Crisis Intervention

Definition of Crisis
A state of disequilibrium - emotional distress that occurs after a stressor or a precipitating event. The person is unable to function in one or more areas of his or her life because of customary coping methods that have failed. Usually lasts 6-8 weeks. Impact may last a lifetime.

Metastasizing Crisis
When a small, isolated incident is not contained and begins to spread. Not easy to excise or remedy at this point.

Perception
How the client views the threat.

1. Threat to life goals - work, maturation, love, intimacy, social interest.

2. Threat to affectional ties.

3. Threat to security.
How individuals interpret events has a great deal to do with how amenable the crisis will be to resolution.

Types of Resolution Coping Methods

1. Active Cognitive Coping

2. Active Behavioral Coping

3. Avoidance Style Coping

Active Cognitive Coping

1. Identify crisis

2. Help them get back to the resolution, the upswing, so that they can function in the world.

3. Help them develop a plan.

4. When people are in this state, they are more receptive to help.

Active Behavioral Coping

1. Now that the client has a plan, they are going to follow it through.

2. If it's not a great plan or not working, go back to individual and start thinking through a better plan and working through the procedure.

Avoidance Style Coping
-Avoidance and denial are not always bad. Sometimes they help a client digest what has just occurred.
-It can help them stay glued.
-We don't want someone stuck in denial.
-In the beginning it's okay because it's helping that person adjust to the sharp blow that has occurred. Eventually, however, we will need to quicky move them along.

Problem Solving
Achieve a goal that's not easily attained.

Cognitive-Behavioral Problem Solving

1. Define a problem as clearly as possible.

2. Review ways that you have already tried to correct the problem, paying attention to what worked and what didn't. Build on their strengths and develop new strengths so that the client can effectively problem solve.

3. Think through the plan of action and possible alternatives.

4. Commit to following through on the plan of action.

5. Review results.

6. Evaluate progress and follow up.

7 Characteristics of Coping Behavior

1. Actively exploring realty issues and searching for information.

2. Freely expressing both positive and negative feelings and tolerating frustration.

3. Actively invoking help from others.

4. Breaking problems into manageable bits and working through them one by one.

5. Being aware of fatigue and pacing coping efforts while maintaining control.

6. Modeling feelings, where possible, being flexible and willing to change.

7. Trusting in oneself and others and having a basic optimism about the outcome.

Applies Crisis Theory

1. Normal developmental maturation crises

2. Situational crises

3. Existential crises

4. Eco-systems crises

Normal Developmental Maturation Crisis
Typical flow of human growth and evolution whereby a dramatic change or shift occurs which produces abnormal responses (birth of child, retirement, aging process, mid-life crisis, college graduation). Can be a positive thng.

Situational Crises
Usually uncommon and extraordinary events that can be frustrating or very controlling (job lay off, terrorist attack, sudden illness, automobile accident, rape). It is random, sudden, shocking, intense and catastrophic.

Existential Crises
Can emerge when we are experiencing inner conflict about important human issues such as the meaning and purpose in life, responsibility, commitment and independence.

Religiosity
Helps people cope and provides hope.

Spirituality
Meaning and purpose in life, a sense of belonging-ness, a sense of universality, a sense of transcencedence, a sense of rising above human suffering.

Eco-Systems Crisis
-Occurs when some natural or human-caused disaster overtakes a person or a group.
-Adversely affects every member of the environment.
-Biological crisis.

Basic Crisis Intervention Theory
Focuses on helping people in crisis recognize and correct temporary affective, behavioral and cognitive distortions brought on by traumatic events.

Brief Therapy Theory
Typically attempts to remediate ongoing emotional problems.

Expanded Crisis Theory
-Psychoanalytic Theory
-Systems Theory
-Eco-Systems Theory
-Adaptational Theory
-Interpersonal Theory
-Chaos Theory
-Developmental Theory

Psychoanalytic Theory
Based on the view that the disequilibrium that accompanies a person's crisis can be understood through gaining access to the individual's unconscious thoughts and past emotional experiences.

Systems Theory
-Based not so much on what happens within an individual in crisis as on the interrelationship and interdependence among people and between people and events.
-Represents a turning away from focusing on only what is going on with the client.

Ecosystems Theory
Looks at crises in relation to the environmental context within which it occurs. Systems in which all elements are interrelated and in which change at any level of those interrelated parts will lead to alteration of the total system.

Interpersonal Theory
-Enhancing personal self-esteem such as openness, trust, sharing, safety, unconditional positive regard, accurate empathy, and genuineness.
-The essence is that people cannot sustain a personal state of crisis for very long if they believe in themselves and in others and have confidence that they can become self-activated and overcome the crisis.
-The goal is returning the power of self evaluation to the person.

Adaptational Theory
Depicts a person's crisis as being sustained through maladaptive behaviors, negative thoughts and destructive defense mechanisms. Based on the premise that the person's crisis will recede when these maladaptive coping behaviors are changed to adaptive behaviors.

Chaos Theory
Emergent complex messiness - evolves into a self organizing mode whenever a critical mass of people come to perceive that they have no way to identify patterns or preplan options to solve the dilemma at hand.

Developmental Theory
-Tasks that are not met and accomplished during particular life stages tend to pile up and cause problems.
-When an external, environmental or situational crisis feeds into a preexisting developmental crisis, intrapersonal and interpersonal problems may reach the breaking point.

Psychological First Aid

1. Seeks to address the immediate crisis situation and provide immediate relief possible to a wide range of individuals.

2. Establishing safety of the client, reducing stress-related symptoms, providing rest and physical recuperation and linking clients to critical resources and social support systems.

3. Prevailing approach is an intervention that is non-intrusive and does not promote discussion of the traumatic event.

4. Designed to provide non-intrusive physical and psychological support.

Approach to Psychological First Aid

1. Contact and engagement - goal: respond to contacts initiated by survivors or to initiate contacts in a non-intrusive, compassionate and helpful manner.

2. Safety and comfort - goal: to enhance immediate and ongoing safety and provide physical and emotional comfort.

3. Stabilization (if needed) - goal: to calm and orient emotionally overwhelmed or disoriented survivors.

4. Information gathering, current needs and concerns - goal: to identify immediate needs and concerns, gather additional information and tailor psychological first aid interventions.

5. Practical assistance - goal: to offer practical help to survivors in addressing immediate needs and concerns.

6. Connections to social supports - goal: to help establish brief or ongoing contacts with primary support persons and other supports (family, friends, community).

7. Information on coping - goal: provide information on stress reactions and coping to reduce distress and promote adaptive functioning.

8. Link to collaborative services - goal: link to services needs presently or in the future.

ACT Model
-Assessment of the presenting problem including emergency psychiatric and other medical needs and trauma assessment.
-Connecting clients to support systems
-Traumatic reactions and posttraumatic stress disorders.

ACT Model Linear Stages

1. Crisis assessment

2. Establishing rapport

3. Identifying major problems

4. Dealing with feelings

5. Generating and exploring alternatives

6. Developing plans

7. Providing follow up

Emic Model
Components that make up individuals, not just what their individual parts are, but how they come together.

ADDRESSING
-Age
-acquired and Developmental Disabilities
-Religion
-Ethnicity
-Social Class
-Sexual Orientation
-Indigenous heritage
-National origin
-Gender

RESPECTFUL
-Religious/spiritual
-Economic class
-Sexual Identity
-Psychological development
-Ethnic/racial identity
-Chronological age
-Trauma and threats to well being
-Family
-Unique physical issues
-Language and location of residence.

Positive aspects of an effective multicultural counselor
-Uses methods and strategies and defines goals consistent with the life experiences and cultures values of the client.
-Worker should demonstrate empathy, caring and positive regard while searching for a role that is compatible with the client's worldview and offers to act as advocate without injecting his or her own values or condition into the situation.

1. Examine and understand the world from the client's viewpoint

2. Search for alternative roles that may be more appealing and adaptive to clients from other backgrounds

3. Help clients from other cultures make contact with and elicit help from indigenous support systems.

Freud's definition of psychic trauma
A process initiated by an event that confronts an individual with an acute, overwhelming threat. When the event occurs the inner agency of the mind loses it's ability to control the disorganizing effects of the experience and disequilibrium occurs.

Complex PTSD
Dramatic personality changes that may occur with long-term intensive trauma.

1. Somatization - physical problems, associated pain and functional limitations.

2. Dissociation - division of the personality into one component that attempts to function in the everyday world and another that regresses and is fixed in the trauma.

3. Affective dysregulation - alterations in impulse control, attention and consciousness, self perception, perception of perpetrators, relationships to significant others and systems of meaning.

Phases of Recovery PTSD

1. Emergency or outcry phase

2. Emotional numbing and denial phase

3. Intrusive-repetitive phase

4. Reflective-transition phase

5. Integration phase

The Emergency or Outcry Phase
Individual experiences heightened fight/flight reactions to the life threatening situation. Termination of the event itself is followed by relief and confusion. Questions about why the event happened and what its consequences are dominate the individual's thoughts.

The Emotional Numbing and Denial Phase
The survivor protects psychic well-being by burying the experience in subconscious memory. By avoiding the experience, the individual temporarily reduces anxiety and stress symptoms. Many individuals remain forever at this stage unless they receive professional intervention.

The Intrusive-Repetitive Phase
Survivor has nightmares, volatile mood swings, intrusive images and amplified startle responses. Other pathological and anti-social defense mechanisms may be put into place in a futile attempt to rebury the trauma. At this point, the delayed stress becomes to overwhelming that the individual is propelled to seek help or becomes so mired in the pathology of the situation that outside intervention is mandated.

The Reflective-Transition Phase
The survivor develops a larger personal perspective on the traumatic events and becomes positive and constructive with a forward, rather than backward, looking perspective. The individual comes to grips with the trauma and confronts the problems.

The Integration Phase
Survivor successfully integrates the trauma with all other past experiences and restores a sense of continuity to life. The trauma is successfully placed fully in the past.

Support Groups
- Emotional attachment and social involvement are basic and important ingredients in armor plating the individual against PTSD. For most of those that suffer from PTSD, social isolation and emotional estrangement are the norm.
-Group work is helpful because of the shared experience, mutual support, sense of community, reduction of stigma and the restoration of self-pride it fosters.
-The primary task of any group therapy is to help people regain a sense of safety and mastery because of a shared sense of having gone through the same trauma.

Journaling
-For PTSD clients, speaking about what has happened to them is difficult.
-This is an excellent method of opening up affect and allowing non-verbal catharsis to occur. By putting down their thoughts in their own words and then hearing them, individuals place their terrible memories at a safe enough psychological distance that they and the worker can analyze them.

Thought Stopping
-Enables the individual to change debilitating, intrusive thoughts to self-enhancing ones.
-Crisis worker sets the scene and builds the images until the fear-evoking stimuli are at maximum arousal and then shouts STOP and replaces them with positive, self-enhancing thoughts.

Numbing/Denial
-This phase is concerned with bringing to conscious awareness the traumatic event and the hidden facts and emotions about it that the individual denies.
- In a gentle but forceful way, the worker guides the individual in the here and now of the therapeutic moment, to re-experience in the fullest possible detail what occurred in the traumatic experience so that submerged feelings are uncovered an ultimately expunged.

Emergency/Outcry
-Major problem is to get the individual stabilized--reducing anxiety and physical responses associated with the trauma.
-Relaxation training and meditation teaches the client how to relax body muscle groups systematically and to focus calmly on mental images that produce psychic relief of boy tensions and stress.

Risks of PTSD Treatment

1. Partial recovery

2. Therapy/hospitalization may impact employment.

3. May get worse before gets better.

4. Interpersonal relationships may be impacted by personality changes.

5. Psychic pain may become intolerable.

6. Individual may fear that giving vent to those emotions will lead to uncontrolled anger and result in physical harm to others. Difficult to give up the idea of revenge.

7. Individual will safeguard against change and may have difficulty doing what others suggest.

8. Individual is in danger of losing patience with the world and falling bck in PTSD vortex.

9. Acceptance of one's own set of infirmities, bad memories may return, relationships might not be perfect, others might get the job for no good reason, etc.

PTSD

1. The person must have been exposed to trauma in which he or she was confronted with an event that involved actual or threatened death or serious injury or a threat to self or others' physical well being.

2. The person persistently re-experiences the traumatic event.

3. The person persistently avoids stimuli.

4. The person has persistent symptoms of increased nervous system arousal that were not present before the trauma.

5. The disturbances cause clinically significant distress or impairment in social, occupational or other critical areas of living.

PTSD - First criteria
The person must have been exposed to trauma in which he or she was confronted with an event that involved actual or threatened death or serious injury or a threat to self or others' physical well being.

Examples: military combat, physical or sexual assault, kidnapping, being held hostage, severe vehicle accidents, earthquakes, concentration camp detention, life-threatening illness.

PTSD - Second criteria
The person persistently re-experiences the traumatic event in at least one of the following ways:

1. Recurrent and intrusive recollections of the event.

2. Recurrent nightmares of the event.

3. Flashback episodes, including those that occur on awakening or when intoxicated, that may include all types of sensory hallucinations or illusions that cause the individual to dissociate from the present reality and act or feel as if the event were recurring.

4. Intense psychological distress on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiologic reactivity on exposure to events that symbolize or resemble some aspect of the trauma such as a person who was in a tornado starting to shake violently at every approaching storm.

PTSD - Third criteria
The person persistently avoids such stimuli in at least three of the following ways:

1. Attempts to avoid thoughts, dialogues, or feelings associated with the trauma.

2. Tries to avoid activities, people, or situations that arouse recollections of the trauma.

3. Has an inability to recall important aspects of the trauma.

4. Has markedly diminished interest in significant activities.

5. Feels detached and removed emotionally and socially from others.

6. Has a restricted range of affect by numbing feelings.

7. Has a sense of a foreshortened future, such as no career, marriage, children, or normal life span.

PTSD - Fourth criteria
The person has persistent symptoms of increased nervous system arousal that were not present before the trauma, as indicated by at least two of the following problems:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating on tasks

4. Constantly being on watch for real or imagined threats that have no basis in reality (hypervigilance).

5. Exaggerated startle reactions to minimal or non-threatening stimuli.

Survivor's Guilt
Mental condition that occurs when a person believes they have done something wrong by surviving a traumatic event when others did not.

Family Treatment PTSD
- One of the worker's major tasks is assessing the family's willingness to engage in treatment.
- Treatment objectives are to develop and implement an intervention program to deal with both the stress disorder of the individual and assorted family dysfunctions that were in place prior to the event or that developed after the event.
- Learning about the disorder, dealing with the boundary distortions of intimacy and separation caused by it, alleviating psychosomatic results of rage and grief, urging recapitulation of the trauma, facilitating resolution of the trauma-inducing family conflicts, clarifying insights and correcting distortions by placing blame and credit more objectively, offering new and more positive and accurate perspectives on the trauma, establishing and maintaining new coping and adapting skills as family dynamics change.

Type I Trauma PTSD
- One sudden, distinct, traumatic experience
- Characterized by fully detailed, etched-in memories, omens such as retrospective rumination, cognitive reappraisals, reasons, misperceptions, and mistiming of the event.

Type II Trauma PTSD
- Longstanding and comes from repeated traumatic ordeals.
- Result in the psyche's developing defensive and coping strategies to ward off the repeated assaults on its integrity.
- Massive denial, psychic numbing, repression, dissociation, self-anesthesia, self-hypnosis, identification with the aggressor and aggression turned against the self and prominent.
-Emotions are an absence of feeling and a sense of rage and/or unremitting sadness.

Children and PTSD

Play Therapy
Directive - collaborative and interactive between the child and the worker
Non-directive - child-centered and worker passive.
Non-directive may cause destructive behaviors or anxiety.
Take the global, nebulous, uncontrollable chaos of the event and make it into a concrete, real object that the child can gain a sense of control over. May allow the therapist to enter the trauma on the child's cognitive terms, reduce the threat of the trauma, establish trust and determine the child's current means of coping and current ways of defending against the trauma.

Hybrid Model of Crisis Intervention
Generally linear in progression but can also be seen in terms of tasks that need to be accomplished. Adaptable.

Task # 1 - Predispositioning/engaging/initiating contact
Task # 2 - Problem exploration: defining the crisis
Task # 3 - Providing support
Task # 4 - Examining alternatives
Task # 5 - Planning in order to reestablish control
Task # 6 - Obtaining commitment
Task # 7 - Follow-up

Task #1 - Predispositioning/engaging/initiating contact
-Predisposing individuals to be receptive to our intervention when in many instances, they may not be enthused about our presence or be so out-of-control that they are only vaguely aware of us.
-Has a lot to do with the attitudinal set and predisposition of how the crisis worker enters the situation.
-The ability to convey empathy and be authentic to who and what you are doing without pretense.
-Establishing a psychological connection - introduce yourself in a non-threatening and helpful way.
-One of the most important elements in making first contact is getting the client's name and introducing yourself.

Task # 2 - Problem exploration: defining the crisis
-Define and understand the problem from the client's point of view.
-Core listening skills: empathy, genuineness and acceptance or positive regard.
-Attempting to identify the precipitating event across the affective, behavioral and cognitive components of the crisis.
-Serves two purposes - 1) the worker sees the crisis from the client's perspective 2) defining the crisis gives the worker info on the immediate conditions, parties and issues that led to eruption of the problem into a crisis.

Task # 3 - Providing support
-Communicating to the client that the worker is a person who cares about the client.
-Psychological support, logisitical support, social support, information support.
-Default task is safety

Task # 4 - Examining alternatives
-Exploring a wide array of appropriate choices to the client
-Situational supports - people known to the client who might care about what happens to the client.
-Coping mechanisms - actions, behaviors or environmental resources the client might use to help get through the present crisis.
-Positive and constructive thinking patterns - ways of reframing that might substantially alter the client's view of the problem and lessen the client's level or stress and anxiety.
-Appropriate choices that are realistic for their situation.

Task # 5 - Planning in order to reestablish control
-Planning to reestablish control to mobilize the client.
-Making plans in collaboration with the client so that the clients feel a sense of ownership of the plan and that they do not feel robbed of their control/autonomy/independence.
-Plans help restore sense of control.
-Planning is about getting through the short term and getting some semblance of equilibrium and stability restored (most plans are measured in minutes, hours, days).
-Psychoeducation

A plan should be able to...

1. Identify additional persons, groups and other referral resources that can be contacted for immediate support

2. Provide coping mechanisms - something concrete and positive for the client to do now.

Psychoeducation
-Benefit client by helping them understand what is going on with them psychologically.
-Definition is to provide information to victims and survivors about what is happening and probably going to happen to them psychologically in the aftermath of a traumatic event.

Task # 6 - Obtaining commitment
-Asking the client to verbally summarize the plan, a handshake, a signed agreement, etc.
-Objective is to enable the client to commit to taking one or more definite, positive, intentional action steps designed to move that person toward restoring pre-crisis equilibrium.

Task # 7 - Follow up
-Time frame of minutes, hours, days.
-Keeping track of clients' success in maintaining pre-crisis equilibrium.
-Short-term is also important as a reinforcing event that tells clients you are still with them.
-Especially important when clients have little social support.

Psychological support
-Deep, empathetic responding using reflection of feelings and owning statements about the client's present condition.
-Serves as a bonding agent that says emphatically I am here with you right now.

Logistical support
-Instrumental (pamphlets, arranging transportation, a drink of water)
-Giving concrete assistance to help weather the crisis.

Informational support
-Giving adequate information to help the client make informed decisions.
-Where, who, and what resources the client can access to get out of the predicament they are in.

Safety
-Default task that is always operational.
-Assessing and ensuring this is always part of the process.
-Important for not only the client but for those who may interact with him or her.
-Nothing is more paramount.
-Pertains to psychological aspects as well.

ABCs of assessing in crisis intervention
-Severity of the crisis is assessed from the client's subjective viewpoint and from the worker's objective viewpoint.
-Affective state
-Behavioral functioning
-Cognitive state

Affective state
Abnormal or impaired affect is often the first sign that the client is in a state of disequilibrium. Client may become overemotional or out of control, withdrawn, detached.
-Often the worker can assist the client to regain control and mobility by helping the client express feelings in appropriate and realistic ways.

Behavioral functioning
-Worker focuses much attention on doing, acting out, taking active steps, behaving or any number of other psychomotor activities.
-Best way to get client to become mobile is to facilitate positive actions that the client can take at once.
-Engage in some concrete or immediate activity.
-Problem in immobility is loss of control.
-Once client becomes involved in doing something concrete, an element of control is restored, a degree of mobility is provided and the climate for forward movement is established.

Cognitive state
May provide answers to important questions:
-How realistic and consistent is the client's thinking about the crisis?
-To what extent, if any, does the client appear to be rationalizing, exaggerating or believing past truths or rumors to exacerbate the crisis?
-How long has the client been engaged in crisis thinking?
-How open does the client appear to be towards changing?

Triage assessment
-Critical in crisis intervention
-Dictates what the interventionist will do in the next seconds and minutes as the crisis unfolds.
-Should be fast, efficient way of obtaining a real-time estimate of what is occurring with a client.

Psychobiological assessment

1. Traumatic events cause dramatic changes in the discharge of neurotransmitters.

2. Abnormal changes in neurotransmitters are involved in mental disorders that range from schizophrenia to depression.
-Legal and illegal drugs have a major effect on mental health.

Assessing the client's current emotional functioning

1. Duration of the crisis (acute/situational, chronic/long-term)

2. The degree of emotional stamina or coping at the client's disposal at the moment (determing how much coping strength is left in the client's reservoir)

3. The ecosystem within which the client resides

4. The developmental stage of the client

Acute state
-Usually requires direct intervention to facilitate getting over the specific event or situation that precipitated the crisis.
-Having reached a state of precrisis equilibrium, the client can usually draw on normal coping mechanisms and support people and manage independently.

Chronic state
-Usually requires a greater length of time in counseling.
-Needs help in examining available coping mechanisms, finding support people, rediscovering strategies that worked during previous crises, generating new coping strategies and gaining affirmation and encouragement from the worker and others as sources of strength by which to move beyond the present crisis.

Client's reservoir of emotional strength
-A client who lacks emotional strength needs more direct responses from the crisis worker than the client who retains a good deal of emotional strength.
-The lower the reservoir of emotional strength, the less the client can get a hold of the future.

Assessing for suicidal/homicidal potential
-Most suicidal and homicidal clients emit definite clues and believe they are calling out for help or signaling warnings.
-Realization that suicide and homicide are always possible.

Open-ended questions
Usually start with what or how to ask for more clarification or details. Encourages clients to respond with full statements and at deeper levels of meaning.

Some guidelines for formulating:


1. Request description

2. Focus on plans

3. Expansion

4. Assessment

5. Stay away from why questions

Closed-ended questions
Used early on in crisis intervention to obtain specific information that will help the crisis worker make a fast assessment of what is occurring.

Some guidelines for formulating:


1. Request specific information

2. Obtain a commitment

3. Increasing focus

4. Avoid negative interrogatives (don't, doesn't, isn't, aren't and wouldn't)

Positive reinforcement
Should be used in regard to a behavior as opposed to a personal characteristic. Often used in crisis intervention to gain compliance. Can be a double-edged sword as it may breed dependency.

Facilitative listening
To function in this 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 messages (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 enter 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.


1. The worker should make initial owning statements that express exactly what he or she is going to do.

2. Respond in ways that let the client know that the crisis worker is accurately hearing bot the facts and the emotional state from which the client's message comes.

3. Facilitative responding - provides impetus for clients to gain a clearer understanding of their feelings, inner motives and choices. Enables clients to feel hopeful and to sense an inclination to begin to move forward toward resolution and away from the central core of the crisis.

4. Helping the clients to understand the full impact of the crisis situation.

Basic strategies of crisis intervention
- Creating awareness
-Allowing catharsis
-Providing support
-Promoting expansion
-Emphasizing focus
-Providing guidance
-Promoting mobilization
-Implementing order
-Providing protection

May be used singly or in combination

Creating awareness
The worker attempts to bring to conscious warded off, denied, shunted and repressed feelings, thoughts and behaviors that freeze clients' ability to act in response to the crisis.

Allowing catharsis
Letting clients talk, cry, swear, berate, rave, mourn or do anything that allows them to ventilate feelings and thoughts. Worker provides a safe and accepting environment that says that it is okay to say and feel these things.

Providing support
The worker attempts to validate the clients' responses as as reasonable as can be expected given the situation. Often, clients believe they must be going crazy, but 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.

Promoting expansion
Helps clients step back, reframe the problem and gain new perspectives. Helps clients resolve stuck cognitive reactions. Effective with clients who are not able to recognive environmental cues that may help them to perceive alternative meanings of events and possible solutions to them.

Emphasizing focus
The worker attempts to partition, compartmentalize, and downsize clents' 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.

Providing guidance
The worker provides information, referral, and direction in regard to clients' obtaining assistance from specific external resources and support systems.

Promoting mobilization
The worker attempts to activate and marshal clients' internal resources and to find and use external support systems to help generate coping skills and problem-solving abilities.

Implementing order
The worker methodically helps clients classify and categorize problems so as to prioritize and sequentially attack the crisis in a logical and linear manner.

Providing protection
The worker safeguards the client from engaging in harmful, destructive, detrimental and unsafe feelings, behaviors and thoughts that may be psychologically or physically injurious or lethal to themselves or others.

Communicating empathy

1. Attending

2. Verbally communicating empathetic understanding

3. Reflecting feelings

4. Nonverbally communicating empathetic understanding

5. Silence as a way of communicating empathetic understanding

Non-verbal communication
Accurately picking up and reflecting more than verbal messages. Involves accurately sensing and reflecting all the unspoken cues, messages and behaviors the client emits. Worker should carefully observe body posture, body movement, gestures, grimaces, vocal pitch, movement of eyes, movement of arms and legs and other body indicators. Worker should be keenly aware of whether nonverbal messages are consistent with the client's verbal messages.

Silent
Remaining _____ but attending closely to the client can convey deep, empathetic understanding.

Communicating genuineness

1. Being role free

2. Being spontaneous

3. Being nondefensive

4. Being consistent

5. Being a sharer of self

Use of referral sources
Many clients need to be referred early to sources of help regarding financial matters, legal assistance, long-term individual therapy, family therapy, substance abuse, severe depression or other personal matters.

Obtaining commitment
The 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. Also provides the worker an opportunity to establish a follow-up checkpoint with the client.

Principles of long-term therapy mode

1. Diagnosis - complete diagnostic evaluation

2. Treatment - focus on basic underlying causes: on the whole person

3. Plan - personalized comprehensive prescription directed toward fulfilling long-term needs

4. Methods - knowledge of techniques to systematically effect a wide array of short-term, intermediate-term and long-term therapeutic gains.

5. Evaluation of results - behavioral validation of therapeutic outcomes in terms of the client's total functioning.

Principles of crisis-case handling mode

1. Diagnosis - rapid triage crisis assessment

2. Treatment - focus on the immediate traumatized component of the person

3. Plan - individual problem-specific prescription focused on immediate needs to alleviate the crisis symptoms

4. Methods - knowledge of time-limited brief therapy techniques used for immediate control and containment of the crisis trauma

5. Evaluation of results - behavioral validation by client's return to pre-crisis level of equilibrium.

Objectives of long-term therapy mode

1. Prevent problems

2. Correct etiological factors

3. Provide systematic support

4. Facilitate growth

5. Re-educate

6. Express and clarify emotional attitudes

7. Resolve conflict and inconsistencies

8. Accept reality

9. Reorganize attitudes

10. Maximize intellectual resources

Objectives of crisis-case handling mode

1. Ensure client safety

2. Predisposition

3. Define problem

4. Provide support

5. Examine alternatives

6. Develop a plan

7. Obtain commitment

8. Follow-up

Client functioning in long-term therapy mode

1. Client shows sufficient affect; manifests some basis for experiencing and understanding his or her emotional state.

2. Client shows some ability to cognitively understand the connection between behavior and consequences - between what is rational and irrational

3. There is some modicum of behavioral control

Client functioning in crisis case-handling mode

1. Affectively, the client is impaired to the extent that there is little understanding of his or her emotional state.

2. Cognitively, the client shows inability to think linearly and logically and formulate strategies to alleviate the crisis. Irrationality is the norm.

3. Behaviorally, the client is out of control and may pose a danger to self or others.

Assessment in long-term therapy mode

1. Intake data - client is stable enough to provide in-depth background regarding the problem. Comprehensive may be performed.

2. Safety - usually not primary focus

3. Time - more time

4. Reality testing - worker assumes client is in touch with reality

5. Referrals - have implications for long-term development

6. Consultation - available as needed

7. Drug use - has information to determine the level and type of prescription medication or illicit drug or alcohol use.

8. Disposition - starts and finished with the same therapist over a course of months. Come and go voluntarily.

Assessment in crisis-case handling mode

1. Intake data - may not be able to fill out intake form because of instability or time

2. Safety - first concern

3. Time - no time for administering formal instruments

4. Reality testing - by using simple questioning procedures

5. Referrals - implications of immediacy

6. Consultation - May be available but most often the worker is on their own

7. Drug use - relies on verbal and visual responses

8. Disposition - starts and stops with the same worker over a course of hours or days.

Disposition
Worker discusses treatment recommendations and possible services with the client. Clients decision to accept or reject services. If accepted, case will be referred to a therapist who will be in charge of case. A full clinical team meeting is held to confirm or alter the initial diagnosis and treatment recommendations. At that time, a primary therapist is designated and assumes responsibility for the case.

Mobile crisis teams
- Geriatric or physically disabled clients may need home visits to provide services.
-When a client is out of control and unwilling or unable to go to a client, crisis workers go wherever the client is.
-The community mental health act of 1963 mandates that those clinics receiving federal funds must provide 24-hours emergency service.

What is covered in CIT (crisis intervention team program) training

1. Cultural awareness of the mentally ill

2. Substance abuse and co-occurring disorders

3. Developmental disabilities

4. Treatment strategies and mental health resources

5. Patient rights, civil commitment and legal aspects.

6. Suicide intervention

7. Using mobile crisis team and community resources

8. Psychotropic medications and their side effects

9. Verbal defusing and de-escalating techniques

10. Borderline and other personality disorders

11. Family and consumer perspectives

12. Fishbowl discussion on-site with mentally ill patients on patient perceptions of the police.

Adolph Stern
American psychotherapist that described a group of clients who did not respond well to treatment and in fact generally got worse. He labeled them as somewhere between neurosis and psychosis (borderline personality disorder).

People with borderline personality disorder
-Ultimate test of the therapist's ability to handle manipulative behavior and can create severe crises for themselves and the therapist if not dealt with in specific ways.
-Somewhere between neurosis and psychosis
-Possible childhood abuse and neglect, complex PTSD
-Hallmark of the person who is in transcrisis
-Severe attachment problems
-Harbor a deep sense of betrayal
-Testing of the relationship and paranoia
-Manipulative

People with borderline personality disorder presenting problem

1. Variety of presenting problems that may shift from day to day, week to week

2. Unusual combinations of symptoms ranging across a wide array of neurotic to sub-psychotic behaviors

3. Self-destructive and self-punitive behaviors ranging from self-mutilation to suicide attempts

4. Impulsive and poorly planned behavior that shifts through infantile, narcissistic or antisocial behavior

5. Intense emotional reactions out of all proportion to the situation

6. Confusion regarding goals, priorities, feelings, sexual orientation and so on

7. A constant feeling of emptiness with chronic free-floating anxiety

8. Unstable low self-esteem and high and unstable negative affect

9. Poor academic, work and social adjustment

10. Extreme approach and avoidance behavior to social relationships

11. Chronic suicidal and/or homicidal ideation

12. Paranoid ideation

13. Depersonalization and hallucinations

14. Drug and alcohol abuse

15. Sexual promiscuity and sexual victimization

People with borderline personality disorder therapeutic relationship

1. Do everything in their power to turn the therapeutic relationship upside down.

2. Frequent crises (suicide threats, drug abuse, sexually acting out, financial irresponsibility, problems with the law).

3. Extreme or frequent misinterpretations of the therapist's statements, intentions or feelings with strong transference issues which can illicit even stronger countertransference issues in the therapist.

4. Strong, negative, acting-out reactions to changes in appointment time, room changes, vacations, fees, or termination in therapy.

5. Low tolerance for direct eye contact, physical contact or close proximity in therapy.

6. Strong ambivalence on issues.

7. Fear of and resistance to change with inability or resistance to carry out therapeutic assignments.

8. Frequent calls to, spying on and demands for special attention and treatment from the therapist.

9. Inordinate hypersensitivity to significant others including the therapist.

Ground rules for counseling difficult clients

1. Start and quit on time. If couples are involved, both parties must be present

2. No physical violence or threats of violence

3. Everyone speaks for themselves

4. Everyone has a chance to be fully heard

5. We deal with the here and now, try not to get bogged down in the past

6. Nobody gets up and leaves because the topic is uncomfortable, everyone stays for the entire session.

7. Everyone gets an opportunity to define the current problems, solutions and make at least one commitment to do something positive.

8. Limits to graphic descriptions, abusive language and swearing/cursing need to be clear as to what will and will not be tolerated.

9. Everyone belongs because he or she is a human being and because he or she is here.

10. The worker will not take sides.

11. No retribution, no retaliation or grudges over what is said in the session. Whatever is said in the session stays in the session.

12. Time spent together is for working on the concerns of the person or people in the group-- not for playing games, making personal points, diversion, ulterior purposes, or carrying tales or gossip outside the session.

13. When we know things are a certain way, we will not pretend they are another way. We will confront and deal with each other as honestly and objectively as we possibly can.

14. We will not ignore the nonverbal or body messages that are emitted, we will deal with them openly if they occur.

15. If words or messages need to be expressed to clear the air, we will say them either directly or with role playing--we will not put them off until later.

16. We will not expect each other to be perfect.

17. No wet clients-- we don't work when clients are drunk or using drugs.

18. If ground rules are broken, the consequences will be discussed by the persons involved immediately with the crisis worker. People who comply with the rules will not be denied services because one person disobeys the rules.

Confidentiality in case handling
An explicit promise to reveal nothing about an individual except under conditions agreed to by the source or the subject. Under scrutiny when the case involves the potential for violent behavior.

Principles of bearing confidentiality

1. Legal principles

2. Ethical principles

3. Moral principles

Legal principles of confidentality
Human service workers have varying degrees of privileged communication. Also, volunteers do not have such protection unless specifically provided by law.

Ethical principles of confidentiality
Do not have the weight of the law. General guiding codes of conduct for a particular profession. Violation may result in censure or loss of license mandated by the professions board, but it does not necessarily expose the professional to legal problems.

Moral principles of confidentiality
When one shares problems of a deeply personal nature, common decency dictates that the recipient should keep the confidence of the individual who shares such information.

Intent to harm and the duty to warn
When the client provides information about doing harm to himself or herself or another person, rules of confidentiality take on an entirely different perspective.

Tarasoff

1. There must be a special relationship, such as therapist to client.

2. There must be a reasonable prediction of conduct that constitutes a danger.

3. There must be a foreseeable victim.

Telephone crisis strategies

1. Making psychological contact

2. Defining the problem

3. Ensuring safety and providing support

4. Looking at alternatives and making plans

5. Obtaining commitment

6. Errors and fallacies

Callers agenda - paranoid
Guarded, secretive and pathologically jealous. Difficult to shake their persecutory beliefs. See themselves as victims and expect deceit and trickery from everyone. Counseling focus is to stress their safety needs.

Callers agenda - schizoid
Restricted emotional expression and experience. Few social relationships and feel anxious, shy and self-conscious in social settings. Guarded, tactless and often alienate others. Counseling focus is to build a good sense of self-esteem through acceptance, optimism and support.

Callers agenda - Schizotypal
Feelings of inadequacy and insecurity. Strange ideas, behaviors and appearances. Counseling focus is to give them reality checks and to promote self-awareness and more socially acceptable behavior in a slow-paced supportive manner.

Callers agenda - narcissistic
Grandiose, self-centered and believe they have unique problems that others cannot comprehend. Tend to see themselves as victimized by others and always need to be right. Counseling focus is to get them to see how their behavior is seen and felt by others, while not enaging them in a no-win debate or argument.

Callers agenda - histrionic
Move from crisis to crisis. Shallow depth of character and are extremely ego involved. Crave excitement and become bored with routine and mundane tasks and events. May behave in self-destructive ways and can be demanding and manipulative. Counseling focus is to stress their ability to survive using resources that have been helpful to them in the past.

Callers agenda - obsessive compulsive
Preoccupied and fixate on tasks. Expend and waste time and energy on these endeavors. Do not hear counselors because of their futile attempts to obtain self-control over their obsessions. Counseling focus is to establish the ability to trust others and the use of thought stopping and behavior modification to diminish obsessive thinking and compulsive behavior.

Callers agenda - bipolar (manic depressive)
Extreme mood swings. Manic phase to depressive phase. Counseling focus is to slow down and pace the client. Confrontation of grandiose plans only alienates them. In depressive stage, suicide prevention is a primary priority.

Callers agenda - dependent
Trouble making decisions and see to have others to do. Feelings of worthlessness, insecurity, fear of abandonment. Prone to become involved and stay in self-destructive relationships. Counseling focus is to reinforce strengths and act as a support for their concerns without becoming critical of them or accepting responsibility for their lives.

Callers agenda - self defeating
Choose people and situations that lead to disappointment, failure and mistreatment by others. Reject attempts to help them and make sure that such attempts will not succeed. Counseling focus is to stress talents and the behavioral consequences of sabotaging them.

Callers agenda - avoidant
Loners who have little ability to establish or maintain social relationships. Fear of rejection paralyzes their attempts to risk involvement in social relationship. Counseling focus is to encourage successive approximations to meaningful relationships through social skills and assertion training.

Callers agenda - passive aggressive
Cannot risk rejection by displaying anger in an overt manner. Rather, they engage in covert attempts to manipulate others and believe that control is more important than self-improvement. Counseling focus is to promote more open, assertive behavior.

Callers agenda - borderline
Chameleon-like and at any given time may resemble any mental disorder. Always at the borderline of being functional and dysfunctional.

Underreporting
50 - 90% of all rapes or attempted rapes go unreported. Date rapes and stranger rapes are not reported out of shame, humiliation, cultural taboos and fear of secondary victimization at the hands of medical and legal authorities. This disparity suggests that only 1 in 9 rapes is actually reported.

Defining rape
-Unwanted act of oral, vaginal or anal penetration committed through the use of force, threat of force or when incapacitated; sexual assault refers to a broader range of criminal offenses such as sexual battery and sexual coercion up to and including rape.

Dynamics of rape
Psychosocial, cultural and personal attitudes of both males and females.

Social/cultural factors of rape

1. Gender inequality - economic, political and legal status of women in comparison to men

2. Pornography - reduces women to sex objects, promotes male dominance and encourages or condones sexual violence against women

3. Social disorganization - erodes social control and constraints and undermines freedom of individual behavior and self determination

4. Legitimization of violence - the support the culture gives to violence as portrayed in the mass media, laws permitting corporal punishment in schools, violent sports, military exploits and video games.

Personal and psychological factors of rape - The male offender:

1. Hostile, aggressive, angry, condescending, domineering and believes he is strong, courageous and manly although he often feels weak, anxious, inadequate, threatened and dependent and believes women are inherently dangerous.

2. Lacks interpersonal skills to make his point in society, particularly with women.

3. Need to exercise power to prove to himself and to the victim that he is powerful and in control.

4. Sadistic patterns, extreme violence and mutilates or murders the victim in order to attain a feeling of triumph over the victim.

5. Sees women as sex objects and his urges are uncontrollable and all consuming.

6. Holds stereotypical views of male/female roles.

7. Chronic feelings of anger, hostility and fear towards women and seeks to control them by his sexual conquests.

Personal and psychological factors of rape - rapist's reasons for assault:

1. Use rape to punish or exact revenge because a specific woman has done them wrong. See all women as responsible for one woman's supposed transgressions.

2. Added bonus - it's here for the taking, so why not?

3. Attaining the unattainable - a woman they would otherwise never have a chance with.

4. Impersonal experience and preferred over any demonstrated caring or mutual affection. No obligations.

5. Gang rapists - see rape as recreation, adventure and proving they are macho. Male bonding.

Myths about rape

1. It's just rough sex.

2. Women cry rape to gain revenge.

3. Motivated by lust.

4. Rapists are weird, psychotic loners.

5. Victims provoked the rape or wanted to be raped.

6. Only bad women are raped.

7. Real rapes only happen in bad parts of town at night in abandoned buildings or lonely fields by strangers or have knives or guns and who engage in brutally beating the victims when they resist heroically, even unto death

8. If the woman doesn't resist, she must have wanted it.

Myths about males and sexual assault

1. Boys and men cant be willing victims

2. Homosexuals are usually perpetrators of sexual abuse of boys.

3. Boys are less traumatized than girls.

4. Boys abused by males will later become homosexuals.

5. Vampire/zombie syndrome - once you get bitten, you become one.

6. If a boy or girl experiences sexual arousal or orgasm from abuse this means he enjoys it.

7. If the perpetrator is female, the boy just got lucky.

Survivors of childhood sexual abuse
If survivors are left untreated, they may experience recurring episodes of revictimization and exhibit debilitating symptoms (transcrisis points) for many years.

Effects of sexual abuse on adult survivors

1. Depression, anxiety, shame, humiliation.

2. Borderline personality disorder, dissociative disorder and PTSD.

3. Social stigmatization, alienation, inhibitions, introversion and interpersonal hypersensitivity.

4. More contacts with medical doctors for somatic complaints including chronic pain problems such as fibromyalgia and irritable bowel syndrome and long term physical health deficits.

5. Negative self image, poor interpersonal relationships and poor parenting skills and suicide.

Child abuse as a predictor of PTSD
-Child abuse has been shown to predict the development of PTSD later in life.
-A younger age of onset of sexual abuse and coercion to maintain secrecy predicted a higher number of total diagnoses.
-Children had more diagnoses when physical abuse had come from males rather than females.
-Adding sexual assault during the rape of children was predictive of chronic PTSD.
-Developmental processes associated with affect regulation and interpersonal relationships skills may be severely disrupted and pave the way for future assaults.

Grounding
-Refocuses clients' attention onto the immediate therapeutic environment or when over the phone or internet, on the physical surroundings they are presently inhabiting as opposed to flashbacks, intrusive thoughts and dissociative states that are beginning to overwhelm them.
-Critical component in which clients are taught to put their feet on the ground, get physically and psychologically anchored and stop the fragmentary thought processes and heightened affect that lead to depersonalization, flashbacks and overpowering emotions.

Grounding steps

1. Attempt to focus the client's attention on the therapist - I am right here, we are together in this room and we are doing exposure therapy. You are not back in the bedroom 20 years ago

2. Ask the client to describe the internal experience he or she is presently having - Describe whats going on right now.

3. Orient the client to the immediate environment that he or she is in- the room with the worker, where it is, how it looks, whats in it and how safe it is and that it is not in the bedroom 20 years in the past.

4. If the client is still indicating stress, start deep breathing and relaxation techniques (teaching these techniques to the client is reccommended).

5. Repeat step 2 and assess the clients ability to return to therapy.

Validation
As a client starts through the process of therapy, numerous transcrisis points will occur as long-buried trauma is brought back to wareness. In an active, directive, continuous and reinforcing manner, the human services worker:


1. Validates that the abuse did happen, despite denial of this fact by significant others; the client is not to blame, it is safe to talk about it and the worker does not loathe the client for having been a participant.

2. Acts as an advocate who is openly, warmly interested in what happened to the survivor as a child and makes owning statements to that effect but still maintains neutrality and neither advocates for nor dismisses legal action The worker also understands there is a high potential for transference/countertransference and is clear and consistent in maintaining boundaries.

3. Reinforces the resourcefulness of the victim to become a survivor.

4. Provides a mentor/reparenting role model to help with childhood developmental tasks that were missed.

Extinguishing trauma
-Facilitating the reduction or loss of a conditioned response as a result of the absence or withdrawal of reinforcement.
-When working through the traumatic events, the client will experience a dramatic increase in affective and autonomic arousal. The social worker must be very careful to provide palatable doses of the traumatic material that do not exceed the client's coping abilities and prompt a crisis within the therapy session. Careful processing with the client before and after each session of extinguishing and reframing traumatic memories is important in preventing such crises.
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Cognitive restructuring
Reframing the client's negative and distorted beliefs about him or herself is critical in allowing the client to separate the fact and fiction of an abusive childhood.

Grief resolution
Client comes to grips with the reality that there is no retrieving the past or changing it and that attempts to do so are fruitless. Only the future holds promise for he/she and he/she can control only that.

Changing behavior through skill building and reconnecting

1. Changing behavior to more self-determining choices is the major end goal of therapy.

2. Reeducation is necessary for survivor skill building.

3. Important to urge survivors to join therapy or support groups so that new behaviors can be tested out and discussed with peers.

4. As survivors reconstruct their lives and start to become interested in developing meaningful relationships, there are 5 basic fears that they will have to deal with: abandonment, exposure, merger, attack, and their own destructive behavior.

Benefits of group treatment

1. The individual's sense of shame, stigmatization, and negative self image are reduced by meeting other survivors who appear normal.

2. Commonality of experience raises members' consciousness about incest, so the experience becomes more normalized and may be seen from an interpersonal and sociocultural perpsective rather than an only me perspective.

3. The group serves as a new surrogate family where new behaviors and methods of communicating , interacting and problem solving can be practiced in a safe, accepting and nurturing environment.

4. The group allows for safe exploration and ventilation of feelings and beliefs that have been denied and submerged from awareness.

5. Childhood messages and rules that were generated within the abusive environment can be challenged and dissected to determine how they still influence the survivor's maladaptive patterns.

Dynamics of sexual abuse in families

1. Do not show feelings, especially anger.

2. Be in control at all times, do not ask for help.

3. Deny what is happening and do not believe your own senses/perceptions.

4. No one is trustworthy

5. Keep the secret because no one will believe you anyway.

6. Be ashamed of yourself, you are to blame for everything.

Phases of childhood sexual abuse

1. Engagement

2. Sexual interaction

3. Secrecy

4. Disclosure

5. Suppression

6. Survival

Conceptual Approaches to Bereavement

1. Kubler-Ross's Stages

2. Bowlby's Attachment Theory

3. Schneider's Growth Model

4. The Dual Process Model

5. The Adaptive Model

Grief Assessment Tools

1. The Texas revised inventory of grief (trig)

2. Grief experience inventory (gei)

3. Hogan grief reaction checklist (hgrc)

4. Inventory of complicated grief (icg)

Kubler-Ross's Stages
Views loss as a series of 5 stages that people go through as they come to grips with their own imminent death:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Little empirical evidence to substantiate its use and it causes problems when people stubbornly refuse to move through its