For A-plus Writer Only

Book Reference

James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

Introduction Accurate and well-honed listening skills are necessary and indeed sometimes sufficient skills that all therapists, but particularly crisis interventionists, must have. For rhat reason, listening skills are a major component of rhe crisis intervention model. Our preferred conceptual mo del for effective listening comes from person- centered counseling (Egan, 1982, 1990; Rogers, 1977). Those skills will be familiar to even neophyte human services workers. However, using them effectively in the heat of a crisis may become daunting. That said, there are a variety of other basic verbal techniques you will meet in this chapter with which many human services workers will probably not be familiar. Many of these verbal sets are much more directive, action oriented, judgmental, and may take some getting used to by veteran workers when first tried out.

Listening in Crisis Intervention Open-Ended Questions Often workers are frustrated by a client's lack lm:ll of response and enthusiasm. Workers may make state- ments such as "All my clients ever do is grunt or shake rheir h eads indicating yes or no." We can do something ab out getting fuller, more meaningful responses if we ask questions that are not dead ends . Open-ended questions usually start with what or how or ask for more clarification or details. Open-ended questions encourage clients to respond with full statements and ar d eeper levels of m eaning. Remember that open-ended questions are used to elicit from clients something ab out their feelings , thoughts, a nd behaviors and are par ticularly helpful in the Problem Exploration phase

of intervention in the Task model. Here are some guidelines for forming open- ended questions.

1. Request description: "Please tell me ... ," "Tell me about ... ,""Show m e . .. ,""In what ways does ... ?"

2. Focus on plans: "What will you do ... ?" "How will you make it happen?" "How will that help you to ... ?"

3. Expansion: "Tell m e more," "Could you give me so me more details?" "How about expanding on that a bit," "So then what happened?"

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74 • PART ONE Basic Training: Crisis Intervention Theory and Application

4. Assessment: "How is that different from before?" "What are you doing about that?" "When that happened, how did you handle it?" "Who might you get to help you?"

5. Stay away from "why" questions: Beginners in the crisis intervention business invariably are intrigued and puzzled by the odd and bizarre things people in crisis think, feel, and do. As a result, beginners feel compelled to find out why a person thinks, feels , or does those "really crazy'' things. It is our contention that "why" questions are generally poor choices for obtaining more information. Even though they may provide the client with an opening to talk more, they also make the client defend his or her actions. Notice the response of Jake, the husband of Rita, whom you will meet later in this chapter, as the crisis worker queries him about the reasons for his behavior.

CW: Why do you continue to beat your wife?

Jake: Hey! If she'd be a little more affectionate, I wouldn't have to beat her up! It's her fault!

As this example demonstrates, what generally hap- pens is that clients become defensive and attempt to intellectualize about the problem or externalize it to somebody or something else without taking responsi- bility for or ownership of the problem.

Closed-Ended Questions Closed-ended questions seek specific, con- Im crete information from the client. They are designed to elicit specific behavioral data and yes or no responses. Closed questions usually begin with verbs such as do, did, does, can, have, had, will, are, is, and was. Contrary to what typically occurs in long-term therapy, closed- ended questions are often used early on in crisis inter- vention to obtain specific information that will help the crisis worker make a fast assessment of what is oc- curring. In most counseling programs, closed-ended questions are a "no-no! " because they indeed tend to close off interaction rather than facilitate dialogue. Thus, using closed questions is problematic for many graduate students whose instructors have harped at them, "Keep it open!" Whereas in long-term therapy the formulation of a plan of attack on the problem might be weeks or months in the making, crisis in- tervention often calls for instigating plans of action immediately. Closed-ended questions are particularly suited to obtaini ng commitments to take action. They are also highly appropriate in regard to safety

issues. We don't mince words about safety issues, and we are not interested in circuitous responses. "Are you going to kill yourself?" may seem insensitive, coarse, and callous. It is not! We'll have a great deal more to say about this issue in Chapter 8, Crises of Lethality.

Here are some guidelines for forming closed- ended questions.

1. Request specific information: "When was the first time this happened?" "Where are you going to go?" "Are you thinking of hurting her?" "Have you gone back there?" "Do es this mean you are going to kill yourself?"

2. Obtain a commitment: "Are you willing to make an appointment to . . . ?" "Will you confront him about this?" "Do you agree to ... ?" "When will you do this?"

3. Increasing focus: "Do you understand what I am saying?" "Can you do this for me now?" "Are you on track with me?"

4. Avoid negative interrogatives: A negative interrogative is a closed question often used as a subtle way to coerce the listener into agreeing with the speaker. Don 't, doesn't, isn't, aren 't, and wouldn't all tend to seek or imply agreement. The negative interrogative statement "Don' t you believe that's true?" really is a camouflaged exclamatory statement saying, "I believe that's true, and if you have an ounce of sense you'll agree with me!"

CW: Don't you think it'd be a good idea if you stay away from Rita?

Such statements generally have little place in a crisis interventionist's repertoire of verbal skills. A far better way of asking for compliance is with an assertive owning statement.

CW: Jake, I understand how difficult it is for you, but for the sake of both you and Rita, I'd really like you to continue to build on last week's success by agreeing to the "stay away from her" contract again this week.

Restatement and Summary Clarification Restatement and summary clarification are lml critical ingredients in crisis intervention. Clients in crisis may have difficulty expressing themselves because of their disjointed thought processes or the chaos that is going on around them in the environ ment. By restating what the client is saying in the crisis worker's own words, the crisis worker can

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gain agreement from the client on what the client is attempting to say, feel, think, and do. Further, good restatement is particularly important in crisis because it tells the client that "Somebody is listening to me!" Restatement generally has to do with the con- tent of the crisis event rather than the underlying feel- ings and thoughts about it. A sort of a default way of looking at this technique is using a famous line coined by Sgt. Joe Friday in the TV series Dragnet, "All we want are the facts," and then giving those facts back in your own words. Restatement can also serve as an effective break point for a client who is freewheeling in an ideational flight of emotions or thoughts.

CW: Time out a second,Jake. You've put a lot out here and my memory banks are getting pretty full. Let me summarize what you've said, and let's see if we are on the same track.

Restatement sounds simple. It is simple if the crisis worker focuses totally on the client's world. Restatement is not simple if the crisis worker is distracted by environmental stimuli or becomes preoccupied with his or her own thoughts , questions , evaluations, agenda, biases, or stereotypes about what the client is saying. So be wary! There are usually lots of environmental stimuli in a crisis, and it is easy to become distracted. Finally, summary clarification ribbon-wraps the dialogue. That is, it packages the preceding dialogue and lets both client and crisis worker know they are on the same wavelength. Particularly at the commitment stage in- tervention, the crisis worker or, better yet, clients may be asked to summarize what the plan is and how they are going to go about doing it.

CW: I want you to summarize what the game plan is, then, when the urge starts to overtake you to go see Rita.

Jake: OK, so I do this thought-stopping thing when the urge to give her a call or cruise by her house starts going off in my head. I don't go to my favorite bar because that just adds to it. Instead I go to the driving range and start hitting golf balls or go get on my game machine and kill aliens . When I get settled down, I write down all my thoughts and feelings and bring them into you next session. As a last resort, I call the crisis line.

Owning Feelings Owning means communicating possession: IDJI "That's mine." Often in conversation we avoid specific

CHAPTER FOUR The Tools of the Trade • 75

... issues by "disowning" statements with phrases such as "They say ... ," "I heard the other day that you ... ," "It's not right for you to ... ," and "Don't you think you ought to . .. ?" Whether intentional or not, such verbal manipulation functions to avoid ownership of responsibility for what's being said or to avoid aware- ness of one's own thoughts and feelings concerning an issue.

Using owning or "I" statements is probably more important in crisis intervention than in other kinds of therapy because of the directive stance the crisis worker often has to take with clients who are immobile and in disequilibrium. It is further important in creating a direct bond between client and worker, particularly when a behavioral emergency is occur- ring and the worker wants the undivided attention of a wildly out-of-control client. Therefore, we illustrate a number of different types of owning statements the crisis worker may find useful for particular problems that occur during intervention. Although used more often in crisis intervention than in normal therapeu- tic settings, owning statements should nonetheless be employed sparingly, because the crisis worker's main job is to focus on the client and not on hims elf or herself. Given that admonition, when working with clients in crisis, it is very important to own your feel- ings, thoughts, and behaviors because many clients are using you as a model. So if you imply "We think this way" (meaning I and the director of the clinic, the school principal, the chief of police, the population of North America, the world, or God), then the client does not have much of a chance against that aweso me cast and is liable to become dependently compliant or defensively hostile as in the following example.

CW: (authoritatively) You know that the Family Trouble Center is a branch of the police d epart- ment, and we can have you arrested, don't you?

Jake: (defiantly) Yeah, well, so what? I might as well be in jail anyway.

Collaborative Owning Statements. Early on in crisis intervention the use of "we" is generally not advised because it implies not only the interventionist's thoughts but a host of others' as well. The only par- ties we are concerned about are the person in crisis and the interventionist. Everybody else can get put on the bench and stay out of the game, at least for the time being. That being said, at some point "we" are going to strike a deal and make movement toward a short-term goal if at all possible. A critical component

76 • PART ONE Basic Training : Crisis Intervention Theory and Application

in eliciting cooperation and compliance from p eople who are sometimes less than cooperative is to build here-and-now relationships that emphasize a col- laborative approach that says "you" are not alone, but "we" are in this together, using what Weiner and Mehrabian (1968) term Relational markers. Rela- tional markers shorten the psychological distance between the client and the worker through the use of such words as "this," "these," "we," "our," "here," and "now" as opposed to "that," "those," "mine," "there," and "then." Notice the difference between the two words "this" and "that" in the crisis worker's response to Jake's statement that it is really hard to change.

CW: Jake, I know it is tough, but this (right now, right here) is something we can work out. While I can't do much about that (past tim e, out there) stalking behavior, we can start on this (right now, right here) self-monitoring anger management model.

Using this language sets the stage for examining alternatives, making plans, undertaking commit- ments , and engaging in safer behavior. It distances the stalking and jealous behavior and brings the new concept up close and personal. It also acknowledges Jake's attempts and desire to change and how tough it is to do that all alone, but indicates that now help has arrived . The crisis worker's response hooks "we" together with "this" thing right here in front of us, as opposed to "you" and "that" thing way out there that is much harder to get a handle on.

Disowned Statements. Many of u s chronically disown many human qualities that indicate we are less than perfect! Beginning crisis workers are particularly vul- nerable to this fallacy because they do not want to be seen as inadequate, insecure, or otherwise unequal to the task. Small wonder that clients learn to distrust or become dependent on such all-knowing, well-inte- grated individuals. Let us take, for example, my feel- ing of confusion.

If I pretend I understand when in fact I am confused, the client who is listening to me is going to be doubly confused. Being willing to own my confusion or frustration and attempt to eliminate it is a trust-reinforcing event for two reasons: (1) both client and worker can reduce the need to pretend or fake understanding of one another and begin to see more clearly where communications are getting crossed, and• (2) the client can begin to become actively involved with the worker in an attempt to work together.

CW: Right now I don't know what to think. You say you love her, yet your actions do everything to drive her away.

Jake: I know 'cause it confused me too! Well, it's like I want her to love me, and then I get jealous and paranoid, and like a switch gets flipped, and then I lose it. It frustrates me. I'm my own worst enemy, and I hate myself for it.

Conveying Understanding. Clients in cnsis often feel that no one understands what they are going through. The "I understand" statement is an own- ing statement that clearly conveys to the client that you do understand that what is happening right now is causing the client distress. This does not mean that you understand what the client is going through, because you don't. I cannot understand what it is like to have prostate or breast cancer. I can understand the fear and anxiety that the client is presently demon- strating and acknowledge that. The "I understand" statement may have to be combined with what is commonly called a "broken CD" (repeated) response because the individual may be so agitated or out of touch with reality that he or she does not hear what is being said the first time.

CW: OK, Jake, I do understand it's frustrating when she gives you the cold shoulder, and all the ways you try to win her affection don't work.

Jake: (pounding his fist on the table and yelling) Every damn thing I do anymore is wrong!

CW: I understand right now that it's so frustrating the only thing that seems to work is lashing out at her physically.

Value Judgments. At times the crisis worker has to make judgment calls about the client's behavior, particularly when the client is in danger of doing something hurtful to himself or herself or to others. Owning statements speak specifically to the worker's judgment about the situation and what he or she will do about it.

Jake: (making threatening gestures and with a trembling voice) I .. . I . .. jus t caaann' t taaake much more . .. of this . I'll huuurt her ... huuurt her real bad.

CW: (m aking a judgment) The way you say that really concerns me. I believe that would not be in your best interests and wouldn't get you what you want, which is back with Rita. I'd have to call the police to see that you are both kept safe.

However, using owning statements does not

0 enerally mean making value judgments about

rhe client's character, because such judgments are putdowns and do nothing to change behavior.

CW: (sarcastically) Yeah, you're a really big man to have to punch your wife out because you aren't as smart as she is. That really shows me a lot. I think maybe a stint out on the county work farm might take some of that energy out of you.

Positive Reinforcement. To be genuine in crisis work is to say what we feel at times. When a client has done well and we're happy and feel good about it, we say so. However, such positively reinforcing statements should always be used in regard to a behavior, a~ opposed to some personal characteristic.

Positive reinforcement is used a great deal in crisis intervention to gain compliance. Many times raking mini-steps to get a client to calm down or stop engaging in a dangerous behavior is tied to positive reinforcement.

CW: Uake is standing up and pounding his fist on the table, swearing.) I need for you to take a deep breath and let it out gently. (With difficulty, Jake complies.) Great! That shows me you can get control of your emotions.

We often use positive reinforcement to succes- sively approximate a client toward a larger goal we are seeking to achieve.

CW: Good! You were able to take a deep breath. Now could you cue yourself that every time you start pounding your fist, you will take at least three deep breaths, lower your arms , and allow yourself to relax and picture that tranquil lake scene? Just do that now. Excellent, I see you starting to relax . Can you feel the tension draining out? Terrific! Just continue to do that and feel the difference. See how great that feels and how you have gained mastery over your emotions? It shows me you have the guts to handle your emotions.

Crisis interventionists use positive reinforcement a lot to successively approximate (use small steps to move toward an ultimate goal) in diffusing out-of-control clients.

CW.· Jake, I know this is about the last place you'd like to be, and I think it took a lot of guts to come in here and admit to me you've got some prob- lems. You've had a lot of tough steps to take but

CHAPTER FOUR The Tools of the Trade • 77

you've made progress and I think are ready to take the next one to watch for ALL the cues you have learned and combine them into the new improved "Serendity Now Jake" (both laugh).

However, the use of positive reinforcement is also a double-edged sword. Many times in crisis interven- tion, reinforcing a client for a behavior may breed dependency or be seen as anything but reinforcing by the client. So be careful about what behavior gets reinforced. That is particularly true of clients with borderline personality disorder who may constantly try to solicit positive comments from the worker to feed their need for approval and acceptance.

Jake: (sneeringly) Guts my ass! If it weren't for the cops, I sure as hell wouldn't be in this stink hole with a jerk like you doing this crap.

CW: (owningfeelings) I'm sorry you feel that way, but I meant what I said.

Personal Integrity and Limit Setting. When a client starts to browbeat, control, or otherwise put us on the hot seat, it does little good to try to hide our anger, disappointment, or hurt feelings. Furthermore, it is important to set clear limits with clients who are starting to get out of control or are trying to manipulate the crisis worker.

Jake: (sneeringly) What do you know? You're nothing but a snot-nosed girl! I don't have to take this crap!

CW: (calmly, owning feelings and setting limits) I don't appreciate the demeaning comments, the language, or your attitude toward me . I'd like an apology, and I'd also like you to be civil. If you can't, I'll assume you'd rather explain your problems to your proba- tion officer, and we'll terminate the session.

Assertion Statements. Finally, because crisis interven- tion often calls for the crisis worker to take control of the situation, requests for compliance in the form of owning statements are often very directive, short, and point specific. These owning statements, also known as assertion statements, clearly and specifically ask for a specific action from the client.

CW: I want you to commit to me and yourself that you'll stay away from her for the next week. I want you to sign this contract that you' ll do that for your own safety and hers as well.

Jake: (wistfully wringing his hands) I dunno, that's a long time. I really miss her right now.

78 • PART ONE Basic Training: Crisis Intervention Theory and Application

CW: I understand it's hard, particularly when you'd like to do something, but I need for you to sign this paper, so I can be sure you're committed to doing this .

Facilitative Listening In summary, listening is the first imperative l!,!D in crisis intervention. When the word listening is used, the term is being applied broadly to several important behavioral and communications skills discussed in this chapter. To function in a facilitative way, workers must give full attention to the client by:

1. Focusing their total mental power on the client's world.

2. Attending to the client's verbal and nonverbal mes- sages (what the client does not say is sometimes more important than what is actually spoken).

3. Picking up on the client's current readiness to en- ter into emotional and/or physical contact with others, especially with the worker.

4. Emitting attending behavior by both verbal and nonverbal actions, thereby strengthening the relationship and predisposing the client to trust the crisis intervention process.

One important aspect oflistening is for the worker to make initial owning statements that express exactly what he or she is going to do. These predispositioning statements are extremely important in crisis interven- tion because many times the client is making contact with the worker for the first time and has no idea what is going to happen or what the worker may do in a threatening, chaotic environment.

CW: Rita, I can see you're really hurting. To fully understand what's going on and what needs to be done, I'm going to focus as hard as I can on what you're saying and how you're saying it. As well as listening to what you say, I'm going to be listen- ing for those things that aren't said, because they may have some bearing on your problems too. So ifl seem to be really concentrating on you, it's be- cause I want to fully comprehend in as helpful and objective a way as possible what the situation is and your readiness to do something about it.

The second important aspect of listening is to respond in ways that let the client know that the crisis worker is accurately hearing both the facts and the emotional state from which the client's message comes. Here we are searching for both the affective and content dimensions of the problem. The crisis

worker combines the dilemma and feelings by using restatement and reflection.

CW: As you lay the problem out-the abuse by your husband, the job pressures, the wonderful yet guilt-ridden times with Sam-I get the feeling of an emotional juggling act with everything from bowling pins to hand axes being juggled and now a burning baton has just been tossed into the mix. Now you're just sitting paralyzed wish- ing you'd never taken the job, wondering how you can get out, wanting answers, but having so many problems that you don't even know the right questions to ask.

The third facet of facilitative listening is facil- itative responding. It provides positive impetus for clients to gain a clearer understanding of their feelings, inner motives, and choices. Facilitative responses enable clients to feel hopeful and to sense an inclination to begin to move forward, toward resolution and away from the central core of the cri- sis. Clients begin to be able to view the crisis from a standpoint of more reality or rationality, which immediately gives them a sense of control. Here the crisis worker targets an action.

CW: So, given all the things you are juggling, which ones do you want to throw out and which ones do you want to keep juggling? You've given me all kinds of information about how well you've handled the business up to this crisis point. Look back on how you handled that particular piece of juggling. What worked then that might work now? Using that as an example, can we sort each one of these out and get the act cleaned up and just say that particular ball isn't important right now and throw it out for at least awhile?

The fourth dimension of facilitative listening involves helping clients understand the full impact of the crisis situation. Such an understanding allows clients to become more like objective, external observ- ers of the crisis and to refocus on it in rational ways rather than remaining stuck in their own internal frame of reference and emotional bias.

Rita: I feel like the whole world is caving in on me. I wonder if I'll ever be able to get out from under all the mess I'm in now.

CW: You're sounding emotionally frozen by what is happening. I'm wondering what would hap- pen if we could step back for a moment and look at it as if we were third-party observers to your

situation-as if you were someone else in a soap opera. What would you say to that person?

Rita: Well ... (moment of thought) ... I'd say she's not the first or only one to experience lots of trouble-that things may look horrible now, but that eventually things get worked out-especially if she's lucky and can bear up long enough.

CW: Then looking at it from outside yourself does give you an additional view.

Helping clients refocus is not a solution in itself It is an extension of the art oflistening that may facili- t ate forward movement when clients are emotionally stuck.

These four aspects of listening don't operate in a fragmented or mechanical way. Such listening requires skill, practice, an emotionally secure listener, a n d both physical and emotional stamina on the part of the listener. The following dialogue gives a brief b u t comprehensive demonstration of how facilitative listening is combined in its many dimensions . The cli- en t now is Jean, Rita's daughter. Don't be perplexed at (he shift in clients. One person in crisis may well also p u t a significant other into a crisis situation as you will see when you meet the Smith family in Chapter 11, Family Crisis Intervention. In this instance, Rita's problems have boiled over into her 13-year-old d a ughter's life.

j ean: I feel put down and ignored by my mother. Every time anything is mentioned about Sam- that's her secret boyfriend-she gets mad and leaves the room. Everything has changed. It's like I'm no longer important to her. I don't know what's happening or what to do.

CW: You're feeling hurt and disappointed, and you're also bewildered by her responses to you.

j ean: (crying and very upset) I ... I feel like I no longer count. I'm feeling like I'm in the way. Like I'm sud- denly no good .... I feel like now I'm the problem.

CW: You're blaming yourself even though you're trying to understand what has happened and what you should do.

Jean: (crying is slowing down) By Sunday night I felt like killing myself I planned to do it that night. I was feeling abandoned, alone, and hopeless. I just wanted to find some way to end the hurting. I didn't think I could go on another day. I felt like I was no longer her daughter-like she had either disowned me or had been living a lie. I don't know ifI can go on.

CHAPTER FOUR The Tools of the Trade • 79

CW: Even though you were feeling you were at the brink of death, you somehow managed to pull out of it. What did you do, and what are you doing now to keep from killing yourself?

jean: (not crying-pondering the crisis worker's last response) Well, Marlene and her parents came by. I spent the night with them. That really helped. It was lucky for me that they came by and invited me . They were so kind and understanding. I had a bad night. Worrying about all that stuff. But they, especially Marlene, helped me so much.

CW: Let's see if you can tell me what you have learned from that experience that can help you the next time you feel like killing yourself

Jean: (pause, as if studying the crisis worker's response) ' To get away . . . with someone who cares and

understands.

CW: Tell me someone you can contact whenever you feel hopeless and lonely and suicidal so that next time you won't have to depend on luck.

jean: Well, I'd call Marlene again ... or my uncle and aunt. They'd be quick to invite me over . . . and there are several friends at school I could call. (Dialogue continues.)

This segment of dialogue contains several of the elements of listening that have been described. It contains accurate reflective listening, open-ended questions, and attention to the client's safety (without asking closed questions, giving advice, or encroaching on the client's prerogatives and autonomy). Also, the crisis worker keeps the focus right on the central core of the client's current concerns, paving the way for the client's forward movement from the immediate crisis toward safer and more adjustive actions. The worker's selective responses are geared toward enabling the cli- ent to become aware of and pursue immediate short- term goals. The worker does not digress into external events, past events, the mother, the secret boyfriend, gathering background information, or conducting long-term therapy.

Basic Strategies of Crisis Intervention Myer and James (2005) have formulated nine II!ll strategies used in crisis intervention. The basic core listening and responding skills already discussed are the foundation of these strategies. There is no formula for using these strategies. They may be used singly or in combination. Their use depends a great

80 • PART ONE Basic Training: Crisis Intervention Theory and Application

deal on the crisis context, the triage level of the cli- ent, and on what task of the crisis intervention model the interventionist is working. Here are the nine strategies.

Creating Awareness. The crisis worker attempts to bring to conscious awareness warded off, denied, shunted, and repressed feelings , thoughts, and behav- iors that freeze clients' ability to act in response to the crisis. Creating awareness is particularly important for Task 2, Problem Exploration.

CW: It would be easier to just put it out of your mind, but I wonder what shoving it back will get you? You came here, so I'm pretty sure you want to get this out in the open and get some resolution. What would all this mess look like if it were sitting out there on the table?

Allowing Catharsis. Catharsis means simply letting clients talk, cry, swear, berate, rant, rave, mourn, or do anything else that allows them to ventilate feelings and thoughts; it may be one of the most therapeutic strategies the crisis worker can employ. To do this , the crisis worker needs to provide a safe and accepting environment that says, "It's OK to say and feel these things." By so doing the crisis worker clearly says he or she can accept those feelings and thoughts no mat- ter how bad they may seem to be. A word of caution here! Allowing angry feelings to continue to build and escalate may not be the wisest course of action. This strategy is most often used with people who can't get in touch with their feelings and thoughts, as opposed to those whose feelings are already volcanic. This strategy is most likely to be used for Task 2 , Problem Exploration, and Task 3, Providing Support.

CW: It's tough to talk about it. After all, it is an affair you are having. Perhaps you think I'll pass moral judgment on you for that . I won't! What I would most like you to do is to open up those push-pull feelings. Tell me more about being scared and angry at the same time .

Providing Support. Often the cns1s worker is the sole support available to the client. As such, the crisis worker attempts to validate that the clients' responses are as reasonable as can be expected given the situation. Many times clients believe they must be going crazy, bi.it they need to understand that they are not "crazy" and that most people would act in about

the same way given the kind, type, and duration of the crisis. Oftentimes in crisis, in an attempt to calm clients, workers state that it is "normal" to have such and such reactions. Nothing could be further from the truth. There is nothing "normal" at all about stress reactions associated with a sexual assault. Such attempts are at best placating and at worst discount- ing of the client. A far better description, we believe, is the word "common." Clients need to understand that while there is nothing "normal" about their feeling, acting, and thinking in a crisis situation, it is certainly "common" to most people. This kind of affirmation is particularly critical to clients who feel they have no support system available to them. That being said, the crisis worker never supports clients' injurious or lethal feelings , thoughts, or actions toward themselves or others.

Providing support is particularly useful when the client is attempting to move into action. In standard therapy, supervisors often express a great deal of con- cern about breeding dependence on the therapist. It should be clearly understood that when we are deal- ing with clients in crisis they may well need to be dependent on us for a short while. That doesn't mean we are going to adopt clients and take them home with us! It does mean that when the client is drained of emotional, cognitive, or behavioral resources, we are supportive, and we provide a shoulder to lean on.

Rita: I don't know which way to turn, what to do. This is not me! I am so confused and so alone. My God! How did I ever get in this awful mess?

CW: Right now you may feel that way, but I am in this with you, and I am going to stay in it until we get some control and direction back for you .

Rita: I don't know how there can ever be any control. (Starts sobbing.)

CW: We are going to get some control, and I am going to stay with you until that happens.

Promoting Expansion. The crisis worker engages in ex- pansion activities to open up clients' tunnel vision of the crisis. Oftentimes clients are so wrapped up in the crisis and are continuously engaging in self-defeating thoughts and behaviors that they are unable to see other perceptions and possibilities. Increasing ex- pansion helps clients step back, reframe the problem, and gain new perspectives. This strategy is primarily used to help clients resolve stuck cognitive reactions. By confronting clients' narrow and restrictive views,

crisis workers help clients consider other perspectives. This strategy is particularly effective with clients who are not able to recognize environmental cues that may h elp them to perceive alternate meanings of events and possible solutions to them.

CW: This may be distasteful, but I want you to think about this. You know one possibility would be to get a restraining order. That is pretty common in most domestic violence situations, but it is used in other instances too.

Emphasizing Focus. Conversely, at times the problem is that clients are too expansive and need to focus their freewheeling, out-of-control flights of ideation a bout the crisis that have little basis in reality. The cri- sis worker attempts to partition, compartmentalize, and downsize clients' all-encompassing, catastrophic interpretations and perceptions of the crisis event to more specific, realistic, manageable components and options. This strategy has utility across all tasks of the crisis intervention model.

CW: Given this huge mess, what is the one thing you need to do right now to get some relief? What could you focus on that would tell you immedi- ately that some pressure was off rather than trying to take care of everything and everybody?

Providing Guidance. The term guidance has come to h ave somewhat of a negative connotation in the fi eld of counseling because it implies that clients a re incapable of helping themselves . However, many times clients in crisis do need guidance a nd direction. They don't have the knowledge o r resources available to make good decisions. Thus, the crisis worker provides information, re ferral , and direction in regard to clients' obtain- ing assistance from specific external resources and support systems. For example, one of the handiest to ols that crisis workers have is a directory of all t he social services available in their catchment area. T his strategy is used almost exclusively to respond to clients' behavioral reactions.

Rita: I have no idea how to go about getting a restraining order.

CW: Up until now you would have had no reason to. However, the staff at the Family Trouble Center can do that for you and would be glad to help you do it. I can give you that number if you want.

CHAPTER FOUR The Tools of the Trade • 81

• Promoting Mobilization. The crisis worker attempts both to activate and marshal clients' internal resources and to find and use external support systems to help generate coping skills and problem- solving abilities so they become mobilized and do not remain stuck in the crisis situation.

CW: There is a support group of women I know of that meets regularly at St. Michael's Catholic church. They all struggle with some of the same relationship issues that you are having. Hearing and interacting with them might give you some new ideas on how to go about solving this knotty problem. You have some good ideas and are pretty geared up to act on them, but it might not hurt to get their perspectives.

Implementing Order. The crisis worker provides order and methodically helps clients classify and categorize problems so as to prioritize and sequentially attack the crisis in a logical and linear manner. Too often clients see the crisis as a mountainous tidal wave washing over them when what they need to do is grab a metaphorical life jacket and float along until it dis- sipates or build a small dike and let it rush by them. These actions, while apparent to an outside observer, are oftentimes blind to the client in the maelstrom of a cns1s.

CW: It seems overwhelming, but let's put it into pieces you can manage. Break it down . If this were your business instead of your love life, how would you parcel the problem out, and what order of priorities would you give to each part? What's the first thing you would do? While it might not make it perfect, what would it take to make this situation more tolerable?

Providing Protection. Providing protection is para- mount in crisis intervention, so important that it is its own overarching task in our model. The crisis worker safeguards clients from engaging in harmful, destructive, detrimental, and unsafe feelings , behav- iors, and thoughts that may be psychologically or physically injurious or lethal to themselves or others.

CW: I want to make the clearest personal statement I can to you Rita. I really fear for your safety. I would not confront Jake alone after work at the garage. I understand you don't want a big scene in front of other people, but to do that alone with nobody around seems to me a really dangerous thing to do.

82 • PART ONE Basic Training: Crisis Intervention Theory and Application

When these nine strategies are used with the basic verbal crisis intervention skills in this chapter, they form the backbone of crisis intervention techniques. By using them with the Triage Ass essment Form, crisis interventionists should have a comprehensive real-time assessment of how they are doing as they move the client through the model.

Climate of Client Growth According to Rogers (1977) , the most effective IDi.I help er is one who can provide three necessary and sufficient conditions for client growth. These condi- tions h e named empathy, genuineness, and acceptance (pp. 9- 12). These therapeutic conditions are partic- ularly critical to doing effective crisis intervention. To create a climate of empathy m eans that the crisis worker accurately senses the inner feelings and meanings the client is experiencing and directly communicates to the client that the worker under- stands how it feels to be the client. The condition of genuineness (also called realness, transparency, or con- gruency) means that the worker is being completely op en in the relationship: nothing is hidden, there are no facades, and there a re no professional fronts . If the worker is clearly op en and willing to be fully himself or herself in the relationship, the client is encouraged to reciprocate . The t er m acceptance (also referred to as caring or prizing) means that the crisis worker feels an unconditional positive regard for the client. It is an attitude of accepting and caring for the client without the client's n ecessarily reciprocat- ing. The condition of acceptance is provided for no other reason than that the client is a human being in n ee d. If these conditions of empathy, genuineness, and acceptanc e can be provided for the client, then the probability that the client will experience positive emotional movement is increas ed.

Communicating Empathy In describing the u se of empathy to help clients, we will focu s on five important techniques: (1) attending, (2) verbally communicating empathic understanding, (3) reflecting feelings , (4) nonverbally communicating empathic unders tanding, and (5) silence as a way of communicating empathic understanding (Cormier & Cormier, 1991; Gilliland &James, 1998, pp. 116 - 118). First, however, it is n ecessary to differentiate empathy from sympathy and distancing.

Sympathy. B eginners in the fi eld confuse empathy with sympathy. Sympathy is fine at the right time

and conveys support, but it means essentially taking on the person's problems and feelings rather than attempting to experience and convey what the person is feeling. Mostly we think of sympathy as a sad feeling with tears attached to it. It can just as well be righteous indignation and anger. Particularly when we are attempting to do exploration with a client in crisis, we will do better to put sympathy on the shelf for a while.

CW: You poor thing. That's terrible! Nobody should be allowed to get away with that kind of behavior. How about I call the police right now!

The behavior, indeed, may be terrible, but the crisis worker will do better to make a deep, reflective response that captures the client's feeling.

CW: You seem really torn-kicking yourself for being a fool , but still wanting and hoping the relation- ship to be something and go somewhere. It sounds like you know it is over, but you don't quite know what to do yet.

Distancing. At times, crisis workers may be so over- whelmed and frightened by what they are confronted with that they seek to distance themselves from the overwhelming affect by engaging in what we call "funeral home counseling." Here are a few examples of what people say when they have no idea what to say but feel they need to say something. These attempts to be palliative are generally not helpful and can, in fact, hinder intervention. Lots of times these statements are centered on a religious/spiritual theme: "It's God's will." "God works in mysterious ways ." "Heaven wouldn't be h eaven if it were only filled with old people." "He/ she's in a better place." Another way of distancing is by rationalizing, discounting, and mini- mizing: "Well, you still have your health." "It could have been worse." "Don't feel guilty about it." "Try to get your mind off it." "Just try and relax a little." "It's tough , but you need to calm down ." These state- ments probably say more about the worker's crisis state than they do about the client's. A far better way, when aspiring crisis workers don't know what to say, is to say nothing or to own the feeling of what they are experiencing. At times , owning our own inability to find words to convey the depth of feeling is probably one of the best ways to indicate that you do feel for the client.

CW: (reaches out and touches Rita's arm and says nothing for a few moments) I wish I had something to say

that would take this pain and confusion away and make this all right, but right now I just don't.

Attending. The first step in communicating empa- thy has little to do with words and a lot to do with looking, acting, and being attentive. The foregoing crisis worker response is much more about attending than saying or doing. In most initial counseling and therapy sessions, the client enters with some anxiety related to the therapy itself in addition to the stress brought on by the crisis. In crisis situations, such anxiety is increased exponentially. Shame, guilt, rage, and sorrow are but a few of the feelings that may be manifested. Such feelings may be blatant and ram- pant or subtle and disguised. Whatever shape or form such feelings take, the inattentive crisis worker can miss the message the client is attempting to convey. Worse, an inattentive attitude implies lack of interest on the part of the worker and does little to establish a trusting relationship .

Mehrabian (1971) reports that 55% of emotional output and communication occurs through face and body while 38% comes from voice tone and only 7% from words used. Whether these percentages of over- whelming nonverbal communication are precise or not, one thing is for sure in the crisis business, the effective worker focuses fully on the client, both in facial expression and in body posture. By nodding, keeping eye contact, smiling, showing appropriate seriousness of expression, leaning forward, keeping an open stance, and sitting or standing close to the client without invading the client's space, the crisis worker conveys a sense of involvement, concern, commitment, and trust. Vocal tone, diction, pitch, modulation, and smoothness of delivery also tell clients a great deal about the attentiveness of the crisis worker. By attending closely to the client's verbal and nonverbal responses, the crisis worker can quickly tell whether he or she is establishing an empathic relationship or exacerbating the client's feelings of distrust, fear, and uncertainty about becoming involved in the relationship.

Attentiveness, then, is both an attitude and a skill. It is an attitude in that the worker focuses fully on the client right here and now. In such moments the crisis worker's own concerns are put on hold. It is a skill in that conveying attending takes practice. It is just as inappropriate for the crisis worker to look too concerned and be in too close proximity as it is to lean back with arms folded and legs crossed, giving a cold stare. Here is an example of an appropriate blend

CHAPTER FOUR The Tools of the Trade • 83

of both verbal and nonverbal skill in attending to a client empathically.

Rita: (Enters room, sits down in far corner_, warily looks about the room, crosses her legs and fidgets with her purse, and avoids direct eye contact, manifesting the appearance of a distraught woman who is barely holding together.)

CW: (rises behind desk, and observing the behavior and physical appearance of the client, moves to a chair a com- fortable distance and a slight angle from Rita's, sits down, leans forward in an open stance, and with an appearance of concern and inquisitiveness looks directly at Rita) I'd like to be of help. Where would you like to start?

The crisis worker sees the apprehension in the client and immediately becomes proactive. The crisis worker moves close to the client but does not sit directly in front of her in what could be construed as a confronting stance. The worker inclines forward to focus attention-eyes, ears, brain, and whole body- onto the client's world. The whole posture of the crisis worker is congruent with the verbal message of offer- ing immediate acceptance and willingness to help. In summary, effective attending is unobtrusive, natural, and without pretense. It is a necessary condition for empathic listening.

Verbally Communicating Empathic Understanding. When you can accurately hear and understand the core emotional feelings inside the client and accurately and caringly communicate that understanding to the client, you are demonstrating effective listening. The deeper your level of listening (understanding), the more helpful you will be to your clients. For instance, reflecting a client's message at the interchangeable level is helpful.

Rita: I'm thinking about just walking in and telling Jake I want a divorce-regardless of what Sam is ready to do. I don't think I can go on much longer. My ulcer is beginning to act up, I'm an emotional wreck, and everyone is expecting more of me than I can give.

CW: You sound like you are feeling a sense of urgency because it's adversely affecting your physical and emotional well-being.

A deeper level of listening and communicating empathic understanding to Rita might be expressed thus:

CW: Rita, your sense of urgency is getting to the point where you seem about ready to take a big risk with

84 • PART ONE Basic Training: Crisis Intervention Theory and Application

both Jake and Sam. I sense that your physical and emotional stresses have about reached their lim- its, and you're realizing that no one else is going to act to give you relief-that you are the one who is going to have to decide and act.

The second response is more helpful because it confirms to Rita a deeper understanding than the first response. Both responses are helpful because they are accurate, and neither adds to nor detracts from the client's verbal, nonverbal, or emotional mes- sages. Whereas the first response is considered mini- mally helpful, the second response is more facilitative because it lets the client know the worker heard a deeper personal meaning (risk) and a personal own- ership of possible action. A word of caution to the worker, however: Beware of reading into the client's statements more than the client is saying, and take care to keep your response as brief as possible.

Reflection of Feelings. Reflection of feelings is a powerful tool to get at shunted or denied affect. In standard therapy, we constantly hammer at uncov- ering affect because of client resistance to dealing with threatening and warded off feelings. However, in crisis intervention the desire to uncover feeling is not always the therapeutic best bet. A client who is scoring an 8, 9, or 10 on the Affective Scale of the Triage Assessment Form probably does not need to have a crisis worker attempt to elicit even more feelings. It is not the job of the crisis worker to tell the client what he or she is feeling. The following dia- logue moves from a reflection to a judgment and tells the client how she feels.

CW: You are bitter and resentful about being in this dead-end marriage. You can't figure a way out.

Rather, what the crisis worker should do is make an educated guess using conditional statements that allows the client to accept or reject the worker's guess.

CW: It seems that you are pretty bitter and resentful about this dead-end marriage and are frustrated that you can' t figure a way out.

Effective communication of empathic understand- ing to the client means focusing on the client's expressed affective and cognitive messages. The worker deals directly with the client's concerns and does not veer off into talking about the client's concerns or some tangential person or event. That distinction is important.

Rita: I'm afraidJaJ<e might attack me even worse ifl tell him I want a divorce .

CW: He did beat you pretty badly. Sam would prob- ably go bananas at that. Your husband Jake has such a violent temper. (talking about the situation and tangentially focusing on Jake)

CW: You're feeling some reservations about telling Jake because you really don't want to be beaten up again . (dealing with Rita's current feelings and concerns)

The latter response is preferred because it stays on tar- get with Rita's feelings and concerns in the here and now and because it avoids getting off onto Jake, Sam, or any other third party or issue.

The central issue in empathic understanding is to hone in on the client's current core offeelings and con- cerns and communicate to the client (in the worker's own words) the gist of what the client is experiencing.

Nonverbal Communication. Empathic understanding means accurately picking up and reflecting more than verbal messages. It involves accurately sensing and re- flecting all the unspoken cues, messages, and behaviors the client emits. Nonverbal messages may be transmit- ted in many ways. The worker should carefully observe body posture, body movement, gestures, grimaces, vo- cal pitch, movement of eyes, movement of arms and legs, and other body indicators. Clients may transmit emotions such as anger, fear, puzzlement, doubt, rejec- tion, emotional stress, and hopelessness by different body messages without using the words that go with those feelings. Crisis workers should be keenly aware of whether nonverbal messages are consistent with the client's verbal messages. "Keenly aware" means that you are always monitoring body language for signs of aggression-particularly toward you! While this may sound like harping, throughout this book we will con- tinuously be talking about safety- both the client's and yours. In fact, Chapter 14, Violent Behavior in Institutions, is specifically designed to keep you out of the hospital or mortuary. Thus, a part of empathic understanding is the communication of such incon- sistency to the client who may not be consciously aware of the difference. For example:

CW: (observing the way Rita's face lights up whenever she speaks or thinks about Sam) Rita, I notice you are talking about all the trouble it is for you to keep seeing Sam on the sly. But your body tells me that those are the moments you live for-that right now your only ecstasy is when you're with Sam.

The crisis worker's main concern with nonver- bal communication also involves the worker's own

body messages. All the dynamics of the client's body language apply to the worker as well. Your nonverbal messages must be consistent with your verbal mes- sages. It would not be empathic or helpful if your words were saying to the client, "I understand pre- cisely what you're feeling and desiring,'' but your body was saying, "I don't care," or "I'm bored," or "My mind isn't fully focused on what you're saying." Your voice, facial expression, posture- even the office arrange- ment and environment-must say to the client: "I'm fu lly tuned in to your world while you're with me. I want to give my total mental and emotional energy to understanding your concerns while you're here . I will not be distracted." If your body can communicate such messages so that they are unmistakably under- stood by the client, then you will have effectively com- • municated empathy to the client nonverbally, and you will stand a better chance of being helpful.

Silence. Silence is golden. Beginning crisis workers o ften feel compelled to initiate talk to fill any void or lapse in the dialogue because they believe they would not be doing their job otherwise. Nothing could be fu rther from the truth. Clients need time to think. To t hrow out a barrage of questions or engage in a mono- lo gue says more about the crisis worker's insecurity in t he situation than it does about resolving the crisis. Silence gives the client thinking time- and the crisis worker too.

Indeed, at such times, verbiage from the crisis worker may be intrusive and even unwelcome. Remaining silent but attending closely to the client can convey deep, empathic understanding. Nonver- bally, the message comes across: "I understand your struggle trying to put those feelings into words, and it's OK. I know it's tough, but I believe you can handle it. However, I'm right here if you need me ."

R ita: The last beating ... I was so ashamed, yet I couldn't seem to do anything except go back to him.

CW: It hurts you not only to get beaten but also that others might find out- which seems even worse. As a result, you don't see any alternatives.

R ita: (thinks hard, eyes focused into the distance for more than a minute) Yes and no! I see alternatives, but I guess until now I haven't had the guts to do anything. I rationalized that something must be wrong with me or that the situation would get better, but it hasn't for five years. It has gotten worse.

CHAPTER FOUR The Tool s of the Trade • 8 5

CW: (silence; looks at Rita for some 30 seconds while collecting thoughts) A couple of things strike me about what you said. First, you've decided to quit blaming yourself. Second, by the fact that you're here now, you've chosen a t least one alternative to that five-year merry-go-round of abuse.

In this scene, silence is allowed to work for both the client and the worker. The client needs time to work through her response to the worker, and she is uncon- ditionally allowed to do this. The same is true of the crisis worker. The client's comment is synthesized and processed for its full meaning. By reacting immedi- ately, the crisis worker might make less than a potent response. Taking time to digest both the content and the affect of the client enables the worker to formulate a response that is more likely to be on target and helpful.

Taking Time. Cochran (2014) proposes that we have "time." At the point that a crisis erupts, clients often have tapped out their human supports, people are tired of them, and don't want to waste any further time with them. It is critical that you are not hur- ried and that you take your time and the client gets a clear sense that you are taking time to carefully un- derstand what's going on.

CW: I know things are hectic, but I want to take time to understand your side of it as it played out today. We have plenty of time, so I'm going to sit down and listen. Start where ever you'd like because we do have time.

Communicating Genuineness Contrary to the thinking of most beginning human services workers, as evidenced by their behavior, being fully oneself and not some pseudotherapist or mimic of a particular therapist one has heard or seen is an absolutely necessary condition, particularly in crisis intervention. Rogers (1969, p. 228) puts it in clear, simple, and succinct terms:

When I can accept the fact that I have many deficiencies, many faults, make a lot of mistakes, am often ignorant where I should be knowledge- able, often prejudiced when I should be open- minded, often have feelings which are not justified by the circumstances, then I can be much more real.

Rogers's statement means putting on no false fronts but rather being oneself in the relationship and com- municating what "oneself" is to the client. In short, it is being honest.

86 • PART ONE Basic Training: Crisis Intervention Theory and Application

The advice to be honest is not simply a platitude. To be honest is to be congruent; it means that the cri- sis worker's awareness of self, feelings , and experience is freely and unconditionally available and communi- cable, when appropriate, during intervention in a cri- sis . Egan (1975, 1982, 1986, 1990) has listed essential components of genuineness that would serve the be- ginning crisis worker well.

1. Being role free . The crisis worker is genuine in life as well as in the therapeutic relationship and is con- gruent in both experiencing and communicating feelings (Egan, 1975, p. 91).

2. Being spontaneous. The crisis worker communicates freely, with tact and without constantly gauging what to say, and behaves freely, without being impulsive or inhibited, rule bound or technique bound. Worker behavior is based on a feeling of self-confidence (p. 92).

3. Being nondefensive. Crisis workers who behave non- defensively have an excellent understanding of their strengths and weaknesses. Thus, they can be open to negative, even hostile, client expressions without feeling attacked or defensive. The crisis worker who is genuine understands such negative expressions as saying more about the client than the worker and tries to facilitate exploration of such comments rather than defend against them (pp. 92-93).

4. Being consistent. People who are genuine have few discrepancies between what they think, feel, and say and their actual behavior. Crisis workers who are consistent do not think one thing and tell a client another or engage in behavior that is con- trary to their values (pp. 93-94).

5. Being a sharer of self. When it is appropriate to the situation, people who are genuine engage in self- disclosure, allowing others to know them through open verbal and nonverbal expression of their feelings (p . 94).

The following dialogue between the crisis worker and Rita demonstrates comprehensively the points both Rogers and Egan make.

Rita: Just what the hell gives? Here I am going crazy, and you put it back on my shoulders. You're sup- posed to help get me out of this mess!

CW: I can see that you're really mad at me because I don' t behave the way you think I ought to .

Rita: Well, how can you be such a caring person if you let me hang out there, pushing me to take such risky chances? I could lose everything.

CW: You see me as being a real hypocrite because I'm pushing you to take some action rather than sym- pathizing with you.

Rita: God knows I could use some . .. and when you act so callously (cries) ... you're like every other damn man!

CW: What would I be doing if I were acting in the most helpful way I possibly could, in your opin- ion, right now?

Rita: Well, I know you can't solve this for me, but I'd sure as hell like for you to point the way or help me solve this.

CW: So, what you're really wanting is to be able to solve this dilemma on your own, and what you're wanting from me is to help you find your own in- ner choices that are best for you. What I want to do is to help you find those choices. Let's look at your current options right now.

The dialogue aptly depicts the crisis worker owning feelings , using "I" statements, and focus- ing on the client's emergent concerns rather than allowing the focus to shift to tangential matters or defensive responses by the worker. Such statements allow the crisis worker to retain integrity, squarely face client hostility without becoming hostile in turn, and model a safe and trusting atmosphere in which clients see that it is all right for them to demonstrate angry feelings and still be accepted by the crisis worker. At the same time, the crisis worker stands by and is consistent with a therapeutic approach with- out being intimidated by or defensive with the client.

• The crisis worker above all has the self-confidence and congruence to make such statements in a way that is facilitative for the client.

Communicating Acceptance

The crisis worker who interacts with complete ac- ceptance of clients exudes an unconditional positive regard for clients that transcends clients' personal qualities, beliefs, problems, situations, or crises. The worker is able to prize, care for, and fully accept clients even if they are doing things, saying things, and expe- riencing situations that are contrary to the worker's personal beliefs and values. The worker is able to put aside personal needs, values, and desires and does not require clients to make specific responses as a condi- tion of full acceptance. That is not easily done with clients in crisis. There is a preferred client acronym in therapy named YAVIS for the young, attractive,

verbal, intelligent, and sociable therapist dream cli- ent . In most crises situations the YAVIS client is not going to magically appear. By the time many clients in crisis get to the worker, they don't act, talk, look, or even smell good. Thus, acceptance is easily said and less easy to manifest.

Rita: (disheveled, clothes look slept in, under arm deodor- ant has failed, make-up in sad repair) I hate to bother you with all my problems. I know you're married and have never been divorced. You must think I'm a terribly screwed-up mess . I look a mess and probably smell like it too. I was so scared I didn't go home, sent Jean to her aunt's, and slept in my truck at the state park.

CW: I hear your concern, and I want you to kno\Y that what has happened to you, or even how you look and what you choose to do have nothing to do with my regard for you. What I'm really hoping we can do is to help you arrive at those choices that will best help you get through this crisis and succ essfully get back in total control of your life.

Rita: I appreciate that very much. But sometimes I wonder whether my running around with Sam doesn't strike you as unwise and immature . Like some barfly, or gutter slut with no morals .

CW: I hope I'm not giving off negative vibes to give you that impression, because yo ur personal pref- erences have nothing to do with my caring for you. It seems like you really have a concern about my feelings about how yo u should act.

Rita: Not really. It's just something inside me - that if I were you, I'd be wondering.

CW: So, a source of concern inside you is whether I may evaluate you negatively. What I want you to know is that my esteem for you is not based on what you do .

Even when clients persist in projecting onto the crisis worker negative evaluations or notions such as those expressed by Rita, the worker doesn't have ro buy into such notions. If the worker can truly feel an unconditional positive regard for the client, there will be no need for denial, defensiveness, or diversion from the reality of the worker's true feelings . If the worker demonstrates caring and prizing of the cli- ent, regardless of the client's situation or status, the client will be more likely to accept and prize himself or herself. That is the essence of acceptance in crisis intervention.

CHAPTER FOUR The Tools of th e Trade • 87

In the Field lftl':W The foregoing scenarios all occur in an offic e ~

where there is time to think, formulate responses, and make thoughtful comments , all with knowledge about the client's history. As such, it is more crisis therapy for a client in a transcrisis state and at a tran- scrisis point. What happen s, when the worker is in the field , has little knowledge about clients or their problem s, and the crisis is escalating by the min- ute? Above anything else in this situation, the crisis worker's initiating techniques are critical to bond- ing with an out-of-control client who is unknown to the responder (Kirchberg, James, Dupont, & Cochran, 2014). While Major Sam Cochran, retired , has formu - lated the following coaching plan and plays specifi- cally for CIT officers (Cochran, 2014), these four plays can be used by any crisis worker in the field. These are simple, initial steps in creating trust and quick bonds that are critical to d e-es calation. Interestingly enough, in the heat of the moment when we are t rain- ing mental health workers or police officers , they sometimes forget to use them!

1. Introduce yourself in a way that says, "I am here for yo u and I am no threat." CW: "Hi, I'm Dick James, I'm part of the mobile crisis team. I can see you are really frustrated. I'd like to help ifl can."

2. Obtain the person's n ame and personalize it if possible. CW: "It must be pretty serious for you to have run everybody out of the house, got a can of gas, and are considering blowing the house apart. I am sorry I didn' t get your name. Could yo u tell me yo ur name please?"

3. Express what you are seeing across affective, be- havioral, and cognitive dimensions and u se "I" statements to do it. CW: "So first off you are really angry and fru strated that your bo ss wouldn' t lis- ten to your plan to save money and blew you off. As a result, it was the last straw and you kicked everybody out of the shop and n ow won't let any- body back in. Seems like you're thinking this will finally get his attention."

4. Summarize the information you have obtained and feed it back so both parties are on the same page. CW: "Is that about right what I said? Let m e know if there is something I missed b ecause I want to be sure we are clear between each other."

Safety in the Field. Setting limits is part of safety procedure and that involves determining the d egree

88 • PART ONE Basic Training: Crisis Intervention Theory and Application

of threat a person is feeling and how they intend to protect themselves from it (Cochran, 2014). It is not uncommon to meet people in crisis in the field who are armed with some kind of a weapon that they are not displaying. They are armed not necessarily to hurt someone else, but rather are trying to protect them- selves. Therefore, if the person is acting in a defensive manner and your triage rating on them is high, as- sume a person may have a weapon, and ask to see it.

CW: Lots of times people in your situation have good reason to believe someone might hurt them and so have a weapon of some kind. If you do, I'd like you to just lay it down beside you. I want to help you out, but I need to feel safe too.

If the person is noncompliant or seems not to hear, back off and get law enforcement help.

Assessing for Medical Problems in the Field. Many of the people the crisis worker will meet in the field have medical problems that are contributory to the crisis. Finding medical staff who have worked with clients is often critical in de-escalating a crisis by getting clients to their medical support system. Many of the clients are well known as repeaters by police officers, EMTs, and 911 operators. Getting them to medical staff and facilities that know them and are their care providers is a first priority. After making initial contact with clients, potential medi- cal issues , both physical and psychological, need to be checked out.

CW: You look a bit pale and fatigued to me . Have you been having some medical problems lately?

If the person doesn't acknowledge any medical issues, don't just dismiss the issue. Query them in regard to any medical staff they have seen.

CW: So OK no major medical problems t hen. What about the small ones? Have you seen any doctors, nurse practitioners, chiropractors, or counselors lately for the day-to-day stuff?

Drugs in the Field. Next to weapons, gathering in- formation on drug use and misuse for both illegal and prescription drugs is critical in planning action steps (James, 2014). It does little good to attempt to de -escalate a person who has misused drugs or, as frequently is the case in mental illness, has stopped taking psychotropic medication, and the illness has resurfaced. It is also not uncommon, particularly in geriatric clients who are taking a variety of drugs , for

bad drug interactions to occur when a new drug is in- troduced into the client's regimen .

CW: (suspected mental illness) You said you are smelling bad things. Have you been taking any medicine for those bad smells? When was the last time you took it?

CW: (suspected bad drug interaction) Mrs. Smith, your children tell me you have really been down in the dumps the last few days since you last visited the doctor. What did the doctor tell you and did he change your medication at all?

Support in the Field. Finding what human support systems are available, what have ceased to exist, and what the client has done to access these systems, if any, are primary to any intervention plan and the dis- position of where the client is physically going to go.

CW: Is there anyone now available to give you some support? By "anyone" I mean family, friends , min- isters, human service workers, boss, coworkers.

Meeting Basic Needs in the Field. If basic needs of food, water, clothing, medical, and shelter are not being met, then little resolution to the crisis will occur, or, at the very least, helping the client get some of these needs met will go a long way toward gaining trust and compliance.

CW: I wonder when the last time it was you had a decent meal. So I wonder if getting something in your stomach wouldn't at least start to feel like

• you had some control back.

Using Cochran's (2014) basic plays and immediately checking out safety, drug use, support systems, and basic needs are typically the precursors of any other techniques used when you are in the field and it is your first meeting with the client.

Acting in Crisis Intervention As shown in Figure 4.1, the crisis worker's Im level of action and involvement in the client's world, based on a valid and realistic assessment of the cli- ent's level of mobility/ immobility, may be anywhere on a continuum ranging from nondirective through collaborative to directive. The appropriateness of alternative coping mechanisms hinges on the cli- ent's degree of mobility. Thus, assessment of client mobility is a key concept governing the degree of the crisis worker's involvement. One of the first things

CHAPTER FOUR The Tools of the Trade • 89

.. Crisis worker is directive. Crisis worker is collaborative. Crisis worker is nondirective.

Client is immobile. Client is partially mobile. Client is mobile.

From the in itiatin g cri sis event to resol ution, counseling should move from left to right on the directive-nondirective worker conti nuum as the c lient moves from immobi le to mob ile.

Darker shading indicates a more directed approach to counseling when th e client is assessed as immobi le.

Lighter shading indicates the crisi s worker becom ing more nond irecti ve and the client becomi ng more mob ile.

U(rll);jijl The Directive- N ondirecti ve A cti on Co ntinuum

ch e worker must determine is what event precipitated rhe crisis. What brought on the disequilibrium? The a nswer may not be very clear in the client's compleX' a n d rambling story. So the worker may have to ask, ea rly in the interview, "What one event brought you to se ek counseling today?" When you discover the major precipitating event that took away the client's autono- m ous coping ability, it will likely signal your primary fo cus with the client.

Directive Intervention

Because the gold standard for standard beginning training in long-term psychotherapy has been to learn the practice of person-centered or nondirec- tive therapy we find that our students have diffi- cu lty transiting into an active, assertive, directive stance as they start to practice crisis intervention. Yet Allen, Wilson, and Armstrong (2014) report that when clinicians received training in trauma-focused co gnitive-behavioral therapy their beliefs changed rn ward the utility of structured/ directive approach to treatment. Directive intervention is not about passing moral judgments or general character appraisal on an individual. Directive intervention is about provid- in g specific information and guidance clients need to m ake decisions , setting limits on behaviors that range from inappropriate to lethal, and apprising them of co nsequences of their affective, cognitive, and behav- ioral responses to the crisis based on the intervention- ist 's expert clinical judgment and the self-same lack t hereof in the client. The directive approach is neces- sary when the client is assessed as being too immobile to cope with the current crisis. A triage score in the h igh teens or twenties typically calls for a good deal of directiveness from the worker. The crisis worker is the principal definer of the problem, searcher for alternatives, and developer of an adequate plan, and

instructs, leads , or guides the client in the action. Directive counseling is an "I" approach. This is an example of a worker-directed statement: "I want you to try something right now. I want you to draw a deep breath, and while you are doing it, I want you to just focus on your breathing. Don't let any other thoughts enter your mind. Just relax and notice how your tensions begin to subside." By using a very directive stance, the worker takes temporary control, authority, and responsibility for the situation.

Rita: I don't know which way to turn . My whole world has caved in. I don't know what I'll do tonight. It's all so hopeless . I'm scared to even think about tonight. (Rita appears stunned and in a state of panic.) I don't know what to do.

CW· I don' t want you to go home in the state you're in now. I'm going to call Domestic Abuse Services, and if they have room for you at their shelter, I want you to consider spending at least one night there. Keep Jean at your sister's house for the time being. Domestic Abus e Services has offices and a counseling service at one location and a shelter at a different address , which is unlisted. I don't want you to worry. We have a van that can take you to the shelter. In the morning you can leave the shel- ter and go talk with the Domestic Abuse Services counselors, or you can come back and talk with me; but right now my main concern is that you are safe for today and tonight .

There are many kinds of immobile clients: (1) cli- ents who need immediate hospitalization because of chemical use or organic dysfunction, (2) clients who are suffering from such severe depression that they cannot function, (3) clients who are experiencing a severe psychotic episode, (4) clients who are suffer- ing from severe shock, bereavement, or loss, (5) clients

90 • PART ONE Basic Training: Crisis Intervention Theory and Application

whose anxiety level is temporarily so high that they cannot function until the anxiety subsides, (6) clients who, for any reason, are out of touch with reality, and (7) clients who are currently a danger to themselves or others. Immobile clients are more apt to be suicidal or homicidal than are clients who are ready to respond to collaborative or to nondirective counseling. Or, be- cause of their inability to function effectively, they are more likely to engage in activities that put themselves or others at risk for serious injury. The worker must be able to make a fairly accurate and objective assess- ment of the client's level of mobility.

However, if the worker make s an error of judg- ment (believing a client to be immobile when in fact he or she is not), no harm is usually done because the client may simply respond by refusing to accept the worker's direction. In most cases of this sort, the worker can then shift into a collaborative mode and continue the helping session. Many times a worker will begin in a directive mode and then shift into a collaborative mode during the session. For example, with a highly anxious client the worker may begin by directing the client in relaxation exercises, which may lower the client's anx iety level to the point where the worker can make a natural shift into a collaborative mode to continue the counseling.

Collaborative Counseling The collaborative approach enables the crisis worker to forge a real partnership with the client in evaluating the problem, generating acceptable alternatives, and implementing realistic action steps. When the triage assessment indicates that the client cannot function successfully in a nondirective mode but has enough mobility to be a partner in the crisis intervention pro- cess, the worker is collaborative to that degree . When a client has a triage score that is in the high single digits to middle teens, the crisis worker can typically operate in a collaborative mode. Many crisis interven- tions operate in this mode . Collaborative counseling is a "we" approach, in contrast to the "I" approach of directive counseling and the "you" approach of non- directive counseling. Consider some typical worker statements in the collaborative mode: "What ' they' are going to do sounds overpowering as you say it, but we haven't really considered what 'we ' can do if we come up with a plan." "You've come up with a lot of good ideas, but you sound a little confused about which one to act on . .,Could we put our heads together and make a priority list of alternatives?" The collaborative client is a full partner in identifying the precipitating

problem, examining realistic alternatives , planning action steps, and making a commitment to carrying out a realistic plan. The collaborative client is not as self-reliant and autonomous as the fully mobile cli- ent, but does have enough ego strength and mobility to participate in resolving the problem. The worker is needed to serve as a temporary catalyst, consultant, facilitator, and support person. Here is an example of a collaborative response to a client.

Rita: I've thought about going to my mother's or going to the battered women's shelter or even calling my school counselor friend for a place to stay tonight.

CW: Let's examine these three choices, and maybe some others available to you that I know of, and we'll see which one will best meet your requirements.

Nondirective Counseling The nondirective approach is desirable whenever clients are able to initiate and carry out their own action steps. While the crisis worker will want to be as nondirective as possible and give the client as much control as the client can handle, in the initial stage of a crisis the worker is seldom nondirective because of the high level of ratings on the Triage Assessment Form (see Chapter 3) . With the "you" approach of nondirective counseling, the worker uses a great amount of active listening and many open-ended questions to help clients clarify what they really want to do and examine what outcomes various choices might produce. These are some pos- sible questions: "What do you wish to have happen?"

,"What will occur if you choose to do that?" "What people are available now who could and would assist you in this?" "Picture yourself doing that- vividly see yourself choosing that route. Now, how does that im- age fit with what you're really trying to accomplish?" "What activities did you do in the past that helped you in situations similar to this? " The worker does not manage, manipulate, prescribe, dominate, or control. It is the client who owns the problem, the coping mechanisms , the plan, the action, the com- mitment, and the outcomes.

The worker is a support person who may listen, en- courage, reflect, reinforce, self-disclose, and suggest. Nondirective counseling assists clients in mobilizing what already is inside them-the capacity, ability, and coping strength to solve their own problems in ways that are pretty well known to them already but that are temporarily out of reach. Here is an example of a nondirective response.

Rita: This is it. I've had the last beating I'm going to take from that jerk! I'm simply going to get myself out of this hell!

CW: You've made a decision to choose a different life for yourself, and you've decided that you are the one who is going to start it.

Action Strategies for Crisis Workers A number of action strategies and considera l!iJl!J tions may enhance the worker's effectiveness in dealing with clients in crisis. However, before committing to doing anything with the client, consider the following "rules of the road."

Recognize Individual Differences. View and respond to each client and each crisis situation as unique . If you really believe you are multiculturally sensitive, this is the essence of an emic multicultural view where both your and the client's social locations will play a big part in what will happen. Even for experienced work- ers, staying attuned to the uniqueness of each person is difficult. Under the pressures of time and exhaus- tion, and misled by overconfidence in their own ex- pertise, workers find it all too easy to lump problems and clients together and provide pat answers and so - lutions. Treating clients generically is likely to cost the worker and the client a great deal more in the long run than it saves in time and effort in the short run. Stereo typing, labeling, and taking for granted any as- pect of crisis intervention are definite pitfalls.

Assess Yourself. Ongoing self-analysis on the part of the worker is mandatory. At all times, workers must be fully and realistically aware of their own values, limitations, physical and emotional status, and per- sonal readiness to deal objectively with the client and the crisis at hand. Crisis workers need to run continu- ous perceptual checks to ascertain if they have gotten in over their heads. (See Chapter 16 for a thorough description of the phenomenon called "burnout.") If for any reason the worker is not ready for or capable of dealing with the crisis or the client, the worker must immediately make an appropriate referral.

Show Regard for Client Safety. The worker's style, choices, and strategies must reflect a continuous consideration of the client's physical and psycho- logical safety as well as the safety of others involved. The safety consideration includes the safety of the worker as well as the ethical, legal, and professional

CHAPTER FOUR The Tools of the Trade • 91

requirements mandated in couns~ling practice. The greatest intervention strategies and tactics are abso- lutely useless if clients leave the crisis worker and go out and harm themselves or others.

The golden rule is "When in doubt about client safety, get help." If you aren't sure what to do, con- sult with another crisis worker. Consultation does not mean you are inadequate. What it does mean is that you are a professional practitioner who is seeking a second opinion to validate your own, or you real- ize that this problem is not an area of your expertise so you are conferring with a person who does have the expertise. Thus, concern for a client's safety may mean appropriate referral interventions, including immediate hospitalization. You need to understand that when you do this, clients may be extremely angry at you; they may say you are unethical, have violated their trust and confidentiality, and even threaten to sue you for unprofessionalism . As hurtful and anxi- ety provoking as that may be, we will see in Chapter 15, Crisis Intervention: Legal and Ethical Issues, that such actions are not only ethical but legally mandated.

Provide Client Support. The crisis worker should be available as a support person during the crisis period. Clients may need assistance in developing a list of pos - sible support people, but if no appropriate support person emerges in the examination of alternatives , the worker can serve as a primary support person un- til the present crisis is over. A warm, empathic, and assertive counseling strategy should be used with cli- ents who are extremely lonely and devoid of supports. For example:

CW.· I want you to know that I am very concerned about your safety during this stressful time, and that I'm available to help. I want you to keep this card with you until you're through this crisis, and call me if you fe el yo urself sliding back into that hopeless feeling again. If you call either of these numbers and don't get an answer or get a busy signal, keep trying until you get me. You must make contact with me. I will be very disturbed if you are in a seriously threatening situation again without letting me become involved with you. I really want to impress on you my genuine concern for you and the importance of making an agreement or contract to call me whenever your safety is threatened. Will you give me that assurance?

92 • PART ONE Basic Training: Crisis Intervention Theory and Application

Define the Problem Clearly. Many clients have com- plicated and multiple problems . Make sure that each problem is clearly and accurately defined from a practical, problem-solving point of view. Many cli- ents define the crisis as someone else's problem or as some external event or situation that has happened. Attempting to solve the crisis of some third party (who isn't present) is counterproductive. Pinpoint the client's own problem with the event or situation, and keep the focus on the client's central core of concern. Also, attempt to distill multiple problems down into an immediate, workable problem and to concentrate on that problem first. We cannot overemphasize the tenacity with which the worker must avoid being drawn off on tangents by some highly emotional or defensive clients with difficult problems.

Consider these exchanges with Rita's husband,Jake.

Jake: You don' t seem to like me much.

CW: Right now, that's not the issue of importance. What I'm trying to do is help you identify the main source of your problem.

Another example:

Jake: Haven't you ever hit your wife too?

CW: No, but that's not what we're working on now. I'm trying to help us figure out a way for you to avoid fighting with her when you first get home each evening.

In both instances, the worker stays focused on the client and does not get caught up on side issues such as worker competency, beliefs , and attitudes. Now the worker is ready to work on Task 4, Examining Alternatives .

Consider Alternatives. In most problem situations, the alternatives are infinite . But crisis clients (and sometimes workers) have a limited view of the many options available. By using simple open-ended ques- tions and open-ended leads, the worker usually can elicit a surprising number of choices from the client of which he or she was previously unaware . Then add your own list of possible alternatives to the client's list. For example, "I get the feeling that it might help if you could get in contact with a counselor at the Credit Counseling Bureau. How would you feel about our adding that to our list?" Examining, analyzing, and listing alternatives to consider should be as col- laborative as possible. The best alternatives are ones that the clie't'lt truly owns. Take care to avoid imposing your alternatives on the client if at all possible.

The alternatives on the list should be workable and realistic. They should represent the right amount of action for the client to undertake now-not too much , not too little. The client will generally express ownership of an option by words such as "I would re- ally like to call him today." Worker-imposed options are usually signaled by the worker's words, such as " You need to go to his office and do that right away." Be- ware of the latter! An important part of the quest for appropriate alternatives is to explore with the client what options have worked before in situations like the present one. Often the client can come up with the best choices, derived from coping mechanisms that have worked well in the past. But the stresses created by the immediate crisis may keep clients from identi- fying the most obvious and appropriate alternatives for them. Here the crisis worker facilitates the client's examination of alternatives.

CW: Rita, you say you're feeling frightened and trapped right now, and you don't know where to turn. But it sounds like you'd take a step in a pos- itive direction if you could get some of your old zip back. What are some actions you took or some people you sought out in previous situations when you felt frightened or stuck?

Rita: Oh, I don't know that I've been in a mess quite this bad before.

CW: Well, that may be true. But what steps have you taken or what persons have you contacted before in a mess like this, even if it wasn't this bad?

Rita: Hmm ... Well, a time or two I did go talk to Mr.Jackson, one of my auto mechanics instructors when I was at the Area Vo-Tech School. He's very understanding and helpful. He always seemed to understand me and believe in me.

CW: How would you feel about reestablishing con- tact with him whenever you're down again?

Plan Action Steps. After developing a short, doable list of alternatives, the worker needs to move on to making plans . In crisis intervention the worker endeavors to assist the client to develop a short-term plan that will help the client get through the immediate crisis as well as make the transition to long-term coping. The plan should include the client's internal coping mechanisms as well as sources of help in the environ- ment. The coping mechanisms are usually brought to bear on some concrete, positive, constructive action that clients can take to regain better control of their

-------------------------~

lives. Actions that initially involve some physical movement are preferred. The plan should be realistic in terms of the client's current emotional readiness a nd environmental supports. It may involve collabo- ration with the worker until the client can function independently. The effective crisis worker is sensitive to the client's need to function autonomously as soon as feasible.

Rita: Right now I'd like to just be free of the whole mess for a few days ... just get off this dizzy merry- go-round long enough to collect my thoughts.

CW: It sounds to me like you really mean that. Let's see if together we can examine some options that might get you the freedom and breathing space you need to pull the pieces back together.

Rita: I can't really let go. Too many people are de- pending on me. That's just wishful thinking. But it would be wonderful to get some relief

CW: Even though you don't see any way to get it, what you're wanting is some space for yourself right now-away from work, kids, Jake, Sam, and the whole dilemma.

Rita: The only way that would happen is for my doc- tor to order it- to prescribe it, medically.

CW: How realistic is that? How would that help you?

R ita: It would call a halt to some of the pressures. The treadmill would have to stop, at least temporarily. Yes, I guess that kind of medical reason wouldn't be so bad.

CW: Sounds like consulting your doctor and laying at least part of your cards on the table might be one step toward getting medical help in carving out some breathing space for yourself

Rita: I think so. Yeah, that's it! That's one thing I could do.

CW: Let's together map out a possible action plan- for contacting your doctor and requesting assis- tance in temporarily letting go. Let's look at when you want to contact your doctor, what you're going to say, and how you're going to say it-to make sure you get the results you must have right now.

The crisis worker is attempting to work collabora- tively with Rita and to facilitate Rita's real ownership of her plan. The worker also implies a view of Rita as co mpetent and responsible.

Use the Client's Coping Strengths. In crisis interven- tion it is important not to overlook the client's own

CHAPTER FOUR The Tools of the Trade • 9 3

strengths and coping mechanisms. Often the crisis events temporarily immobilize the i'ridividual's usual strengths and coping strategies. If they can be iden- tified, explored, and reinstated, they may make an enormous contribution toward restoring the client's equilibrium and reassuring the client. For example, one woman had previously relieved stress by playing her piano. She told the worker that she was no longer able to play the piano because her piano had been re- possessed. The crisis worker was able to explore with her several possible places where she could avail her- self of a piano in times of stress .

Use Referral Resources. An integral aspect of crisis intervention is the use of referral resources. A ready list of names and phone numbers of contact people is a necessity. It is also important for the crisis worker to develop skill in making referrals as well as in working with a wide variety of referral agencies. Many clients need to be referred early to sources of help regarding financial matters, legal assistance, long-term individ- ual therapy, family therapy, substance abuse, severe depression, or other personal matters. Here are sug- gestions we have found to be useful in working with a variety of agencies. Generally, we find that a break- down in communication with agencies follows our having overlooked a few obvious and simple cautions . So do as we say, not as we sometimes do!

1. Keep a handy, up-to-date list of frequently used agencies. Keep up with personnel changes.

2. In communities that publish a directory of human services, have available the most recent edition.

3. Cultivate a working relationship with key people in agencies you use frequently. Get on community boards, join organizations, and become integrated into the provider system.

4. Identify yourself, your agency, and your purpos e when telephoning. Know secretaries and recep- tionists by name, and use their names when you call. Treat them with dignity, respect, and equal- ity, and thank them for helping you.

5. Follow up on referrals you make-within 24 hours if at all possible.

6. Don't assume that all clients have the skill to get the services they need. Be prepared to assist clients who may be unable to help themselves avoid run- around and bureaucratic red tape.

7. Whenever necessary, without engendering depen- dency, go with clients to the referral agencies to assist and to ensure that effective communication takes place.

94 • PART ONE Basic Training: Crisis Intervention Theory and Application

8. Write thank-you messages (with copies to their bosses) to persons who are particularly helpful to you and your clients.

9. Don't criticize fellow professionals or the agen- cies they represent, and don't gossip about either workers or agencies.

10. Keep accurate records of referral activities, so you have a paper trail.

11. Know frequently used agencies' hours, basic services, mode of operation, limitations, and, if possible, pol- icies such as insurance and sliding scale fees.

12. Be aware of any agency services the client is already using, so services don' t get duplicated.

13. Use courtesy and good human relations skills when dealing with agency personnel. Put yourself in their shoes, and treat them as you would like to be treated.

14. Avoid expecting perfection of other agencies. Give agencies feedback on how they did, and obtain feedback from them.

15. Be aware of sensory impairment in clients, especially in older adults, and make those impair- ments known in referrals.

16. If the agency has an orientation session, seek to attend and to participate in it.

17. Practice honesty in communicating to referral agencies regarding the status or needs of clients. (Honest and ethical portrayal of the client's needs will build credibility with other agencies.)

18. Don't be afraid to use the Internet or geograph ically distance agencies that you have checked out as legitimate. It can bring a wealth of agencies and people to your electronic doorstep, and they may have the resources that you locally don' t have.

Develop and Use Networks. Closely allied with referral is a function called networking (Haywood & Leuthe, 1980). Networking, for crisis workers, is having and using personal contacts within a variety of agencies that directly affect our ability to serve clients effec- tively and efficiently. Although each person in your network is a referral resource, it is the relationship you have with that individual that defines it as a network. Effective crisis workers can't sit behind a desk and wait for assistance to come to them. They must get out into the community and get to know personally the key individuals who can provide the kinds of services their clients require. A personal relationship based on understanding and trust between the worker and vital network people is invaluable in helping the worker cut

through bureaucratic red tape, expedite emergency assistance, and personalize many services that might otherwise not be available to clients.

As crisis workers, we do not operate alone in the world. We are interdependent. Networking permits us to spread the responsibilities among other helping professionals. We mean "helping professionals" in the broadest possible context: lawyers, judges, parole offi- cers, ministers, school counselors, federal, state, and lo- cal human services workers, directors and key people in crisis agencies, prison staff, business and civic leaders, medical doctors, dentists, police, and political leaders may play important roles in the networking process. The development and use of effective networking are indispensable functions of the successful worker.

Get a Commitment. A vital part of crisis intervention is getting a short-term commitment from the client to follow through on the action or actions planned. The crisis worker should ask the client to summarize verbally the steps to be taken. This verbal summary helps the worker understand the client's perception of both the plan and the commitment, and gives the worker an opportunity to clear up any distortions. It also provides the worker an opportunity to establish a follow-up checkpoint with the client. The commit- ment step can serve as a motivational reminder to the client and also encourage and predispose the client to believe that the action steps will succeed. Without a definite and positive commitment on the part of the client, the best of plans may fall short of the objectives that have been worked out by the worker and the client.

CW: So, Rita, it seems to me that what you've decided to do is to reinitiate some kind of meaningful contact with Mr. Jackson. So that we're both very clear on what you've committed yourself to do- ing, would you please summarize how and when you're going to proceed?

Rita: I'm going straight to my office today and phone him at school. I'll either talk to him or leave a mes - sage for him to call me. As soon as I talk to him, I'll set up a definite day and time to meet with him.

CW: And when you've set up .. .

Rita: Oh, yes! And when I've set up my appointment with him, I'm going to phone you and let you know how it went.

CW: Good. And in the meantime, you have my number on the card if you need me-especially if the safety of either you or your children becomes jeopardized.

Rita: That's right, and I'll call if I lose my nerve with Sam. I've got to get some space for myself there-at least some temporary space.

Experienced crisis workers are generally able to sen se how far and h ow fast the client is able to act.

Crisis intervention from a practitioner's standpoint incorporates a number of fundamental counseling skills that are specifically tailored to crisis intervention. Listening is fundamental to all successful counseling, rncluding crisis intervention, and includes such [echniques as restatement, reflection, owning state- aients, and open- and closed-ended questions. Essential components of effective listening and communication include effective attending, empathy, genuineness, and acceptance. Action skills range across nondirec- rive, collaborative, and directive worker strategies. T hese strategies may include helping the client focus or expand awareness, providing guidance and informa- tion, allowing cathartic release of emotions, providing support and protection, and mobilizing the client to action. As opposed to doing crisis therapy with a cli- ent whom the worker has a working history, field work

CHAPTER FOUR The Tools of the Trade • 95

... Usually the client is encouraged to commit to as much action as feasible. If we cannot get her or him to make a giant leap forward, we'll accept one small step in a positive direction. T h e main idea is to facili- tate some commitment th at will result in movement of the client in a constructive direction.

often means meeting a client for the first time. Thus, ba- sic introduction and attending skills along with an as- sessment of client weapon and drug use, availability of support systems and whether basic food, water, shelter, clothing, and medical needs are being met are critical to de-escalation and stabilization. Finally, the worker is not an island unto himself or herself. Building human services provider resources and establishing working relationships with them is critical to any crisis work.

Visit CengageBrain.com for a variety of study e tools and useful resources such as video ex- ~ amples, case studies, interactive exercises, flas~~: W I cards, and quizzes. __J