Study Guide for Crisis Intervention Strategies Flashcards
What is Advocacy?
Supporting and promoting the needs of clients (individuals, groups and communities) and the counseling professions at all levels (local, state, regional and national).
Examples include teaching clients to self-advocate, being involved in changes in public policy, writing policymakers, etc. Can take many forms, such as educating people about the counseling profession, providing leadership and advocacy training, networking with the media to have imp. issues covered, and working w/community organizations to meet the needs of clients.
Trauma Informed Advocacy is the assessment of an individual’s unique trauma symptoms to service a plan for the client to effectively reduce symptoms that are biological, psychological, and social. See p. 11 in NCE book for more, 1.1.4
Definition of Crisis
A crisis is a time-limited period of disequilibrium caused by a precipitating event (stressor) that temporarily affects an individual’s normal coping abilities, rendering him or her inadequate in dealing with circumstance.
Importantly, crises have potential for both negative outcomes and positive growth.
Eric Lindemann was a pioneer in the development of crisis models, having treated and studied survivors of the famous Cocoanut Grove Nightclub fire of 1942 in which 493 people perished (Lindemann, 1944). He observed that mental health professionals can help those people affected by traumatic events to grieve and mourn properly, thereby preventing further mental health complications.
His colleague, Gerard Caplan, expanded Lindemann’s work by applying public health and preventive psychiatry principles.
Aspects of a Crisis
A period of intense distress when normal stress management and solution-finding skills are not adequate for the situation - that is the perceived or actual stressors exceed perceived or actual resources. Although a crisis is considered short-term, a trauma consists of a longer-term crisis for which thee is not resolution or balance of stressors and available resources.
Acute Phase
Initial crisis reactions in response to a traumatic event usually encompass
the physiological and psychological realm. Reactions include overwhelming
anxiety, despair, hopelessness, guilt, intense fears, grief, confusion, panic,
disorientation, numbness, shock, and a sense of disbelief. In this acute stage
of crisis, the victim may appear incoherent, disorganized, agitated, and
volatile. Conversely, the victim may present as calm, subdued, withdrawn,
and apathetic.
Outward Adjustment Phase
For some people, the outward adjustment phase can begin within
24 hours of the trauma. The individual may then attempt to gain mastery
by resuming external control through engaging in routine activities (Yassen
& Harvey, 1998). However, this should not preclude the possibility that
victims who outwardly appear to be “back to normal” may inwardly
remain “deeply affected.” Other victims isolate themselves from sources of
support; they may appear to have withdrawn from society completely. The
tension and fluctuating reactions involved in this phase should be noted as
an attempt to return to normal while still processing the trauma.
Integration Phase
In this phase, the victim attempts to make sense of what has happened.
An important task of this phase is to resolve one’s sense of blame and guilt.
Individuals who can recognize and identify the assumptions about their
world and others that have changed because of the trauma develop a sense
of integration sooner. Most importantly, clients should begin to make the
changes necessary to minimize the recurrence of a crisis.
Some clients will cycle and recycle through these phases as they attempt
to come to terms with their trauma. There are also those clients who cycle
through phases too quickly or even skip a phase altogether. It may come as
no surprise to find these clients later overwhelmed.
Aspects of listening - What happened to you? not What’s wrong with you?
Listening involves focusing, observing, understanding and responding with empathy, genuineness, respect, acceptance, non-judgment and sensitivity.
Listening strategies include:
Using open-ended questions
Using close-ended questions to seek specific details, designed to encourage specific sharing, Used to gather specific information or to understand person’s willingness to commit to a particular action (e.g. to complete a safety plan).
Restating and clarifying what has been said can help clarify whether worker has an accurate understanding of what survivor intended to say, feel, think and do. Restating can also be used to focus the discussion on a particular topic, event or issue.
Owning feelings and using statements that start with “I” in crisis intervention can help provide direction by being clear about what will occur (e.g. ‘I am going to explain the steps we will take today’), what is being asked of the survivor (e.g. ‘I would like to ask whether you agree to the steps I have described’).
Facilitative listening helps to build trust and strengthen relationship with trauma survivor. It involves focusing entirely on the experience by: Noticing verbal and nonverbal communication. For example, “I noticed that when you talked about the time you spent with your daughter, your eyes lit up and there was excitement in your voice.”
Notice when survivor is ready to make emotional or physical contact.
Use non-verbal cues to show that you are listening (e.g. by nodding the head, making eye contact, facing the woman).
Boundaries in crisis work
In rating clients on the TAF, we move from high to low. This backward rating process may seem confusing at first glance, but the idea is that we rule out more severe impairment first. So if we were rating affect, we would first look at whether the client fits any of the descriptors under Severe Impairment. If not, we would then consider the descriptors under Marked Impairment.
If we were able to check off at least two of those descriptors, the client would receive a rating of 9. If we could identify fewer than two of the descriptors, the client would receive an 8. We would repeat this rating process across all three dimensions to obtain a total rating. Based on the total rating, which will range from 3 to 30, we generally group clients into three categories.
A 3–10 rating means minimal impairment; these clients are generally self-directing and able to function effectively on their own.
A rating of 11–19 means that clients are more impaired; they may have difficulty functioning on their own and need help and direction. This midscore range is the most problematic as far as disposition of clients is concerned.
Low teen scores (11–15) call for at least some guidance and directiveness from the worker to get the client on course as opposed to a single-digit score where the client can be pretty much self-directed with minimal guidance and information.
High teen scores (16–19) are indicative of clients who are losing more and more control of their ability to function effectively and call for a good deal more than passive and palliative responses from the worker so that they do not escalate into 20 territory.
CLARITY IN SETTING BOUNDARIES AND FINDING SPECIFIC AND CONTINUOUS SUPPORT SYSTEMS FOR THE IMMEDIATE FUTURE IS GENERALLY CALL FOR WHEN SCORES FALL INTO THIS RANGE.
Clients with a total score of 20 or above are moving deeper into harm’s way; they are likely to need a great deal of direction and a secure and safe environment so they do not escalate into the lethal range. Scores in the high 20s almost always mean that some degree of lethality is involved, whether it is premeditated or clients are simply so out of control that they cannot stay out of harm’s way.
Rating clients on the triage scale also means rating the crisis worker! How is this so? If the worker is effective in stabilizing a client, the triage scale score should go down. If it does not, then the worker probably needs to shift gears and try another approach. While the TAF is not absolutely precise and is not intended to be, it does give a good numerical anchor that the crisis worker can use in making judgments about client disposition and the effectiveness of the intervention. Our students very quickly become skillful at making these ratings on sample cases, and so will you.
Burnout -
Burnout is exhaustion stemming from repeated exposure to stressful circumstances that result in emotional exhaustion, depersonalization, and reduced personal accomplishment. Crisis counselors repeatedly encounter stressful client circumstances and normal counselor coping mechanisms may not serve as persistent protective factors. (ongoing occupational stress). NCE p. 88, 100, 101 (table 4.1)
2.) Burnout (cont.)
PERSONALITY FACTORS
Type A personality characteristics (e.g., perfectionist, compulsive, and competitive)
Neuroticism: the tendency to experience negative emotional states such as anxiety, anger, guilt
Orientation to achievement
Low self-esteem
External locus of control
ORGANIZATIONAL FACTORS
Work overload
Lack of employee autonomy
Insufficient reward
Absence of fairness
Conflicting employee and organizational values
Poor communication
Lack of clarity regarding one’s role in the organization
Myths that engender burnout
“My job is my life.” This means long hours, no leisure time, and difficulty delegating authority. Anxiety, defensiveness, anger, and frustration are the result when things do not go perfectly.
“I must be totally competent, knowledgeable, and able to help everyone.” Unrealistic expectations of performance, a need to prove oneself, lack of confidence, and overriding guilt occur when one is not perfect.
“To accomplish my job and maintain my own sense of self-worth, I must be liked and approved of by everyone with whom I work.” Such workers cannot assert themselves, set limits, say no, disagree with others, or give negative feedback. Therefore, they get manipulated by others in the work setting—including by clients. Self-doubt, passive hostility, insecurity, and subsequent depression are the reward.
“Other people are hardheaded and difficult to deal with, do not understand the real value of my work, and should be more supportive.” Stereotyping and generalizing about specific problems and people occur, and lack of creativity, wasted energy, and decreased motivation result. The person has a defeatist attitude and a passive acceptance of the status quo.
“Any negative feedback indicates there is something wrong with what I do.” The person cannot evaluate his or her work realistically and make constructive changes. There is a great deal of anger with critics, which may manifest itself in either passive or aggressive hostility, depending on the person toward whom the anger is directed. Frustration and immobilization are the outcomes.
“Because of past blunders and failures by others, things will not work the way they must.” Old programs are not carried to fruition, nor are new ones created. Stagnation and decay in the work setting are the result.
“Things have to work out the way I want.” The person’s behavior is thus characterized by working extra hours and checking up on staff members’ work, an inability to compromise or delegate, over attention to detail, repetition of tasks, impatience with others, and an authoritarian style.
“I must be omniscient and infallible.” The person can never be wrong. The very act of doing therapy with humans in all their infinite ways of behaving means fallibility for the worker, particularly when the client is in crisis.
Chronosystem
Bronffenbrenner (1978) proposed a systems perspective to explain the processes that occur between people and their environments.
Microsystem-(e.g., family), mesosystem - (e.g., communities), exosystem - (e.g., local and global economies), macrosystem (e.g., political organizations), and chronosystem ( e.g., historical eras).
Complicated Grief - the study of grief is known as thanatology
Listed as “Persistent Complex Bereavement Disorder” (DSM-5, p. 789-792.)
The nature and severity of grief is beyond expected norms for the relevant cultural setting, religious group, or developmental stage.
Can occur at any age after the age of 1. Includes a heightened dependency on the deceased person -persistent after 12 months (6 months for children).
Complicated grief is like being in an ongoing, heightened state of mourning that keeps you from healing. Signs and symptoms of complicated grief may include: Intense sorrow, pain and rumination over the loss of your loved one. Focus on little else but your loved one’s death.
People with complicated grief experience prolonged grieving that causes distress and impairment that can affect both physical and mental health (Shear & Mulhare, 2008).
Countertransferance
A psychoanalytic term used to describe the emotions and fantasies a counselor unconsciously transfers to the client. Typically, these feelings stem from the counselor’s own unresolved conflicts and past relationships.
Crisis Intervention Models
Five fundamental crisis intervention models are equilibrium, cognitive, psychosocial transition, developmental-ecological, and contextual-ecological.
Crisis Intervention - Equilibrium Model
The equilibrium model, probably the most widely known model of the five, defines equilibrium as an emotional state in which the person is stable, in control, or psychologically mobile. It defines disequilibrium as an emotional state that accompanies instability, loss of control, and psychological immobility.
Crisis Intervention - Psychosocial
The Psychosocial Transition Model
The psychosocial transition model assumes that people are products of their genes plus the learning they have absorbed from their particular social environments. Because people are continuously changing, developing, and growing, and their social environments and social influences (Dorn, 1986) are continuously evolving, crises may be related to internal or external (psychological, social, or environmental) difficulties.
The psychosocial model does not perceive crisis as simply an internal state of affairs that resides totally within the individual. It reaches outside the individual and asks what systems need to be changed. Peers, family, occupation, religion, and the community are but a few of the external dimensions that promote or hinder psychological adaptiveness.
With certain kinds of crisis problems, few lasting gains will be made unless the social systems that affect the individual are also changed, or the individual comes to terms with and understands the dynamics of those systems and how they affect adaptation to the crisis. Like the cognitive model, the psychosocial transition model seems to be most appropriate after the client has been stabilized. Theorists who have contributed to the psychosocial transition model include Adler (Ansbacher & Ansbacher, 1956), Erikson (1963), and Minuchin (1974).
Client Assessment during crisis - six steps
James and Gilliland six-step model for assessing client needs during a crisis
-Define the problem
client’s conceptualization and perception of it as crisis vs. obstacle. Validate
client. Examine the seriousness of crisis, client’s emotional state, behavior
impairment or cognitions, and any potential threats of harm to self or others.
-Ensure client safety
ongoing process re: mental and physical safety. Ethical standards of
reporting. Be in touch with law enforcement, medical, child protective
services, etc. to collaborate on plan of action for client to follow.
-Provide support
A counselor should support regardless of actual even or client’s W.V. Use
unconditional positive regard or empathy.
-Examine alternatives
Help make decisions overwhelming or not poss. for client. Working list with
client to choose appropriate action. Empower, don’t railroad.
-Make plans
After examining alternatives. Help client to discover support system (family,
friends, community) and come up with uplifting behaviors (exercise,
journaling). Imp. for client to establish a sense of control by being involved
in devising these plans.
-Obtaining commitment.
Ensure the client will stick to the plan and commit to reasonable action to
begin to get life back on track.
