Final Project

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Week 1 Guided Reading

Site: Welcome to LSU Online! Course: 2021 Second Spring SW 7807 for Charlotte Tryforos Book: Week 1 Guided Reading

Printed by: Kishon Hunter Date: Monday, April 26, 2021, 9:22 AM

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Description

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Table of contents

1. Understanding Crisis 1.1. Defining Crisis

1.2. Theoretical Influences

1.3. Types of Crises

1.4. How a Crisis Develops and Reactions to Crises

1.5. Crisis as a Danger and Opportunity

2. History of Crisis Intervention 2.1. Timeline of Key Events

2.2. Models of Crisis Assessment

2.3. Models of Crisis Intervention

3. ABC Model of Crisis Intervention

4. Review of Key Concepts

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1. Understanding Crisis

This section will highlight key concepts in the recommended readings and introduce some additional information about crisis theory.

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1.1. De�ning Crisis

Gerald Caplan, who is often noted as the father of crisis intervention, made four key assumptions that define crisis theory:

1. A crisis begins with a precipitating event 2. Cognitive interpretation or appraisal of the event, which means that not everyone responds to the event in

the same way 3. Crises create a state of disequilibrium and disorganization leading to emotional stress 4. Coping mechanisms that were once helpful are no longer effective for the person in crisis

I would add one more component--Hazardous Atmosphere. Hazardous Atmosphere describes the circumstances in a person's life that make them vulnerable to crisis. We'll explore this further later in this reading.

The purpose of crisis intervention is to increase functioning. Social workers can do this by helping the person in crisis to change their perception of the event and learn new coping strategies. You will learn some of the essential skills for crisis intervention in Week 2.

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1.2. Theoretical In�uences

Several intervention theories have influenced crisis theory:

Psychoanalytic Theory

Sigmund Freud is often considered the "father of psychoanalysis" (pictured on left). Psychoanalytic theory focuses on the unconscious mind and internal drives and has stages of psychosexual development.

Psychoanalytic theory posits that a person has a finite amount of psychic energy. This explains the disequilibrium that occurs during a crisis when a person's psychological energy is depleted and usual coping fails.

This also can explain why people with mental illness often respond poorly to crisis--because their psychic energy is already being used to manage their psychological symptoms.

The American Psychoanalytic Association's website provides an overview of psychoanalytic theory.

Existential Theory

Existential theory posits that there is an inherent anxiety in the human condition due to existential "givens", including freedom, death, isolation, and meaninglessness. These "givens" are the focus of an entire type of crises--existential crises.

Two key concepts from existential theory are reflected in crisis theory:

1) Anxiety is a normal part of existence

2) The focus of intervention is choice. In a crisis, the choice is between danger and opportunity, or to avoid or address the crisis.

You can learn more about the existential approach to psychotherapy at this site.

Humanistic Approach

The humanistic approach was established by Carl Rogers (pictured on right). This type of therapy is sometimes called Rogerian therapy or client-centered therapy. Humanistic approaches posit that people have their own answers, and counselors can help people find them by creating an authentic, empathetic environment unconditional positive regard, acceptance, and congruence. We will discuss this in further detail in Week 2.

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Contemporary crisis intervention models focus heavily on establishing rapport through empathetic listening. If a person does not feel like they are heard or understood, the change will not likely occur. Like the humanistic approach, crisis intervention also actively involves clients, especially in planning and implementing changes to restore coping after a crisis event.

This website provides an overview of Rogerian or client-centered therapy.

Nonviolent Communication

Like the Rogerian therapy, nonviolent communication focuses on empathy. Marshall Rothenberg, the founder of this approach, defines nonviolent communication as "a way of communicating that leads us to give from the heart." The video below reviews the 4 components of nonviolent communication and 3 other key concepts. This style of empathetic listening is a critical tool used by crisis counselors.

You have an opportunity to earn extra credit in this class by reading the book summarized in this video and

completing a guided reading activity. See the "Extra Credit" tab on Moodle for details.

Cognitive-Behavioral Theories

Cognitive-behavioral theories posit that thoughts, emotions, and behaviors are related. By changing your thoughts or behaviors, you can change your emotions. Cognitive theories assert that people have automatic thoughts when in a situation, and these thoughts lead to emotional, behavioral, and physiological reactions (See image to left.) These reactions are more connected to a person's perceptions or thoughts than the situation itself.

The idea from cognitive theories that a person's perceptions of an event are more closely linked to their reactions than the event itself is evident in crisis theory. Crises are formed based on a person's perception or cognitive appraisal of the precipitating event, and a primary strategy for addressing crises is helping a

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person restructure these cognitions. Like crisis theory, cognitive theories stress homework and follow-up.

Crisis intervention models also borrow the problem-solving method of behavioral theories. This problem- solving approach uses the following steps:

1) Define the problem

2) Review ways already tried to correct the problem

3) Decide what you want when the problem is solved

4) Brainstorm alternatives

5) Select alternatives and commit to following through

6) Follow-up

To learn more about cognitive-behavioral theories, browse the Beck Institute's website. (Aaron Beck is one of the

founders of cognitive-behavioral therapy, and his daughter Judith Beck has followed in his footsteps as a CBT-

focused psychologist.)

Dialectical Behavioral Therapy

Dialectical Behavioral Therapy, or DBT, is a specific cognitive-based approach that was developed by Marsha Linehan to treat women with borderline personality disorder (BPD). DBT therapists collaborate with clients to support them in learning new skills to regulate their emotions and reframe their cognitions. Linehan talks a lot about "radical acceptance." I find the principles of DBT especially useful in suicide intervention.

This article provides a good overview of DBT. You can watch some really fascinating videos from Linehan here (not required): 

Brief Therapy

While crisis intervention is a short-term approach, it is not synonymous with brief therapy. Crisis intervention is a type of brief therapy with the goal of increasing positive coping after a crisis. Brief therapy can have other goals, and it is broader than crisis intervention. Research has shown that brief therapies are often as effective as long-term therapies.

One of the most influential schools of brief therapy is Solution-Focused Brief Therapy. Learn more about SFBT at the

Institute for Solution-Focused Therapy

The Transtheoretical Model (Stages of Change)

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Prochaska and DiClemente (1983) developed the Stages of Change Model through studies examining the experiences of people who quit smoking. They learned that regardless of supportive intervention, people quit smoking when they were ready to. The Transtheoretical Model helps us understand where our clients are in the process of deciding to make changes in their lives.

This model describes five stages that people go through on their way to change: 

Precontemplation--no intention to take action in the foreseeable future (defined as the next 6 months). Client may be unaware or unwilling to recognize that their behavior is problematic. They may also underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior. Contemplation--client is considering a change within the next 6 months. The client recognizes that their behavior may be problematic and is weighing the pros and cons of change. The client likely still has some ambivalence about committing to change. You will learn more about addressing ambivalence in Week 3, when we study suicide intervention. Preparation--the client has decided to change their behavior and is ready to take action within the next 30 days. They may start taking small steps toward the behavior change. Action--the client is in the process of changing their behavior (or has changed in the last 6 months) and intends to continue moving forward. Maintenance--the client has sustained their behavior change for more than 6 months and intends to maintain the behavior change long-term

As you work with clients in crisis intervention, use this theory to help you suggest appropriate steps for the client's plan of action. For example, suggesting Alcoholics Anonymous to someone who is not ready to stop drinking is unlikely to be helpful.

This website provides an overview of the Transtheoretical Model.

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1.3. Types of Crises

There are four main types of crises: 1) developmental, 2) situational, 3) existential, and 4) psychiatric.

Developmental Crises

In a developmental crisis, the precipitating event is part of the normal maturation process or life cycle.

Erik Eriksons's psychosocial theory provides a framework for understanding when key developmental crises may occur. Erikson posited that people move through 8 stages across the lifespan. To move from one stage to the next, a person must resolve a particular challenge or crisis. Each stage is marked by specific developmental tasks that must be mastered before moving on to the next stage successfully.

Situational Crises

Situational crises are typically what people think of when they hear the word crisis. We will be focusing on situational crises in this course. Characteristics of situational crises:

Clear, external precipitating event Unanticipated and unpredictable Emergent quality Can impact more than one person

Examples: loss of a job or relationship, involvement in an accident, exposure to violence or suicide, death of a loved one, sudden medical illnesses or injuries, major damage to or loss of one's home, natural disasters, terrorist attacks, school shootings, crimes, child abuse, intimate partner violence.

Existential Crises

Characteristics of existential crises: Tend to happen after traumatic events Often difficult to identify because may be experiencing with other symptoms

Examples: questioning meaning of life, disconnectedness of people, the meaningfulness of his or her work

Psychiatric Crises

Characteristics of psychiatric crises: Precipitating event difficult to identify Not everyone with a psychiatric condition will experience a crisis Often accompanied by other types of crises

Examples: person with bipolar who stops taking medication and experiences severe mania or depression; psychotic symptoms with command hallucinations (e.g., instructing to harm self or others); overdose on pain medication

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1.4. How a Crisis Develops and Reactions to Crises

Two people can experience the same event, and it could be a crisis for one but not for the other. This is due to several factors:

Hazardous atmosphere. Stress at work, family conflict, a history of childhood trauma, underlying mental illness, financial insecurity, etc. may combine to create a vulnerable state that makes clients susceptible to crisis. It's important to explore this and reflect it back to the client to help them gain insight.

Supports/Buffers. Supports and buffers help maintain the client’s functioning. These are friends and family, positive coping skills, etc. Utilizing them will be key in helping the client recover from crisis.

Client's perception (cognitions) of the event. For example, let's say two classmates fail a test. Classmate A thinks, "I failed the test. This is horrible. I'm gong to fail the class and lose my scholarship." With this perception of the event, failing the test is likely to be a crisis. On the other hand, Classmate B may experience failing the test with the following thought pattern: "I failed the test. I'm not happy that I failed the test but it is not a big deal because I can get As on all the other assignments." For Classmate B the event is unlikely to be perceived as a crisis.

Generally speaking, the more unexpected the crisis event, the more severe the crisis reaction.

Types of Reactions to Crises

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In most cases, reactions to crisis are time-limited and will resolve on their own with or without intervention. Normal crisis responses resolve within a matter of hours, days, or weeks. If symptoms last longer than 6-8 weeks, a person may meet criteria for a psychiatric diagnosis. Stress, Adjustment, and Depressive Disorders Related to Crisis

Diagnosis in crisis intervention is controversial because it can be seen as pathologizing reactions of victims of crimes, such as sexual assault. I would recommend avoiding diagnosis during the acute crisis stage unless it's required for some reason (ie: billing, inpatient admission, etc).

Diagnoses commonly given to people who have experienced trauma or crisis are: post- traumatic stress disorder (PTSD), acute stress disorder, adjustment disorder, and major depressive disorder.

Criteria for PTSD per DSM-5:

Person has experienced or witnessed a traumatic event, or learning that a traumatic event happened to a close family member or friend Recurrent distressing memories or dreams of event Flashbacks in which person feels as though event is recurring Distress caused by internal or external cue that serves as a reminder of the event Persistent avoidance of reminders of traumatic event Persistent negative cognition and moods in aftermath of event Symptoms begin within 1 month of traumatic event

Criteria for acute stress disorder are the same as PTSD except for duration. For acute stress disorder, symptoms last 3 days to 1 month, and for PTSD, symptoms last longer than one month.

Criteria for adjustment disorder per DSM-5:

"stressor" is catalyst for symptoms Emotional or behavioral symptoms occurring within 3 months of "stressor" Distress is out of proportion to severity or intensity of stressor Significant impairment in social, occupational, or other areas of functioning

Criteria for major depressive disorder per DSM-5:

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Five or more of the following must have been present nearly every day over the past two weeks: Depressed mood most of the day Markedly diminished interest or pleasure in activities Significant weight gain or loss or changes in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Di�iculty concentrating and/or indecisiveness Recurrent thoughts of death or suicide, or a specific plan for suicide

Symptoms cause significant distress or impairment in functioning The episode is not attributable to substance use, another medical condition, or better explained by another mental disorder There has never been a manic or hypomanic episode

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1.5. Crisis as a Danger and Opportunity

A crisis is often thought of as both a danger and an opportunity. In the Chinese language, crisis consists of two symbols: one meaning danger and one meaning opportunity.

The English word crisis is derived from the Greek word krinein, which means "to decide." It is thought that the decisions made by a person in crisis on how to handle the event determines their outcomes.

A crisis becomes a danger to a person if they do not take steps to restore their functioning. When crises are not addressed, they can snowball into dangerous crises, such as homicide, suicide, and psychosis.

By addressing a crisis, a person can use a crisis as an opportunity for growth, insight, and enhanced coping.

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2. History of Crisis Intervention

This section highlights key concepts in the history of crisis intervention and presents a timeline of important historical events and themes that have influenced the field of crisis intervention.

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2.1. Timeline of Key Events

This interactive timeline will introduce you to some key historical events and themes related to the development of the field of crisis intervention.

To print the story please do so via the link in the story toolbar.

History of Crisis Intervention

CD Cassie Dinecola | copy of Timeline Template by Sutori View on sutori.com

This interactive timeline includes important historical events and themes in the field of crisis intervention.        

Cocaonut Grove Nightclub Fire • November 28, 1942

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The Cocoanut Grove Night Club Fire in 1942 in Boston, MA marked the beginning of modern crisis intervention. There were so many people affected by this traumatic event that lay people were called on to respond to the crisis--this is the beginning of the trend of the use of paraprofessionals in crisis intervention. Paraprofessionals are still used widely on crisis hotlines and mobile response teams today. This video shows more about the cause and impact of this event that sparked the beginning of crisis intervention.

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1950s

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1960s

1970s

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Powered by Sutori

1980s-present

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(Note: My colleague Dr. Cassie Dinecola created this timeline using a website called Sutori. You do not have to make comments on the timeline, but they are welcomed. If you want to make comments, you will need to create a free account for Sutori. )

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2.2. Models of Crisis Assessment

Karl Slaikeu's BASIC Model 

B: Behavior (day to day functioning, suicidal/homicidal ideation, agitation)

A: Affect (emotional response)

S: Somatic (physical or medical complaints)

I: Interpersonal (social functioning, relationships with social support)

C: Cognitions (perception of precipitating event, cognitions related to the crisis)

Hendricks & McKean's Assessment Model

"frontline" model: for people responding to crises in the field (e.g., EMS, police, firefighters)

Phase 1: assessment of the crisis scene (safety and who/what/where/how)

Phase 2: assessment of the individual in crisis (current and pre-crisis levels of functioning and coping)

Myer's Triage Assessment Model 

1) affective (emotional)

anger/hostility

anxiety/fear

sadness/melancholy

2) cognitive (thinking)

transgression

threat

loss

3) behavioral (actions)

Parad & Caplan's Guidelines for Assessing Families in Crisis  

1) The stressful event poses a problem that the family cannot fix in the immediate future.

2) The problem overtaxes the psychological resources of the family, meaning their usual problem-solving strategies are not working.

3) The situation is perceived as a threat or danger to the life goals of the family members.

4) Time-limited in nature

5) The crisis situation awakens unresolved problems from past

Collins & Collins' Developmental-Ecological Model 

A: a�ect (emotion)

B: behavior

C: cognition 

D: developmental considerations (age and developmental stage could a�ect how one reacts to a crisis)

E: ecological considerations (one's immediate environment: support system, finances, etc.)

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2.3. Models of Crisis Intervention

Slaikeu's Comprehensive Model for Crisis Intervention

First order vs second order intervention

First-Order Intervention "psychological first aid" Goals: establish coping, reduce lethality, link to referrals Usually only lasts one session Immediate assistance offered to a person in crisis

Second-Order Intervention Crisis therapy Goes beyond immediate "first aid" Attempts to bring about a resolution to the crisis

Five Stages of Psychological First Aid

1) Making Psychological Contact (empathetic listening, establish rapport)

2) Exploring Dimensions of the Problem (who/what/when/how)

3) Examining Possible Solutions (what has worked before, brainstorm alternatives)

4) Taking Concrete Action (facilitative or directive depending on safety concerns)

5) Follow-Up (check on progress)

Flannery & Everly's Crisis Intervention Model 

Known as critical incident stress management (CISM) and critical incident stress debriefing

Goal: restore the person in crisis back to equilibrium, restore functioning, lessen the impact of the traumatic event

Guidelines

1) Intervene immediately (as soon as possible)

2) Stabilize (mobilize social supports)

3) Facilitate Understanding (help person understand facts about event)

4) Focus on Problem Solving (use social support and resources to assist with problem-solving)

5) Encourage Self-Resilience (empowering victims to do tasks that they can)

Aguilera's Model of Crisis Intervention 

1) Assessment

Focused on precipitating event and "here and now" Includes lethality assessment

2) Planning Therapeutic Intervention

Helping individual gain an intellectual understanding of crisis Helping individual become aware of present feelings Exploring coping mechanisms Reopening the social world

3) Resolution of Crisis and Anticipatory Planning

Reinforces coping strategies that have used in past Identify how this crisis may help in dealing with future crises

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Roberts' Seven-Stage Crisis Intervention Model

Roberts is a social worker! Advocates that crisis counselors be active but without taking away ownership from the person in crisis Convey acceptance and optimism Applicable to many types of crises

1) Plan and conduct a Crisis Assessment (which includes lethality)

2) Make psychological contact, establish rapport, and readily establish a relationship

3) Identify major problems and examine dimensions (precipitating event, previous coping methods, danger/lethality)

4) Encourage exploration of feelings and emotions

5) Generate and explore alternatives

6) Develop an action plan

7) Establish a follow-up plan and agreement

James & Gilliland's Six-Step Crisis Intervention Model

Very similar to Roberts' 7-stage model

Listening Steps

1) Defining the problem

2) Ensuring client safety

3) Providing support

Acting Steps

4) Examining alternatives

5) Making plans

6) Obtaining commitment

Greenstone & Leviton's Crisis Intervention Model

Strong advocates for follow-up and referral Provides suggestions for types of skills that crisis counselors can use (questioning, clarifying, reflecting, summarizing)

1) Immediacy (act as soon as possible)

2) Control (bring structure and definition to crisis resolution)

3) Assessment (focus on the present crisis, do not overwhelm with too many questions)

4) Disposition (decide how to handle the situation after it has been assessed)

5) Referral (counselors should have knowledge about eligibility)

6) Follow Up

Kanel's A-B-C Model of Crisis Intervention

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A--Developing and Maintaining Contact

Establishing rapport Use attending skills, questioning, clarifying, summarizing

B--Identifying the Problem

Exploration of crisis and assessment of the client's reaction to the crisis Pre and post-crisis functioning in behavior, social, academic, occupational realms May provide educational information, empowerment statements, supportive statements, or reframe the crisis

C- Coping

How have they coped in the past? Explore alternatives The counselor helps identify new coping behaviors

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3. ABC Model of Crisis Intervention

In this course we will combine the ABC Model of Crisis Intervention with the model that I was trained in at the Baton Rouge Crisis Intervention Center, which operated a telephone crisis line for more than 45 years (read more about the center here). We will review this in detail in Week 2. An overview of the ABC Model can be found below.

A: Use of Basic Attending Skills to Develop and Maintain Rapport

Attending behaviors

Open-ended and appropriate closed-ended questions Paraphrasing and clarifying Reflection of feelings Summarizing

B: Identifying the Nature of the Crisis and Therapeutic Interaction

Identify the precipitating event Identify and explore cognitions Identify emotional distress Identify impairments in functioning: behaviorally, socially, academically, occupationally Ethical checks: suicide, homicide, organic issues, psychosis, substance abuse, child abuse, elder abuse Therapeutic interaction statements: educational, empowerment, validation, reframing

C: Coping strategies

Explore how the client has tried in the past to cope Explore other things client can do to cope O�er alternative strategies for coping

Support groups Twelve-step groups Marital or family therapy Lawyer Doctor Bibliotherapy Reel therapy Assertion training Stress management Shelters or other agencies

Create a plan Obtain commitment Follow-up

Kanel, K. A Guide to Crisis Intervention (5th ed.). Stamford, CT: Cengage Learning.

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4. Review of Key Concepts

Four components of crisis formation: Precipitating event: something that occurred within the past few days or weeks to cause a sudden and significant decrease in functioning.

Cognitions: the client's perception of the precipitating event determines whether it's a crisis or merely an unfortunate circumstance

Emotional distress: the client feels a wide range of emotions related to disequilibrium and disorganization.

Decrease in functioning: the client experiences disruption in self-care, occupational/academic, family, and social functioning. 

Other important factors: Hazardous atmosphere/stressors: Hazardous atmosphere creates a vulnerable state that makes clients susceptible to crisis. This can be stress at work, family conflict, a history of childhood trauma, underlying mental illness, financial insecurity, etc. 

Supports/bu�ers: Supports and bu�ers help maintain the client’s functioning. These are friends and family, positive coping skills, etc.

Coping: These are things the client has done to cope with stress in the past, including maladaptive coping, as well as strategies the counselor may suggest to help the client restore their usual level of functioning.