74,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The fast-paced, unpredictable, and high-risk nature of crisis intervention creates critical ethical dilemmas that can result in personal harm and professional liability if not handled appropriately. Applying a traditional model of ethical decision-making is often impractical when time is limite and decisions must be made quickly. This counseling tool kit offers a new operational approach for integrating ethical decision-making in crisis intervention. Following detailed discussions of crisis intervention within the framework of realtional-cultural theory, a triage assessment system, and an original ethical decision-making protocol, nine diverse case studies in hospital, telebehavioral health, school, clinical, and public settings are presented. Students and practitioners will build a repertoire of ethical decision-making skills to de-escalae crisis incidents and provide an appropriate level of support to individuals experiencing crisis.
*Requests for digital versions from ACA can be found on www.wiley.com
*To purchase print copies, please visit the ACA website
*Reproduction requests for material from books published by ACA should be directed to [email protected]
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 562
Veröffentlichungsjahr: 2021
Ähnliche
Table of Contents
Cover
Title Page
Copyright Page
Dedication Page
Preface
Chapter Overviews
Acknowledgments
About the Authors
CHAPTER 1: Crisis Roots and Building Blocks
You Say You Want to Work in Crisis Intervention
Crisis Defined
A Brief History of Crisis Intervention
The Future Is Now
Crisis and the Tools That Go With It
Conclusion
CHAPTER 2: Assessment in Crisis Intervention
Triage Assessment in Crisis Intervention
Case Application of the TAF: CIR
SAFETY Locations of Diversity in Crisis Intervention
Integrating and Applying the SAFETY Locations and the TAF: CIR
Conclusion
CHAPTER 3: Ethics and Crisis Intervention
History
Crisis Is Missing
A Crisis Is Not an Ordinary Event
Theoretical Framework for the Ethical Delivery of Crisis Intervention
LASER Protocol and Crisis Intervention
CASE STUDYCasey
Backdrop of Personal Beliefs
Legal Issues
Assessment
Setting
Ethical Principles
Resolution
Conclusion
CHAPTER 4: Instruction for Case Studies
Responding to the Questions
Heads Up!
SAMPLE CASE STUDYDisaster Reception Center
Part I Questions
Composite Summary and Analysis for Part I
SAMPLE CASE STUDYDisaster Reception Center
Part II Questions
Composite Summary and Analysis for Part II
Part III Questions
CHAPTER 5: Case Studies
CASE 1 Hospital Pandemic: Daniel
CASE 3 Metastasizing School Crisis: Sweathogs
CASE 4 Partial Hospitalization: Chen
CASE 6 Public Setting: Contagious Lee
CASE 7 School Counseling Transcrisis: Desperate Josh
CASE 8 Family Crisis: Tangled Web
CASE 9 Community Crisis: Disoriented Roger
CHAPTER 6: Case Commentaries
CASE 1 Hospital Pandemic: Daniel
CASE 2 Telebehavioral Health: Disgruntled Jacob
CASE 3 Metastasizing School Crisis: Sweathogs
CASE 4 Partial Hospitalization: Chen
CASE 5 School Crisis: Complicated Romance
CASE 6 Public Setting: Contagious Lee
CASE 7 School Counseling Transcrisis: Desperate Josh
CASE 8 Family Crisis: Tangled Web
CASE 9 Community Crisis: Disoriented Roger
APPENDIX A: Triage Assessment Form: Crisis Intervention (Revised)Triage Assessment Form: Crisis Intervention (Revised)
APPENDIX B: Format for Critical Thinking in Ethical Decision-MakingFormat for Critical Thinking in Ethical Decision-Making
Part I Questions
Part II Questions
Part III Questions
References
Index
Technical Support
End User License Agreement
List of Illustrations
Chapter 3
FIGURE 3.1 LASER Protocol for Ethical Decision-Making in Crisis Intervention
Guide
Cover Page
Title Page
Copyright Page
Dedication Page
Preface
Acknowledgments
About the Editors
Table of Contents
Begin Reading
Triage Assessment Form: Crisis Intervention (Revised)
Format for Critical Thinking in Ethical Decision-Making
Bibliography
Index
Technical Support
WILEY END USER LICENSE AGREEMENT
Pages
i
ii
iii
vii
viii
ix
x
xi
xiii
xv
xvi
xvii
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
CRISIS INTERVENTION
Ethics Casebook
Rick A. MyerJulia L. WhisenhuntRichard K. James
American Counseling Association2461 Eisenhower Avenue ◆ Alexandria, VA 22331www.counseling.org
Copyright © 2022 by the American Counseling Association. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the written permission of the publisher.
AMERICAN COUNSELING ASSOCIATION2461 Eisenhower Avenue ◆ Alexandria, VA 22331
Associate Publisher ◆ Carolyn C. Baker
Digital and Print Development Editor ◆ Nancy Driver
Senior Production Manager ◆ Bonny E. Gaston
Copy Editor ◆ Kay Mikel
Cover and text design by Bonny E. Gaston
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA
Names: Myer, Rick, author. | Whisenhunt, Julia, author. | James, Richard K., 1942- author.Title: Crisis intervention ethics casebook / Rick A. Myer, Julia L. Whisenhunt, and Richard K. James.Description: Alexandria, VA : American Counseling Association, [2022] | Includes bibliographical references and index.Identifiers: LCCN 2021033772 | ISBN 9781556203961 (paperback)Subjects: LCSH: Crisis intervention (Mental health services) | Crisis intervention (Mental health services)—Moral and ethical aspects—Case studies.Classification: LCC RC480.6 .M942 2022 | DDC 362.2/04251—dc23LC record available at https://lccn.loc.gov/2021033772
Dedication
This book is dedicated to everyone who has helped someone through a crisis. We thank professional counselors and other human service professionals who encounter clients in crisis on a daily basis, health care workers in emergency rooms and other health care settings who assist patients and families in times of crisis and trauma, and a special thanks to first responders such as law enforcement officers, firefighters, EMTs, and anyone else who is on the front lines helping people in crisis. Thank you for your service and dedication in helping others when they cannot help themselves.
Preface
This introduction provides material that is going to be important for you to know when you build your own crisis intervention counseling tool kit. We cover stuff here that nobody told you about; and you are bound to encounter situations similar to those described in the case studies sooner or later—our bet is probably sooner rather than later. If you’re a veteran crisis worker, we hope these decision-making tools will help you when you’re rubbing your chin and scratching your head amid chaos and tough ethical decisions have to be made.
This casebook focuses on the reality of stepping out into the gritty real world of doing crisis work when everything is going haywire. If you are already in practice, you may feel that we’re preaching to the choir. In this casebook, we go far beyond the everyday grind of therapy and explore what happens when all hell breaks loose and even the most seasoned crisis workers can become frozen and transfixed with indecision. At that point, chaos theory overrides every counseling theory and technique you thought you knew. You may resemble a deer frozen in the headlights, paralyzed with indecision regarding your therapeutic approach, the ethical problems that go with it, institutional policies that countermand it, and political realities that negate it. Think that won’t happen to you? We sure hope it won’t, but it has happened to us. So we also explore how to respond ethically when faced with potential legal and political ramifications for actions taken in response to a crisis situation. Our hope is that what you learn in these cases will help change immobility to action as you confront similar situations.
This casebook is about crises. It is not about trauma or disaster, although crises certainly occur in both. Overlap exists in these three areas, but crisis intervention counseling practiced during traumatic events ranging from lethal auto wrecks to natural disasters is very different from long-term trauma therapy. Crisis intervention may include assisting someone who is suicidal or homicidal, but it also includes non-life-threatening situations such as child custody fights, school failure, drug use, and a host of other situational and transient problems (Myer & James, 2007). In contrast, trauma counseling often follows crisis intervention with people who are not able to reestablish a daily routine because the memory of the incident creates an independent schema that affects functioning over a period of time (McFarlane & Yehuda, 1996).
While writing this book, we realized that the application of ethical principles during crisis intervention is awkward at best and nearly impossible in the worst case scenario. How do you maintain confidentiality when working in a Red Cross shelter with a person or family whose house has been destroyed by a wildfire? People are walking around looking for help, and private spaces are rarely available. What can the crisis worker do when someone is unable to make a phone call to get information or much-needed resources? How will the client get the assistance necessary to restore a sense of control? You may need to make that phone call to help the person. Applying ethical principles in crisis intervention is like putting a square peg into a round hole. No matter what you do, there are gaps. Please don’t misunderstand. We are not suggesting that ethical principles do not apply to crisis intervention work. Rather, we are looking for ways to apply ethical principles that make sense in this situation.
We believe that the concepts of relational-cultural theory (RCT) provide a framework that can fill those gaps (Duffey & Haberstroh, 2020; Jordan 2018; J. B. Miller, 1976). RCT was developed by Jean Baker Miller (1976), who understood that emotional relationship needs are important when trying to help women and those in marginalized populations (Duffey & Haberstroh, 2020). The concept of mutual empathy is perhaps most central to RCT. Jordan (2000) described mutual empathy as a relationship in which both people are affected by the other and both people recognize and value the empathic connection. Jordan (2000) further stated that it is necessary for the client to experience or “feel” the counselor’s empathic connection for therapeutic intervention to be effective; counselors should not appear distant, unaffected, or disengaged. Indeed, particularly in times of great distress, clients should feel that they matter.
Since its initial development, RCT has evolved into a model that values using relational mindfulness to guide therapeutic interactions in a safe manner for clients (Jordan, 2018). In various places throughout this book, we address RCT to explain the application of ethical principles in crisis intervention and expand on RCT principles that are germane to crisis intervention. RCT fits well with crisis intervention because it is not so much about techniques as it is about building relationships and bonding, two key ingredients in the fluid environment of a crisis. For a more in-depth analysis of the application of RCT to crisis intervention, see Duffey and Haberstroh (2020).
The fluid environment of crisis work means that the intervention process is not fixed to client type, time, temperature, place, setting, socioeconomic class, or any other definable characteristic. Crisis work may occur in the warm, comfortable confines of an office, or it may occur on a bus, in the middle of a school cafeteria, at a church sanctuary, in a hospital waiting room, at a juvenile inpatient facility, in a house, or on a bridge railing. In addition, in a lot of these places, spectators will be offering their unsolicited advice on how you should solve the problem. What to do in that situation therapeutically and ethically is what this book is about, but don’t expect clear-cut answers. The nature of ethical dilemmas is that what is right and wrong depends, in large part, on the unique situation.
To quote Robert Burns (1785), “The best laid schemes o’ Mice an’ Men gang aft agley. An’ lea’e us nought but grief an’ pain.” What you learned in your legal and ethical issues class may not cleanly or clearly apply in a crisis situation. In a high school hallway with two female gangs getting ready to go at one another, you will have to make rapid decisions to diffuse the situation before it goes viral on social media, and these decisions will have ethical and legal implications. Not only do you have a chaotic crisis to deal with, but you have an ethical Gordian knot (first attributed to Alexander the Great) to untie. We decided to put the two together and make you as formidable as Alexander in your ability to unravel the complex crisis counseling knots you are undoubtedly going to face. That sounds pretty presumptuous of us, doesn’t it?
Chapter Overviews
Chapter 1: Crisis Roots and Building Blocks
We begin by defining the different forms of crises that you will encounter and offer a brief history of how crisis intervention has evolved from a therapeutic backwater to a major new therapeutic field. We introduce you to the tools of crisis intervention work and discuss nine strategies used in crisis intervention and explain how these strategies can be applied. We also introduce some of our “rules of the road” in crisis intervention and their ethical relevance, and we outline protocols for situation-specific, individual, transcrisis, metastasizing, and ecosystemic crises.
Chapter 2: Assessment in Crisis Intervention
In this chapter, we introduce you to two assessment procedures that are at the core of crisis intervention. The Triage Assessment Form: Crisis Intervention (Revised), or TAF: CIR, provides a highly validated, real-time assessment of a client’s affective, behavioral, and cognitive stability. Client scores provide a guide for how directive the crisis counselor needs to be. The TAF: CIR is used throughout the case studies to help you learn to evaluate clients’ reactions and stability across these three domains.
Social locations are a way of looking at a person’s idiosyncratic cultural background, and when making first contact with people in crisis, this is important. The second assessment tool we describe helps crisis workers evaluate clients’ social locations and diversity factors. We introduce you to the SAFETY model, which addresses mental and physical stability, affect, friction, environment, temperament, and yearning. Social locations are critical assessment components in crisis intervention (Brown, 2008), and they provide a different way of looking at multiculturalism that we believe has a great deal of application in the world of the crisis interventionist.
Chapter 3: Ethics and Crisis Intervention
In crisis situations, well-established ethical principles may come into conflict with the legal, moral, cultural, and political dynamics confronting crisis workers, commingling with and confounding the crisis response. We provide an overview of the ethical, legal, moral, cultural, and political issues you are likely to face in crisis intervention work. Nobody talks about the politics that undergirds many crises, but avoiding the politics of a crisis is like putting the proverbial ostrich’s head in the sand. If you ignore the politics in the chaos, all kinds of negative outcomes, including lawsuits and possible job loss, may result.
We introduce you to the LASER protocol in this chapter, a model that fuses Legal Issues, Assessment, Setting, Ethical Principles, and Resolution for in-the-moment ethical decision-making during crisis intervention. This model is an excellent guide for navigating the storming seas of crisis intervention and avoiding a shipwreck on the ethical reefs and shoals. We also discuss the way RCT fits into crisis intervention work and ethical decision-making.
Chapter 4: Instruction for Case Studies
In this chapter, we provide specific details on how we would like you to think about, discuss, and operationalize both intervention strategies and ethical decision-making when you assess the case studies in Chapter 5. Although this “stuff” may seem boring at first glance, and at times excruciatingly grinding in coming to a decision, it is the best way we know to give you the muscle memory to rapidly move through the reservoir of options you have built up when you are faced with a client in crisis. We also include three sets of questions to consider as you read the cases. The first two sets of questions ask you to answer the way you believe the crisis worker in the case would respond. The third set of questions asks you to respond as if you are the crisis worker.
Chapter 5: Case Studies
The nine case studies presented in this chapter take you through the process of ethical decision-making in crisis intervention. The case studies represent a variety of settings and issues that complicate the decision-making process. We created these cases based on our combined experiences in crisis intervention; they do not represent any actual case. Several of the case studies touch on controversial topics, and we use these topics purposefully because crises happen regardless of our political or personal perspectives.
Chapter 6: Case Commentaries
In this chapter, we provide our preliminary analysis for each case study presented in Chapter 5 and explain how crisis intervention skills were utilized or ways the crisis worker could have intervened more effectively. We then walk you through the LASER protocol and highlight some of the primary considerations for each case. Your perspective may differ, and that’s OK. We encourage you to refrain from looking at our commentary until after you make your own assessment of each case. This is your opportunity to apply your understanding of crisis intervention skills and the LASER protocol to the case studies. When you refer to our commentary, you will be able to identify your strengths and growth edges related to ethical decision-making in crisis situations.
Acknowledgments
We would like to acknowledge the students who sat through our courses, especially the crisis intervention courses. Their questions and curiosity helped shaped this book. Many times a simple question challenged our thinking and caused us to do research. This research led to increasing our knowledge and helped us become better instructors. A special thanks to the students in the crisis intervention courses taught in the summer and fall of 2019 at the University of Texas at El Paso. These students helped shape the LASER protocol.
About the Authors
RICK A. MYER, PhD, licensed psychologist, is a full professor and chair of the Department of Educational Psychology and Special Services of the University of Texas at El Paso. He obtained his bachelor’s degree in sociology from Union University in Jackson, Tennessee; a master’s of divinity degree from the Southern Baptist Theological Seminary in Louisville, Kentucky; and a PhD in counseling psychology from Memphis State University (now the University of Memphis). He has taught at Northern Illinois and Duquesne Universities and has 34 years of experience as a counselor educator.
Rick developed the Triage Assessment Form you will be introduced to in this book, and it has been adapted for use in training manuals designed for college environments (Myer et al., 2007), police departments (Myer & Moore, 2006), marriage and family counseling (Myer et al., 2014), and the U.S. Border Patrol (Myer & James, 2017b). He is currently working with the El Paso, Texas, Police Department and Emergence Health Network to develop a crisis intervention team program for El Paso. He also has worked with and trained agents in the U.S. Border Patrol peer support program in advanced crisis intervention skills.
His large-scale disaster crisis intervention skills were refined following the 9/11 disaster as he worked to support New York employees returning to work and consulted with management to understand the human impact of the attack and how to support their employees. Rick also has the dubious distinction of providing crisis intervention after four mass shootings: two in Pittsburgh, Pennsylvania; one in DeKalb, Illinois; and the August 2019 shootings at a Walmart in El Paso, Texas. Rick’s other clinical experiences include working in a college counseling center, in private practice, and at a residential treatment facility for children and adolescents who are sexually aggressive.
JULIA L. WHISENHUNT, PhD, LPC, NCC, CPCS, is an associate professor at the University of West Georgia (UWG) and is director of the EdD in Professional Counseling and Supervision program. Julia entered college while still a high school student and obtained her BA and MA in psychology from UWG. She also completed her EdS in guidance and counseling at UWG and obtained her PhD in counselor education and practice from Georgia State University. Julia has worked as a counselor educator since 2012 and developed the crisis intervention course at UWG in 2013.
Julia specializes in suicide prevention and intervention and self-injury intervention. She served on a campus suicide prevention program funded by the Substance Abuse and Mental Health Services Administration and has spent considerable time engaged in suicide prevention advocacy, including work with police related to suicide intervention and suicide by cop. She is a certified applied suicide intervention skills trainer (ASIST) and regularly teaches counselors-in-training in the art of suicide intervention.
Julia has clinical experience in secondary school counseling, college counseling, and counseling in partial hospitalization settings. She also serves as a disaster mental health volunteer and directs a study team in Ecuador that provides pro bono counseling and speech-language pathology services to members of small rural communities under the supervision of local licensed practitioners. In this capacity, Julia has had the opportunity to supervise and directly intervene to support individuals in a transcrisis state and those who have significant trauma history.
RICHARD “DICK” K. JAMES, PhD, NCC, NCSC, LPC supervisor, is in his 55th year of active counseling, writing, and consulting and recently retired as a full professor after teaching for 40 years at the University of Memphis. Dick received both his bachelor’s degree and a master’s degree in school guidance from Eastern Illinois University. He received a PhD in counseling psychology from Indiana State University in 1974 and was one of the first counseling psychology students to do his fieldwork at a federal correctional facility in Terre Haute. This introduction to corrections counseling gave him valuable insights into criminal behavior and a lifelong empathy for people who are incarcerated.
Dick developed a comprehensive academic and behavioral remediation program for underachieving students, and this led to establishment of the Intensive Care Unit in Mattoon, Illinois, which utilizes academic and behavioral prescriptions, teaching teams, parent groups, and pupil personnel teams of school psychologists, school social workers, and school counselors for individual and group counseling, teacher consultation, and parent training. The program was successful, achieved state validation as an exemplary innovative education program, and has been exported to other school systems in Illinois.
Dick’s next stop was as coordinator of the school counseling program at the University of Memphis. He also served as the field placement coordinator of practicum and internships and coordinator of the Jackson, Tennessee, extension center. In his idle hours, he wrote Crisis Intervention Strategies (James, 2008) and coauthored Theories and Strategies of Counseling and Psychotherapy (James & Gilliland, 2003) and This Is Not a Fire Drill: Crisis Intervention and Prevention on College Campuses (Myer et al., 2011), as well as numerous book chapters, manuals, grants, and journal articles.
Dick can’t seem to stay out of jail. He spent the last 5 years of his academic life working with his doctoral students to develop a group treatment, stay-out-of-jail program for inmates diagnosed with severe mental illness (Cox et al., 2015, 2017, 2019). His most notable achievement was helping to develop the Memphis Police Department crisis intervention team program in 1987 (Myer et al., 2014). That program is overwhelmingly popular, and Dick has trained more than 2,000 police officers and mental health workers from all over the world. More than 2,400 local U.S. jurisdictions and numerous foreign countries currently use the Memphis model.
Along with Rick Myer, lately Dick has been doing advanced crisis intervention training with the U.S. Border Patrol’s peer support program.
CHAPTER 1Crisis Roots and Building Blocks
This chapter provides a brief overview of the basic theory and tools of crisis intervention. Suffice it to say that this chapter is not a condensed course in crisis intervention, but we believe providing some basis information on crisis intervention will help you as you work through the cases. If you have not taken or do not have a crisis course available, see the reference list for crisis works that provide an in-depth understanding of how crisis intervention is carried out.
You Say You Want to Work in Crisis Intervention
The business of trauma and crisis intervention has become a growth industry. To pass muster, programs accredited under the Council for Accreditation of Counseling and Related Educational Programs (2016) are required to provide instruction on crisis intervention. It is interesting to note that neither social work nor psychological accreditation programs mention crisis intervention.
One of the major positive outcomes of increased consciousness and understanding of disaster mental health has been the emergence of national crisis response teams (CRTs) that can be mobilized and deployed hours after a major disaster. CRTs were formed through the efforts of the National Organization for Victim Assistance (NOVA). Originally developed to help victims of crime, this nonprofit agency established the National Crisis Response Project and set up CRTs, which include representatives from all of the primary mental health professions. Once a disaster occurs, community leaders can ask for assistance, and after consultation with NOVA, a trained CRT will be sent to the community (Young, 1991).
There are a lot of local emergency management agencies in the country, but not many of them have administrators with mental health backgrounds. If you are in the mental health business, you might be seen as a valuable staff member and be able to find a job there. If you are in criminal justice, it doesn’t take a week of viewing the national news to see the scrutiny and anger that boils over after police department shootings, particularly when racial/ethnic minorities are the victims. The need for police officers with verbal de-escalation skills is one of the faster tracks to promotion in contemporary departments.
If you are employed by a Federal Emergency Management Agency (FEMA) state or local affiliate, you may have a chance to attend the Emergency Management Institute in Emmitsburg, Maryland. There you can learn everything you ever wanted to know about emergency management, including rounding up domestic and wild animals (Emergency Management Institute, 2019). Programs from a bachelor’s degree to a PhD in the crisis counseling/emergency management field are available. Search online for “crisis intervention degrees” or “crisis management degrees,” and you will find a range of programs from certification in emergency management areas to associate’s, bachelor’s, and master’s degrees as well as doctorates. There is a crisis intervention program out there to fit almost everyone.
Crisis Defined
There are about as many definitions of “crisis” as there are ways to have one (Belkin, 1984; Caplan, 1961; Carkhuff & Berenson, 1977; France, 2014; Hoff et al., 2009), and this debate is ongoing. That debate should tell you that this is still a growing and changing field. In this book, we use a modified definition of crisis that one of the authors (James) has been using for a long time: “A crisis for an individual is the perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms, and means of support are either missing or unequal to the task of helping alleviate the crisis” (James & Gilliland, 2017, p. 9). This definition has three key components. First, the crisis is intolerable, or as Albert Ellis (1984) described it, “I have a case of I can’t stand it itis. And it can’t be put up with any longer” (p. viii). Second, whatever positive attitudes, willingness to work, faith in good works, and resiliency were available to an individual before the crisis are now gone, and the person’s affective, behavioral, and cognitive resources well has run dry. Third and most important, support systems are gone, and a shoulder to lean on or cry on is difficult to find. Either physically or psychologically, or both, individuals are now alone with the crisis.
Transcrisis
Most crises were generally thought to be of limited duration, lasting 6 to 8 weeks and then slowly dissipating (Caplan, 1961; Janosik, 1984). That perspective has changed with the advent and formalization of posttraumatic stress disorder (PTSD) as a bona fide clinical mental health problem (American Psychiatric Association, 1980). However, it should be clearly understood that individuals do not have to be diagnosed with PTSD to be in transcrisis, even though transcrisis states are a hallmark of PTSD.
For many people, a crisis may subside for a while and become quiescent, much like arthritis, then flare up at transcrisis points and become intolerably painful and disabling; this disequilibrium can last a lifetime (van der Kolk & McFarlane, 1996). Until the original crisis is dealt with, the transcrisis state may continue (James, 2008). Individuals suffering from domestic or interpersonal violence and those with substance use problems are common examples of people in transcrisis who experience numerous transcrisis points. These individuals are most often participants in long-term therapeutic interventions, and when these transcrisis points erupt, their treatment might better be called “crisis therapy.” These are the tough, intractable cases that can lead to counselor burnout.
Systemic Crisis
To suppose that a crisis affects only an individual in isolation is an incorrect assumption. Rarely does a crisis affect just one person. Whether it is a diagnosis of childhood leukemia, the sexual assault of a college student, an unemployed construction worker who dies by suicide, a person with an addiction who is involved in a fatal car crash, a new case of HIV, a family wiped out in a house fire, a community destroyed in a tornado, or a whole coastline devastated by a hurricane, we are all affected. John Donne’s (1624) classic poem ends, “For whom the bell tolls, it tolls for thee.” Because of the advent of social media and instantaneous worldwide news, it is difficult for any of us to escape the tsunami waves that spread from the epicenter of a crisis, be it large or small.
From that standpoint, crisis can also be defined systemically (Hermann, 1963; Roberts, 2005; Zdziarski et al., 2007). For us, a systemic crisis may be defined as a crisis event that overwhelms communities and institutions such that communications systems break down, basic infrastructures are destroyed, and emergency responders are unable to effectively contain and control the event with regard to both physical and psychological reactions to it. When this happens, the crisis has become systemic (James & Gilliland, 2017, pp. 10–11).
Metastasizing Crisis
Although you may go through American Red Cross disaster training and be called to the scene of a large-scale ecological disaster, it is far more likely that you will be involved in what we call a metastasizing crisis (James & Gilliland, 2017, p. 11). A metastasizing crisis may start out very small, such as a series of escalating phone texts between two teenage girls fighting over a boyfriend. As their messages spread over social media, sides are chosen, and opposing gang members may become involved to the point that a gang war erupts and drive-by shootings occur. When a crisis metastasizes, a crisis team composed of numerous individuals with different areas of expertise that include mental health, law enforcement, media, and government social services is required to contain it and keep it from turning into a wide-scale systemic crisis (Myer et al., 2011, pp. 55–57). Given the multiple descriptions of crisis, let’s look at how this business of crisis intervention got started, and where it is going.
A Brief History of Crisis Intervention
A crisis probably occurred when a Cro-Magnon was about to become a cave lion’s dinner and, in desperation, picked up a sharp limb and solved the crisis by stabbing the lion, and in the process invented a thing called a “spear.” But it is within the last century that the words “crisis” and “intervention” have been formalized. Crisis intervention is a formal therapeutic procedure to help people out, and it is probably the first therapeutic approach to use technology. In 1906, a crisis phone line was established by the National Save-a-Life League for suicide prevention (Bloom, 1984).
Here Comes Alcoholics Anonymous
Although not identified as crisis intervention, Alcoholics Anonymous (AA) meetings in the 1930s had a firm foundation in crisis intervention techniques. AA is oriented to the here and now and does not look past the next few hours in dealing with the presenting problem of wanting to drink. It is reality oriented and honest in its face-to-face group meetings. AA’s 12-step program resembles a crisis plan in that it is faith based, solution focused, and directly addresses the dynamics of addiction (AA, 1939). AA’s operational approach to staying sober through continuous group meetings and sponsorship by fellow members is a gold standard for a person in transcrisis, along with its book of daily readings that can keep yearning to drink in abeyance. Finally, the support system it establishes is a core feature of all crisis intervention strategies because the support system for many people in crisis is either gone or unequal to the task of helping them.
Crisis Becomes a Construct
Bill Wilson’s group in Akron, Ohio, started to expand at a rapid rate in the late 1930s, but little research about the dynamics or aftermath of people experiencing a crisis occurred until the packed Coconut Grove nightclub caught fire in 1942 and more than 400 people were burned or trampled to death in the ensuing hysteria to escape. Eric Lindemann (1944) treated many of the survivors of that fire and wrote about the commonality of survivors’ grief reactions. Later, Gerald Caplan (1961, 1964) worked with survivors and made the first attempt to explain the dynamics of crisis, start to build a theory of crisis intervention, and apply it in the community.
Here Comes the Community Mental Health Movement
With the advent of the first psychotropic medications in the late 1950s and early 1960s, it was thought that a panacea for chronic mental illness was at hand and that the large holding facilities of state mental hospitals for individuals with a chronic mental illness could be closed down. As a result, the Community Mental Health Act of 1963 put into place a provision for treating individuals with a chronic mental illness in a community setting with support from local professionals and family members.
If you walk down any large urban main street today, you can see how badly that idea has failed. You should know that in each crisis opportunity also exists. One of the outcomes of closing down the large state hospitals was that there were not nearly enough psychologists or psychiatric social workers available to adequately handle the huge influx of people with a severe mental illness in the community who might or might not take their medication, might or might not have support from family members, and did not have housing and jobs to keep them emotionally and financially stable. As a result, in the 1970s, counseling departments started to turn out “community agency counselors,” which slowly evolved into the licensed professional counselor–mental health service provider professional designation. People with chronic and severe mental illnesses and their crises came back to Main Street.
At that time, jobs in the counseling profession could be put into four general categories: schools (mainly high school), rehabilitation (mostly physical), career/occupational counseling (working at state employment services), and college student personnel (mainly doing academic and financial advising). For a variety of reasons, these counselors found employment and filled a huge gap, providing mental health services to individuals with severe mental illnesses. They were not academically trained to do this kind of work, and if they stuck with it, they would experience some intense on-the-job training in crisis intervention. This began the slow evolution of counselors as mental health service providers and the many legal and political fights state by state to licensure as licensed clinical mental health providers.
Here Comes PTSD
PTSD and its symptoms are common knowledge today, but in the early 1970s, PTSD did not exist! That is, it did not exist in name, but people obviously experienced the symptoms of PTSD. The late 1960s and early 1970s were not just a time of psychedelic drug consumption (embodied in the phrase “turn on, tune in, and drop out”) and rock festivals such as Woodstock. These years encompassed social upheaval that cut across society. The Vietnam War, civil rights struggles, drug use, and the women’s movement would change the way the world looked at a lot of things. One of those “things” was what happened to people who experienced extreme trauma. The shock of combat had been given many names, from the Civil War’s “soldier’s heart,” to World War I’s “shell shock,” to World War II’s “combat fatigue.” The witches’ brew of political and social carnage that affected the United States during the Vietnam War led to a huge upsurge in veterans who were reporting severe psychological symptoms that existed and were maintained far beyond their return from Vietnam (MacPherson, 1984).
At the same time, Helen Reddy’s (1971) song lyric “I am woman, hear me roar” and Gloria Steinem’s (1983) feminist writing were feminist cultural touchstones that women rallied around in their push for social justice. A large part of that social justice movement was bringing sexual assault and domestic violence out from behind closed doors and into the public view. Researchers were finding that women and children who suffered physical and sexual abuse didn’t just “get over it”; they had long-term psychological effects (Herman, 1997).
As researchers dug deeper into the traumatic wake of sexual assault and domestic violence survivors, they started to find disturbingly familiar parallels between “rape trauma syndrome,” “abused child syndrome,” “traumatic neurosis,” and “Vietnam veterans’ syndrome” (van der Kolk & McFarlane, 1996). The political and social heat to recognize these similar symptoms finally generated enough specific, evidence-based symptoms for the third edition of the American Psychiatric Association’s (1980) Diagnostic and Statistical Manual of Mental Disorders to understand and label the symptoms as PTSD.
Here Come the Cops
Regrettably, the Community Mental Health Act of 1963 resulted in increased police interaction when individuals had psychotic breaks and became violent. Although the provisions of the act were meant to improve the lives of people with mental illness, not nearly enough mental health practitioners were available in the community to provide services, nor were they mobile enough to respond to on-the-scene crisis events. These calls often ended in disaster, with severe injuries both to the police and to the people they were attempting to restrain. In 1987, a man diagnosed with schizophrenia was shot and killed after a nasty altercation with the Memphis Police Department. Demands from the public created a citizen, mental health provider, and police task force to develop a training program to teach patrol officers the verbal skills to de-escalate and defuse potentially violent situations involving people in psychological distress (James & Crews, 2014).
Pre- and postevaluation of the program a year after implementation saw a significant increase in the number of mental illness calls, a decrease in the number of officer injuries, and a significant decrease in callouts for the tactical team (SWAT; Carrier-Wright, 1993; Dupont & Cochran, 2000). The success of the program has resulted in it being implemented in more than 2,400 jurisdictions around the world and led to establishment of CIT International, a professional organization of law enforcement, mental health professionals, and consumer advocates who provide a platform for research information exchange and program development for law enforcement interaction with people with a mental illness. This police approach has also found its way into the public school system through training school resource officers in crisis intervention techniques (Eklund et al., 2018; James et al., 2011).
Here Comes the Red Cross
With the ready availability of disaster crisis intervention training by the American Red Cross at every American Counseling Association (ACA) conference, one might think we have been in the disaster counseling business for a long time. The constant media coverage of federal, state, and local emergency management following tornadoes, floods, forest fires, and hurricane landfalls might also lead one to think that the government has a long history of crisis response. The fact is that the Red Cross started mental health training for their own staff in the early 1990s because of their prolonged deployments from Hurricane Hugo in South Carolina and the Loma Prieta earthquake in California (Morris, 2011). The federal government didn’t get into the disaster mental health business until 1974 when the Disaster Relief Act was passed, with a section that authorized the National Institute of Mental Health (NIMH) to start training professionals to provide counseling services to disaster survivors.
FEMA came into existence in 1978, and it subsumed a veritable smorgasbord of government agencies that might somehow be involved in a disaster. Then, 9/11 came along, which proved to be as much of a disaster for FEMA as it was for the country. FEMA ceased to exist as a stand-alone entity and was subsumed under the new U.S. Department of Homeland Security. It took the debacle of Hurricane Katrina in New Orleans to demonstrate what a really bad idea that was (James & Gilliland, 2017, pp. 580–582). FEMA has now regained its own departmental status, and with some really hard lessons learned, FEMA and its state and local emergency management agencies have earned fairly high response marks.
Here Comes Technology
The first use of technology in counseling was in 1906 when the first crisis hotline was created, but technology has come a long way since then. A quick search shows multiple websites and smart-phone applications to support, prevent, and intervene with individuals in crisis. Specific apps such as suicide, runaway, and domestic violence prevention are also easily downloaded onto smartphones. These sites and apps include synchronized and asynchronized chat lines, guidelines for helping friends and family members in crisis, strategies for monitoring individuals in crisis, referral resources, helpful tips, and much more information designed to assist individuals in crisis. These sources include local, regional, national, and international resources for helping people in crisis. Literature about the benefits and potential pitfalls from using this type of intervention continues to grow (e.g., Barnett & Kolmes, 2016; Hetrick et al., 2016; Krysinska et al., 2019). Although telebehavioral health has been around for several years, the COVID-19 pandemic has increased the services being offered remotely as agencies and organizations work to assist people in crisis. As technology advances, we are confident that remote services will continue to increase.
In an attempt to get ahead of the ever-expanding e-curve, the National Board for Certified Counselors (NBCC, 2016a, 2016b) has published guidelines for the ethical practice of distance professional services and has periodically updated them since 1997. Note, in particular, NBCC’s use of the term “distance professional services” (NBCC, 2016b, p. 1). Rather than focusing only on the provision of “internet counseling,” this policy expands the terminology to include other types of professional services that are beginning to be used in distance formats. Regardless of the arguments for and against using technology as a crisis intervention method, usage will likely spread and delivery systems and therapeutic innovation will rapidly evolve, as will the ethical issues associated with the use of technology in crisis intervention (Anthony & Nagel, 2010, pp. 58–72; DeJong, 2014; Drum & Littleton, 2019; Hsiung, 2002; Kraus et al., 2010; Luxton et al., 2016; Weinberg & Rolnick, 2020).
The Future Is Now
No matter what counseling field you choose, sooner or later, and most likely sooner, you’ll need the skills in this book. Our hope is that you can use this book to build practice memory that can help you respond more effectively and ethically the next time you have an ethical dilemma in your crisis intervention work. Currently, counselors who specialize in crisis counseling can be found in schools; emergency rooms; victim assistance programs; a smorgasbord of community and national hotlines and veterans hospitals; substance abuse centers; correctional institutions; geriatric facilities; rehabilitation centers; police departments; university counseling centers; mobile mental health teams; and local, state, and national disaster response teams (James & Gilliland, 2017). The need for counselors who have specialized skills in crisis intervention will continue to grow as technology advances and our world grows even smaller and more interconnected.
We are also going to need counselor educators who have experience to teach in this area. Although some research on crisis management has been conducted and reported (France, 2014), the majority of our information is provided through client self-reports or data collected from telephone hotlines. Probably the most solid, hard data we have has come from police involvement in crisis intervention team activity during crisis intervention (Carrier-Wright, 1993; Dupont & Cochran, 2000; Finn & Sullivan, 1989; Khalsa et al., 2018; Ritter et al., 2011; Watson et al., 2010). It is difficult to conduct research in this field because of the logistics and the ethical issues involved in conducting control groups of people in crisis. We need more research on evidence-based practices in crisis intervention. To our knowledge, this is the first book to marry crisis with ethical standards. We are the first to admit that lots of gaps need to be filled. So if you want to get published, this topic is probably a good place to start.
Crisis intervention isn’t for everyone. Constantly dealing with horrific issues that often accompany crisis intervention make it high on the list for burnout (Distler, 1990; Figley, 2002; Pearlman & Saa-kvitne, 1995). Adequate and constant quality supervision, timely debriefing, and institutional group support are critical if you work in the crisis field (Cooper-Nurse, 2018; East et al., 2001; Lawrence, 2018). That said, when done well, we believe crisis intervention is at the top of the heap in therapeutic practice.
Crisis and the Tools That Go With It
Psychological first aid (PFA) was a term first used by Beverly Raphael, an Australian psychiatrist and one of the preeminent international stars in applied crisis and trauma research and practice (Raphael, 2000). PFA attempts to establish safety, reduce stress, and provide rest and physical recuperation (NIMH, 2002). It is a primary, evidence-based first-order intervention to provide immediate short-term relief to disaster survivors.
The National Center for PTSD developed Psychological First Aid Field Operations Guide (Brymer et al., 2006) for both professional and paraprofessional mental health workers. Indeed, it can be taught and used effectively by anyone as part of their community emergency response team (CERT) training (CERT, 2019). It is a tool that all counselors should have in their toolbox and use in initiating contact with people in crisis. Its core components are as follows (Brymer et al., 2006, p. 18):
Contact and Engagement
Goal: To respond to contacts initiated by survivors, or to initiate contacts in a nonintrusive, compassionate, and helpful manner.
Safety and Comfort
Goal: To enhance immediate and ongoing safety and provide physical and emotional comfort.
Stabilization
(if needed)
Goal: To calm and orient emotionally overwhelmed or disoriented survivors.
Information Gathering: Current Needs and Concerns
Goal: To identify immediate needs and concerns, gather additional information, and tailor PFA interventions.
Practical Assistance
Goal: To offer practical help to survivors in addressing immediate needs and concerns.
Connection With Social Supports
Goal: To help establish brief or ongoing contacts with primary support persons and other sources of support, including family members, friends, and community helping resources.
Information on Coping
Goal: To provide information about stress reactions and coping to reduce distress and promote adaptive functioning.
Linkage With Collaborative Services
Goal: To link survivors with available services needed at the time or in the future.
For you neophytes who are about to get into this business, you may overthink the problem and attempt to perform therapeutic miracles. In crisis intervention, that’s not how it works. The fact of the matter is, if you can use the foregoing PFA points well, you are most likely going to be an all-star in the crisis business. You will find the PFA list to be a handy reference when you get into the case studies and role playing in later chapters.
Breaking Down What It Means to Be in Crisis
Let’s revisit our definition of a crisis: “A crisis for an individual is the perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms, and means of support are either missing or unequal to the task of helping alleviate the crisis” (James & Gilliland, 2017, p. 9). If we break down this definition into its component parts, you should start to get an idea of how the therapeutic process works differently in a crisis.
If a situation is “intolerable” for you, then it is pretty straightforward that you can’t deal with it anymore. You are at your wits’ end; you are unable to think straight or keep your emotions under control. You are probably not going to be very reasonable about what’s going on around you, and what is happening to you is definitely not going to be reasonable. So a standard, calm dialogue with thoughtful give-and-take and long-term planning is not going to work. Why is this? Your playbook of “coping mechanisms” that have seen you through other crisis situations isn’t working anymore, and you can’t come up with any viable alternatives. You are now affectively, behaviorally, and cognitively paralyzed, and the high-quality crisis worker is going to be not only empathic and client focused but also directive and guiding.
Support Systems Are Gone
Worse yet, “supports” are now missing. Supports come in the form of physical resources such as food, housing, and shelter. Indeed, the primary work of disaster response counselors has a lot more to do with helping people with basic survival problems than with providing “counseling.” Support also comes in the form of significant others who are there to provide both physical and emotional resources. Support is institutional and may include making connections with social, medical, financial, and religious institutions that are no longer available. If you find yourself in this situation, it is easy to see how “hopeless” and “helpless” become major descriptors of your life.
Above all else in a crisis, it is critical to have support systems in place to help people who are temporarily unable to support themselves get through the crisis and return to equilibrium. When those physical supports are not in place in the form of significant others or institutions, crisis workers must step up and intervene directly as the immediate support in the person’s life.
Essential Skills
The definition we provided for a crisis also alludes to how we conduct therapy differently and, at times, are much more directive than we are in other situations. Although we still use Rogerian client-centered counseling as much as possible, “as much as possible” may not be possible with a client whose current resources and coping mechanisms are shot to pieces. From that standpoint, we move along a nondirective to directive continuum depending on how much control the client has over affect, behavior, and cognition (James & Gilliland, 2017).
Along with this flexible and elastic movement, our basic verbal building blocks to counseling change. Typical restatement for content clarification and reflective statements to tap into affective and cognitive client bases may rapidly change to more directive, action-oriented, assertion-reinforcing, real-time owning statements. For many students and probably many professors, being directive and action oriented may feel awkward and uncomfortable. Some of the techniques we are going to illustrate take time to learn and require some acclimation.
Use Owning Statements
Most owning statements are set in real-time, here-and-now present tense and start with “I.” The “I” is important because, for the time being, you are taking control of the situation. First and foremost, this is because you are the professional on the scene, and you are responsible to intervene. Second, if any of the “theys” or “thems” could have helped, they would have done so by now. In a crisis, the focus needs to stay on two people: you and the client. You want the focus to stay on you and what you are doing to help the client stabilize rather than focusing on a lot of extraneous by-products of the crisis that can delay resolution or even exacerbate it. Put everything and everybody else in orbit around the asteroid belt! The following examples are ways of using owning statements in crisis intervention when chaotic conditions leave clients with little control. Here are some brief examples of what we are talking about and, if you are doing role playing in any of the cases, what you need to be practicing.
Deflect Back to Real Time
In the midst of a crisis, many clients will jump immediately into telling you about their past traumas, challenges, and other difficult life events. Although you can empathically acknowledge those injustices and validate the client’s experience, it is the crisis worker’s role to help the client focus on the present moment. No one can control the past or the future; any control that is to be found can be achieved only in the present moment. In crisis intervention, we do not chase the tears; that is, we do not seek to uncover past wounds. Doing so can promote further distress for the client and prevent the client from achieving stabilization. The crisis worker’s role is to focus on what needs to be done to help the client regain control in the present moment.
Client (with abandonment experiences):
It all started back when my mother abandoned me when I was 3 on a Greyhound bus in New Mexico.
Crisis Worker:
OK, so the split between you and mom goes way back (
restatement affirming past issues of the client
). Right now, though, the big fight with your parents about moving out of their basement has got you out in the middle of a busy street, extremely distraught with two busted whiskey bottles in your hand, and the cops are here. (
Summary content restatement and reflection of current feeling, bringing the problem into real time.
)
Wiener and Mehrabian (1968) used relation markers to keep clients in real time. “This” and “that” are indefinite pronouns and, in dissertation writing, are the bane of our editing existence when appropriate descriptive antecedents do not precede them. In crisis intervention, however, indefinite pronouns can serve a useful purpose in that they can bring specific components of a problem that are doable into operation and help to keep those aspects that aren’t particularly relevant out of the issue. This thing, person, or event is right here, up close and personal, whereas that thing is way over there, in the past, and not relevant at the present moment.
Crisis Worker:
So this (
up close and relevant
) current problem has to do with you getting asked to leave the house after the latest argument about them nagging you about getting a job while that (
distancing and irrelevant)
has been going on a long time. Right now, I’d like to look at this (
real-time and relevant
) situation in the middle of the street as not the best method of handling that problem and see if we can come up with something that leads to a better solution than this.
Always Make Safety First
Immediately upon making contact, assess safety for both you and the client (Myer et al., 2013). Before anything else happens, it is extremely important that the situation is safe. In crisis intervention, safety always comes first.
Crisis Worker:
Jill, we’re out in the middle of a busy street in 5 o’clock traffic. The police are barely holding back because they see you have two broken beer bottles in your hands. I am concerned about your safety and mine too. (
Owning real time “I” statement regarding current observable threat conditions for both the safety of the client and the intervener.
)
Use Assertion Statements
Think back to your eighth-grade English class when you diagrammed simple sentences for the subject, verb, object, and action to be taken. That syntax works well in crisis intervention because it keeps sentences simple and asks for only one action at a time. Remember that most people in crisis are overwhelmed by the experience, which (understandably) can interfere with their ability to think clearly and maintain perspective on the situation. Using compound complex sentences will not help you to communicate effectively in a crisis situation. Instead, crisis workers should be clear and succinct, noting specific directions when safety is an issue.
Crisis Worker:
I want you to put the whiskey bottles down. (
Simple declarative assertion, action-specific statement.
)
Sound Like a Broken Record
Most of you may not be old enough to know what happens when a vinyl record has a crack in it and the sound needle hits it. When that happens, the record doesn’t move the song forward but hops back and plays it over and over again. Most of us have selective hearing under normal conditions.
Partner 1:
Honey, you need to take the garbage out!
Partner 2:
(
Watching Green Bay Packers in a nail-biter football game
) What did she . . . Whoa! The Green Bay quarterback gets sacked again! (
Partner’s request gets sacked as well.
)
The selective deafness problem becomes exponential when a crisis is at hand, which calls for restating the same assertions.
Crisis Worker:
Jill, did you hear what I said about setting down the bottles? No cops are going to rush you, so you can put them down. And I would feel a little less anxious if you could put the bottles down.
Make First Contact Count
In Chapter 2, we spend a lot of time talking about social locations and relational-cultural theory. We introduce you to a new multicultural way of looking at making initial contact in a crisis. But for now, let’s just say that the first few words uttered—particularly when the client is not well known or is unknown—make a great deal of difference in how well you bond with the client and what the outcome will be. Consider the following introduction.
Crisis Worker:
(
With hands and arms folded across chest, upright ramrod straight stance with piercing gaze directly to the eyes of client
) Hello there, I am Dr. James, licensed psychologist, licensed professional counselor–mental health service provider, supervisor certified, national board certified counselor, and national board certified school counselor. Oh! And commercial driver’s license volatile liquids (retired). What’s going on to get you in this mess?
A tad egotistical and overbearing you say? Although this example is wildly exaggerated, for many people in crisis who have suffered past injustices at the hands of mental health professionals and law enforcement, any attempt to begin with an authority-based greeting is not going to be received with reverence and enthusiasm. A much more personal, client-focused introduction to establish a working bond will do a whole lot more toward establishing a trusting relationship.
Crisis Worker:
