Crisis intervention

Crisis Intervention can be defined as emergency psychological care aimed to assist individuals in returning to normal levels of functioning and to prevent or alleviate potential negative psychological trauma. Crisis can be defined as one’s perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms. The priority of crisis intervention/counseling is to increase stabilization. Crisis interventions occur at the spur of the moment and in a variety of settings, as trauma can arise instantaneously. Crisis counselors must keep in mind that crises are temporary, no longer than a month, although the effects may become long-lasting.

Types of crisis
Crises can occur on a personal or societal level. Personal Trauma is defined as an individual’s experience of a situation or event in which he/she perceives to have exhausted his/her coping skill, self-esteem, social support, and power. These can be situations where a person is making suicidal threats, experiencing threat, witnessing homicide or suicide, or experiencing personal loss. While a person is experiencing a crisis on the individual level it is important for counselors to primarily assess safety. Counselors are encouraged to ask questions pertaining to social supports and networks, as well as give referrals for long term care.

Societal or mass trauma can occur in a number of settings and typically affect a large group or society. These are instances such as school shootings, terrorist attacks, and natural disaster. A counselor’s primary concern when call to these types of crises is to assess people’s awareness of resources. Individuals experiencing trauma in large scales need to be aware of shelters that offer food and water; places that met their basic necessities for survival.

Typical responses to crisis
Counselors are encouraged to be aware of the typical responses of those who have experienced a crisis or currently struggling with the trauma. On the cognitive level they may blame themselves or others for the trauma. Oftentimes the person appears disoriented, becomes hypersensitive or confused, has poor concentration, uncertainty, and poor troubleshooting. Physical responses to trauma include: increased heart rate, tremors, dizziness, weakness, chills, headaches, vomiting, shock, fainting, sweating, and fatigue. Some emotional responses the person may experiences consist of apathy, depression, irritability, anxiety, panic, helplessness, hopelessness, anger, fear, guilt, and denial. When assessing behavior some typical responses to crisis are difficulty eating and/or sleeping, conflicts with others, withdrawal from social situations, and lack of interest in social activities.

Universal principles of crisis intervention
While dealing with crisis, both personal and societal, there are five basic principles outlined for intervention. Victims are initially at high risk for maladaptive coping or immobilization. Intervening as quickly as possible is imperative. Resource mobilization should be immediately enacted in order to provide victims with the tools they need to return to some sort of order and normalcy, in addition to enable eventual independent functioning. The next step is to facilitate understanding of the event by processing the situation or trauma. This is done in order to help the victim gain a better understanding of what has occurred and allowing him or her to express feeling about the experience. Additionally, the counselor shoule assist the victim(s) in problem solving within the context of their situation and feelings. This is necessary for developing self-efficacy and self-reliance. Helping the victim get back to being able to function independently by actively facilitating problem solving, assisting in developing appropriate strategies for addressing those concerns, and in helping putting those strategies into action. This is done in hopes of assisting the victim to become self-reliant.

General approach to crisis intervention
The ACT model of crisis intervention developed by Roberts as a response to the September 11, 2001 tragedy outlines a three stage framework:Assessment Crisis Intervention Trauma Treatment (ACT). This theory of crisis intervention integrates numerous assessment tools and triage procedures; Roberts’ seven stage crisis intervention model and the ten step acute traumatic stress management protocol creates one comprehensive model for responding to crisis that can be utilized in most all crisis situations. It is important to note that this should be followed as a guide not to be followed rigidly.

The first step is the assessment stage; this is done by determining the needs of victims, other involved persons, survivors, their families, and grieving family members of possible victim(s) and making appropriate referrals when needed. Three types of assessments need to be conducted. The first is triage assessment, which is an immediate assessment to determine lethality and determine appropriate referral to one of the following: emergency inpatient hospitalization, outpatient treatment facility or private therapist, or if no referral is needed. A crisis assessment also needs to be completed which consists of gathering information regarding the individual’s crisis state, environment, and interpersonal relationships in order to work towards resolving the current crisis. This step helps facilitate development of an effective and appropriate treatment plan. The last area of assessment includes a biosocial and cultural assessment. This would be completed by using systematic assessment tools to ascertain the client’s current level of stress, situation, present problem, and severe crisis episode.

The goal of the crisis intervention stage of Robert’s ACT model is to resolve the client’s presenting problems, stress, psychological trauma, and emotional conflicts. This is to be done with a minimum number of contacts, as crisis intervention is intended to be time limited and goal directed.Stage one of the seven step approach focuses on assessing lethality. The clinician is to plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment; this should be done promptly at the time of arrival. Once lethality is determined one should establish rapport with the victim(s) whom the clinician will be working with. The next phase is to identify major problem(s), including what in their life has led to the crisis at hand. During this stage is it is important that the client is given the control and power to discuss their story in his or her own words. While he or she is describing the situation the intervention specialist should develop a conceptualization of the clients “modal coping style”, which will most likely need adjusting as more information unfolds, this is referred to as stage three. As a transition is made to stage four feelings will become prevalent at this time thus deal with those feelings will be an important aspect of the intervention. While managing the feelings the counselor must allow the client(s) to express his or her story, and explore feelings and emotions through active listening and validation. Eventually, the counselor will have to work carefully to respond to the client using challenging responses in order to help him or her work past maladaptive beliefs and thoughts, and to think about other options. At step five, the victim and counselor should begin to collaboratively generate and explore alternatives for coping. Although this situation will be unlike any other experience before the counselor should assist the individual in looking at what has worked in the past for other situations; this is typically the most difficult to achieve in crisis counseling. Once a list has been generated a shift can be made to step six, development of a treatment plan that serves to empower the client. The goal at this stage it to make the treatment plan as concrete as possible as an attempt to make meaning out of the crisis event. Having meaning in the situation is an important part of this stage because it allows for gaining mastery. Finally, step seven, the intervention specialist is to arrange for follow-up contact with the client to evaluate his or her post crisis condition in order to make certain resolution towards progressing. The follow up plan may include “booster” sessions to explore treatment gains and potential problems.

After the situation has been assessed and crisis interventions have been applied the aim is at eliminating PTSD symptoms, thus treating the traumatic experience. A comprehensive view of how to treat the trauma consists of ten stages outlined by Lerner and Shelton (2001). These steps relate similarly to the crisis intervention steps. The first step is to assess for danger/safety for self and others, this means for the victim, counselor, and others who may have been effected by the trauma. Then the counselor should consider the physical and perceptual mechanisms of injury. Once injury is assessed the victim’s level of responsiveness should be evaluated and any medical needs should be addressed. Each individual who witnessed or is experiencing a crisis should be observed to identify his or her sign’s of traumatic stress. After the assessment of the situation is completed the interventionist should introduce his or her self, state their title and role, and begin building rapport. Building this relationship allows for a more fluid approach to grounding the individual, this can be done by allowing him or her to tell his or her story. Again, the counselor is encouraged to provide support through active and empathetic listening, normalize, validate, and educate. Finally, the intervention specialist is to bring the person to the present, describe future events, and provide referrals as needed.

Criticisms
Critical incident debriefing is a widespread approach to counseling those in a state of crisis. This technique is done in a group setting 24–72 hours after the event occurred, and is typically a one-time meeting that lasts 3–4 hours, but can be done over numerous sessions if needed. Debriefing is a process by which facilitators describe various symptoms related PTSD and other anxiety disorders that individuals are likely to experience due to exposure to a trauma. As a group they process negative emotions surrounding the traumatic event. Each member is encouraged continued participation in treatment so that symptoms do not become exacerbated.

Critical incident debriefing has been criticized by many for its effectiveness on reducing harm in crisis situations. Some studies show that those exposed to debriefing are actually more likely to show symptoms of PTSD at a 13 month follow-up than those who are not exposed to the debriefing. Most recipients of debriefing reported that they found the intervention helpful. Based on symptoms found in those who received no treatment at all, some critics state that reported improvement is considered a misattribution, and that the progress would naturally occur without any treatment.