis intervention model by Roberts (2005a; Yeager & Roberts, 2015b) describes more completely the stages of crisis intervention (see Figure 9.1). It can be used with a broad range of crises, and can facilitate the assessment and helping process for effective crisis intervention across diverse types of clients and trauma situations. This model is useful to delineate the specific tasks and strategies necessary for effective crisis intervention. The model adapts easily to the different levels of crises and to different time frames for intervention. All of these stages can be completed within one contact if necessary, and in many crisis situations, that may be all the time that is available.

FIGURE 9.1  Seven-stage crisis intervention model.

Stage 1: Plan and Conduct a Crisis Assessment (Including Lethality Measures)

Assessment in this model is ongoing and critical to effective intervention at all stages, beginning with an assessment of the lethality and safety issues for the client. With depressed or suicidal clients, it is critical to assess the risk for attempts, plans, or means to harm oneself at the current time, as well as any previous history of suicidal ideations or attempts. With victims of rape, family violence, child abuse, or assault, it is important to assess if the client is in any current danger and to consider future safety concerns in treatment planning. In addition to determining lethality and the need for emergency intervention, it is crucial to maintain active communication with the client, either by phone or in person, while emergency procedures are being initiated (Roberts, 1998, 2005b; Yeager & Roberts, 2015b).

To plan and conduct a thorough assessment, the crisis worker also needs to evaluate the severity of the crisis, the client’s current emotional state, the client’s immediate psychosocial needs, and the level of the client’s current coping skills and resources. In the initial contact, assessment of the client’s past or pre-crisis level of functioning and coping skills is useful; however, past history should not be a focus of assessment unless related directly to the immediate traumatic event.

The goals of this stage are assessing and identifying critical areas of intervention while also recognizing the hazardous event or trauma and acknowledging what has happened. At the same time, the crisis survivor becomes aware of their state of vulnerability and initial reactions to the crisis event. It is important that the crisis worker begin to establish a relationship based on respect for and acceptance of the client, while also offering support, empathy, reassurance, and reinforcement that the client has survived and that help is available. In crisis intervention, stages 1 and 2 may occur simultaneously; however, the most important goal in stage 1 is to obtain information to determine whether the client is in imminent danger (Roberts, 2005b; Yeager & Roberts, 2015b).

Stage 2: Establish Rapport and Rapidly Establish a Relationship

Stage 2 also relates to the initial contact between the crisis worker and the client, with the main tasks of establishing rapport and conveying genuine respect for and acceptance of the client. Survivors of trauma may question their own safety and vulnerability, and trust may be difficult for them to establish at this time. Therefore, active listening and empathic communication skills are essential to establishing rapport and engagement with the client. Even though the need for rapid engagement is essential, the crisis worker should try to let the client set the pace of treatment (Roberts, 2000). Many crisis victims feel out of control or powerless, and should not be coerced, confronted, or forced into action, until they have stabilized and dealt with the initial trauma reactions.

Trauma survivors may require a positive future orientation, with an understanding that they can overcome current problems and with hope that change can occur. During this stage, clients need support, positive regard, concern, and genuineness. Empathic communication skills such as minimal encouragers, reflection of thoughts and feelings, and active listening can reassure the client and help establish trust and rapport with the client. The crisis worker needs to be attentive to the tone and level of the verbal communications to help the client calm down or de-escalate from the initial trauma reactions.

The crisis worker must also pay attention to their body language and facial expressions, because trauma survivors may have been violated physically and be hypersensitive to physical space and body movements, which can frighten or startle the survivor. Facial expressions can be difficult to monitor due to their automatic nature, but this is especially important when working with disaster or trauma victims when physical damage and destruction is evident. Being observant of the survivor’s physical and facial reactions can provide cues to the worker’s level of engagement with the client, as well as be a gauge to the client’s current emotional state. It is also important to remember that delayed reactions or flat affect is common with trauma victims, and to not assume that these types of reactions mean that the survivor is not in crisis.

Stage 3: Identify Major Problems (Including the “Last Straw” or Crisis Precipitants)

The crisis worker should help the client prioritize the most important problems or impacts by identifying these problems in terms of how they affect the survivor’s current status. Encouraging the client to talk about the precipitating event can lead to problem identification, and some clients have an overwhelming need to recall the specifics of the trauma situation. This process enables the client to figure out the sequence and context of the event, while providing information to assess and identify major problems for work.

Other crisis clients may be in denial or unable to verbalize their needs and feelings, so information may need to be obtained from collateral sources or significant others. It is essential to use a systems framework during the assessment and identification of problem stages, since crisis situations may impact at all levels of practice. Family members and significant others may be important to intervention planning in supportive roles or to ensure the client’s safety. However, they may be experiencing their own reactions to the crisis situation, and this should be taken into consideration in contracting and implementing the intervention plan.

The crisis worker must ensure that the client system is not overwhelmed during this stage, and the focus should be on the most immediate and important problems needing intervention at this time. The first priority in this stage is meeting the basic needs of emotional and physical health and safety; after these have stabilized, other problems can then be addressed. In some cases, it can also be useful to identify the precipitating event or “last straw” that led the client to seek help now, and to briefly explore any previous attempts or coping strategies to deal with the problem. The focus must clearly be on the present crisis, and any exploration of past problems or issues must be done rapidly and only to aid in intervention planning (Roberts, 2005a; Yeager & Roberts, 2015b).

Stage 4: Deal With Feelings and Emotions (Including Active Listening and Validation)

Helping the client calm down and attending to physiological reactions such as hyperventilation are important activities for the crisis worker in this situation. The primary technique used by the crisis worker is active listening, which involves listening in an accepting and supportive way, in as private and safe a setting as possible. It is critical that the crisis worker demonstrates empathy and an anchored understanding of the survivor’s experience, so that the client’s symptoms and reactions are normalized and can be viewed as functional strategies for survival. Many victims blame themselves, and it is important to help the client accept that being a victim is not one’s fault. Validation and reassurance are especially useful in this stage because survivors may be experiencing confusing and conflicting feelings.

Many clients follow the grief process when expressing and ventilating their emotions. First, survivors may be in denial about the extent of their emotional reactions and may try to avoid dealing with them in hopes that they will subside. They may be in shock and not be able to access their feelings immediately. Some clients will express anger and rage about the situation and its effects, which can be healthy as long as the client does not escalate out of control. Other clients may express their grief and sadness. The crisis worker must also be self-aware of their own emotional reactions and level of comfort in helping the client during this stage. It is important to attend to your own self-care needs to avoid burnout, emotional fatigue, and secondary traumatization effects.

Stage 5: Generate and Explore Alternatives

In this stage, effective crisis workers help clients recognize and explore a variety of alternatives for restoring a pre-crisis level of functioning. Such alternatives include (a) using support systems, such as people or resources that can be helpful to the client in meeting needs and resolving problems in living as a result of the crisis; (b) developing coping skills, which are behaviors or strategies that promote adaptive responses and resolution of the crisis; and (c) increasing positive and constructive thinking patterns to reduce the client’s levels of anxiety and stress.

The crisis worker can facilitate healthy coping skills by identifying client strengths and resources. Many crisis survivors feel they do not have a lot of choices, and the crisis worker needs to be familiar with both formal and informal community services to provide referrals. For example, working with a battered woman often requires relocation to a safe place for her and the children. The client may not have the personal resources or financial ability to move out of the home, and the crisis worker needs to be informed about possible alternatives, which could include a shelter program, a protective order, or other emergency housing services.

It is important to help the client generate and explore previously untried coping methods in a collaborative way, and it is equally important to examine and evaluate the potential consequences of, and the client’s feelings about, those alternatives. The crisis worker may need to be more active, directive, and confrontational in this stage if the client has unrealistic expectations or inappropriate coping skills and strategies. Clients are still distressed and in disequilibrium at this stage, and professional expertise and guidance could be necessary to produce positive, realistic alternatives for the client.

Stage 6: Develop and Formulate an Action Plan

The success of any intervention plan depends on the client’s level of involvement, participation, and commitment. The crisis worker must help the client look at both the short-term and long-range impacts in planning intervention. The main goals are to help the client achieve an appropriate level of functioning and maintain adaptive coping skills and resources. It is important to have a manageable treatment plan that the client can follow through and be successful. Do not overwhelm the client with too many tasks or strategies, because this may set the client up for failure (Roberts, 2000).

The client must also feel a sense of ownership in the treatment plan, so that the client can increase the level of control and autonomy in their life and not become dependent on other support persons or resources. Obtaining a commitment from the client to follow through with the action plan and any referrals is an important activity for the crisis worker that can be maximized by using a mutual process in intervention planning. Ongoing assessment and evaluation are essential to determine whether the intervention plan is appropriate and effective in minimizing or resolving the client’s identified problems. During this stage, the client should be processing and reintegrating the crisis impacts to achieve homeostasis and equilibrium in their life. Termination should begin when the client has achieved the goals of the action plan or has been referred for additional services through other treatment providers. Many trauma survivors may need longer term therapeutic help in working toward crisis resolution, and referrals for individual, family, or group therapy should be considered at this stage.

Stage 7: Establish a Follow-Up Plan and Agreement

It is hoped that the sixth stage has resulted in significant changes and resolution for the client with regard to their post-crisis level of functioning and coping. This last stage should help determine whether these results have been maintained or if further work remains to be done. Typically, follow-up contacts should be done within 4 to 6 weeks after termination. It is important to remember that crisis resolution may take many months or years to achieve, and survivors should be aware that certain events, places, or dates could trigger emotional and physical reactions to the previous trauma. For example, a critical time is at the first anniversary of a crisis event, when clients may reexperience old fears, reactions, or thoughts. This is a normal part of the recovery process, and clients should be prepared to have contingency plans or supportive help through these difficult periods.

APPLICATION TO FAMILY AND GROUP WORK

The crisis intervention model is applicable to family and group crisis intervention, although there are certain considerations in relation to these levels of practice. Certain crisis situations, such as shifts in family structure and developmental changes, can affect family members differently, so the crisis worker may have to assess who in the family is experiencing crisis and who in the family will be participating in treatment. Other crisis events, such as child abuse, family violence, or criminal offenses, involve demands from community agencies that a family member change certain behaviors or ways of coping. Then there are traumatic situations that may affect all family members involved in the critical incident, such as disasters, accidents, and death.

During assessment, the family structure, dynamics, relationships, communication patterns, and support systems need to be evaluated as to potential strengths and areas in need of treatment. Assessment of how family members react to each other and to the crisis situation, including any issues of blame or guilt, is important to consider when planning interventions. How the crisis impacts on the family system as a whole and on the individuals, the amount of family cooperation, and consideration of the family’s support system in terms of local community resources are also important in assessment and intervention planning. Extended family may often be involved during intervention, both at the time of active crisis and later as sources of support and resources for stabilization.

Group crisis work is used with clients experiencing similar types of trauma, such as sexual assault and child abuse survivors, individuals in community or institutional disasters, persons with chemical dependency, combat veterans, and individuals dealing with loss and bereavement. Having the support of and interaction with others who have shared similar crisis events are important benefits of group therapy. Group members can learn from each other about ways to cope and go on with their lives. As in families, group members may have different reactions, experiences, feelings, and coping skills, so intervention has to be directed at the individual level, as well as with the group as a working system. The need for individual treatment in addition to group work should be part of the assessment and action plan. Self-help and time-limited groups are also excellent resources for longer term crisis or grief work.

CRITIQUE OF CRISIS INTERVENTION

One of the strengths of crisis intervention is its effectiveness across diverse types of crises and client populations. However, although research and literature exist on specialized types of crises and clients, there is not much literature on cultural, gender, or age factors among crisis client populations (Congress, 2000; Cornelius et al., 2003; Dykeman, 2005; Stone & Conley, 2004). A meta-analysis of the federal Crisis Counseling Program (CCP) disaster mental health services for approximately 160,000 people over a 5-year period indicated that the 36 programs studied were at least at a pre-competent level of cultural competence. The programs did make efforts to reach out to diverse communities by hiring staff from different cultures, providing training in cultural competence, and engaging in ongoing cultural reassessment to improve their knowledge and services. The authors also noted that the CCPs were successful in serving racial and ethnic minority groups by recruiting indigenous community leaders as counselors and providing free mental health services in the community (Rosen et al., 2010).

More research is also needed on sexual orientation, and gender and age differences in dealing with crises, especially in the expression of emotion (Dyregrov & Regel, 2012; Goldbach et al., 2019). A study on male police officers who report traumatic exposures indicates that they adhere to traditional male gender norms and prefer not to share their memories and emotions with their peers. The authors recommend strategies that focus on strengths and provide goal-directed professional development and training for critical incident stress management (Pasciak & Kelley, 2013).

CONCLUSION

Crisis intervention is an eclectic approach that is effective across diverse types of crises, client populations, and settings. It is essential that social workers be knowledgeable and trained in basic crisis intervention skills to meet the needs of their clients. Continuing professional development through workshops, training, and professional literature on evidence-based crisis intervention models and skills is necessary for social workers and counseling professionals to provide effective and appropriate services. Further research studies on crisis intervention models and strategies are needed to develop and evaluate best practices, and program evaluations are critical for accountability and appropriate provision of crisis intervention services. This chapter has provided an overview of the principles, theoretical constructs, and basic intervention skills in crisis intervention. Crisis work can be both demanding and difficult, but its rewards can be immediate and long-lasting for both clients and social workers.

SUMMARY POINTS

•crisis intervention is grounded in an generalist-eclectic orientation and theory base and incorporates the basic principles and perspectives from systems theory, ego psychology (including life cycle/human development theory), and cognitive behavioral theories into a holistic framework for crisis intervention with diverse client populations and types of crises;

•crisis theory does not view the individual in crisis as pathological or mentally ill, since all human beings experience and deal with challenges presented during crises and trauma as a normal part of the human condition;

•crisis theory postulates that intervention is time limited to a period of 4 to 6 weeks with the goal of mobilizing needed support, resources, and the adaptive coping skills of the client to resolve or minimize the disequilibrium experienced by the precipitating event;

•crisis intervention places an emphasis on client strengths and empowerment. A strengths-based approach is inherent in the crisis intervention strategy of building on the client’s own coping skills and natural support system;

•client empowerment is a natural outcome of this approach, because the focus in crisis work is to provide the support and resources for clients to resolve any negative impacts through their own growth and development and not to become dependent on others in their social environment to meet those needs;

•crisis intervention emphasizes holistic, multilevel assessment within an ecosystem perspective, and must address the biological, psychological, and environmental damage and trauma, from both a macrosystemic and an individual perspective to be effective;

•it is essential that social workers be knowledgeable and trained in basic crisis intervention skills to meet the needs of their clients. Continuing professional development on evidence-based crisis intervention models and skills is necessary for social workers and counseling professionals to provide effective and appropriate services.