Fundamentals of Crisis Counseling E-Book

Geri Miller

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 489

Veröffentlichungsjahr: 2011

Beschreibung

An indispensable handbook for assisting clients in crisis and in their journey toward healing Integrating practical training with both research and theory, Fundamentals of Crisis Counseling offers students and professionals proven hands-on techniques to assist clients in recovery from crisis and towards an eventual return to their day-to-day lives. Written in the author's gentle yet purposeful voice, this reader-friendly guide is filled with lessons on current evidence-based counseling, how to operate as a client stress manager, and information on finding resources that facilitate client resilience. In addition, the author helps counselors improve counseling effectiveness by gaining a better understanding of their own strengths and weaknesses and emphasizes the importance of self-care. Stemming from the author's thirty-five years of experience as a crisis counselor, this book contains valuable information on: * Crisis theory and intervention models * Concepts, techniques, assessment, and treatment for disaster mental health work * Legal and ethical concerns regarding working with individuals, groups, couples, and families * Assessment and instrument selection * Main concepts and techniques of brief therapy, motivational interviewing, stages of change, positive psychology, grief therapy, client resilience, and spirituality * Multicultural crisis counseling techniques centered on age, gender, sexual orientation, and ethnicity * Counselor self-care complete with case studies and examples Ideal for all mental health professionals looking for guidance on best practices in crisis counseling, this book is also suitable for training professionals and counseling students. The book includes access to an online instructor's test bank, PowerPoint slides, and syllabi in line with 2009 Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards. Fundamentals of Crisis Counseling imparts useful knowledge on little utilized crisis counseling abilities, preparing counselors at every stage to effectively respond to the immediate and lasting affects of crisis.

Leseprobe

Contents

Preface

Acknowledgements

Chapter One: Introduction/Overview

Personal Reflections on the Overall Book

Definitions of Crisis, Crisis Counseling, and Crisis Intervention

History of Crisis Intervention

Helpful Characteristics of Counselors

Interagency Collaboration

Summary

Questions

Exercise

Suggested Readings

Web Sites

Chapter Two: Crisis Theories, Domains, and Intervention Models

Crisis Theories

Exercise 2.1

Exercise 2.2

Exercise 2.3

General Crisis Interventions

Exercise 2.4

Exercise 2.5

Crisis Intervention Models

Exercise 2.6

Summary

Questions

Suggested Readings

Videotapes

Web Sites

Chapter Three: Disaster Mental Health Counseling

Main Concept

Techniques

Assessment

Treatment

Summary

Questions

Exercises

Suggested Readings

Videotapes/DVDs

Web Sites

Chapter Four: Settings and Commonly Occurring Diagnoses

Settings

Commonly Occurring Diagnoses

Exercise 4.1 Addiction

Exercise 4.2 Co-Occurring Disorders

Exercise 4.3 Intimate Partner Violence

Exercise 4.4 Sexual Abuse

Exercise 4.5 Eating Disorders

Summary

Questions

Suggested Readings

Manuals/Workbooks

Videotapes/DVDs

Web Sites

Chapter Five: Special Populations and Legal/Ethical Issues

Individual

Exercise 5.1 Individual

Group

Exercise 5.2 Group

Couple/Family

Exercise 5.3 Couple

Exercise 5.4 Family

Ethical/Legal

Summary

Questions

Suggested Readings

Manuals/Workbooks

Videotapes/DVDs

Web Sites

Chapter Six: Assessment

Overview of Assessment

Instrument Selection Guidelines

Mental Health/General Trauma

Exercise 6.1 Mental Health/General Trauma

Addiction

Exercise 6.2 Addiction

Co-Occurring Disorders

Exercise 6.3 Co-Occurring Disorders

Intimate Partner Violence

Exercise 6.4 Intimate Partner Violence

Sexual Abuse

Exercise 6.5 Sexual Abuse

Eating Disorders

Exercise 6.6 Eating Disorders

Suicide

Exercise 6.7 Suicide

Homicide

Exercise 6.8 Homicide

Summary

Questions

Suggested Readings

Manuals/Workbooks

Videotapes/DVDs

Web Sites

Chapter Seven: Current Additional Therapies and Concepts

Brief Therapy

Motivational Interviewing

Stages of Change Model

Positive Psychology

Grief Therapy

Client Resilience

Spirituality

Summary

Questions

Exercises

Suggested Readings

Manuals

Workbooks

Videotapes/DVDs

Web Sites

Chapter Eight: Working With Different Cultures

Definition of Multicultural

Overview of Multicultural Counseling

Social-Environmental Aspects

Breakdown of Communication

Multicultural Competence

Dialogue

General Counseling Suggestions

Multicultural Counseling in the Context of Crisis Counseling

Influencing Factors

Exercise 8.1 Age

Exercise 8.2 Gender

Exercise 8.3 Sexual Orientation

Exercise 8.4 Ethnicity

Summary

Questions

Suggested Readings

Videotapes/DVDs

Web Sites

Chapter Nine: Self-Care

Self-Care in the Context of the Mental Health Profession

Burnout and Its Causes

Self-Care Approaches

Community of Support

Case Example

Summary

Questions

Exercises

Suggested Readings

Web Sites

References

Author Index

Subject Index

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Library of Congress Cataloging-in-Publication Data:

Miller, Geraldine A., 1955–

Fundamentals of crisis counseling / Geri Miller.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-43830-5 (pbk. : alk. paper); 978-1-118-15633-9 (eMobi); 978-1-118-15634-6 (ePub); 978-1-118-15635-3 (ePDF)

1. Crisis intervention (Mental health services) 2. Counseling. I. Title. [DNLM: 1. Crisis Intervention. 2. Counseling—methods. WM 401]

RC480.6.M48 2012

362.1'04256—dc23

2011021837

This book is dedicated to Ron Hood, my husband and friend, who has survived and shared personal and professional crises with me;

Gale, Abby, and Jason Miller; and

Tom, Laura, Natalie, and Kate Prow—my family;

The many clients I have had the honor of counseling in crisis work;

all of us who have weathered the storms of crisis;

and especially to Lisa Gebo, editor with Wiley, who originally inspired and encouraged this book, who bravely fought for her life,

and who finally succumbed to the cancer in 2010.

Preface

Fundamentals of Crisis Counseling evolved from my initial national work as a disaster mental health counselor with the American Red Cross in response to the 9/11 tragedy in New York, and then again in 2005 in response to Hurricane Katrina. In 2006, I met Lisa Gebo, Wiley editor, and she encouraged and inspired me to write this book because of my work at local and national levels with the American Red Cross. I would never have taken on this book without her belief in me and her unwavering support. The book is also based on my work in the mental health field since 1976; crisis counseling has always been a part of my work as a counselor under different professional titles.

I have always enjoyed crisis counseling work. Being with clients at their most vulnerable times is an honor, and watching them turn their lives around when they could easily give up is a touching testimony to the power of the human spirit and the loving communities that feed that spirit and keep it alive during adversity. I believe I have watched miracles occur that have inspired me to be a better counselor and person in this world. I have seen counselors committed to the professional field state or demonstrate the same views and feelings I have about this work. I have learned a great deal from my mentors, supervisors, and colleagues, and I hope that I pass on a small amount of this to my own graduate students in counseling.

I wrote this book with my students in mind: what I want them to know of the basics of crisis counseling work. I hope that this book may be helpful to all the readers of the text (students, counselors, etc.) in providing some core information about this important work. This book encourages the application of crisis counseling approaches through the use of case studies, exercises, and questions throughout the book chapters. Also, each chapter provides suggested readings and Web sites; some chapters provide manual, workbook, and videotape/DVD recommendations.

The following is a brief summary of each chapter of the book:

Chapter 1, Introduction/Overview, provides a general overview of crisis counseling and the philosophy of the author toward crisis counseling.

Chapter 2, Crisis Theories, Domains, and Intervention Models, describes crisis theory and general crisis interventions as well as specific crisis intervention models.

Chapter 3, Disaster Mental Health Counseling, summarizes disaster mental health work in terms of its main concepts, techniques, assessment, and treatment.

Chapter 4, Settings and Commonly Occurring Diagnoses, discusses various settings for crisis work (phone, school, agency, private practice) and common diagnoses that can emerge during crisis work (addiction, co-occurring disorders, intimate partner violence, sexual abuse, eating disorders).

Chapter 5, Special Populations and Legal/Ethical Issues, provides an overview of working with specific populations (individual, group, couples/family) with ten practical suggestions for each, as well as a discussion on ethical/legal concerns.

Chapter 6, Assessment, presents an overview on assessment and instrument selection in addition to providing an overview, instruments, case studies, and exercises in each of the following areas: mental health/general trauma, addiction, co-occurring disorders, intimate partner violence, sexual abuse, eating disorders, suicide, and homicide.

Chapter 7, Current Additional Therapies and Concepts, provides the main concepts and techniques of brief therapy, motivational interviewing, stages of change, positive psychology, grief therapy, client resilience, and spirituality.

Chapter 8, Working With Different Cultures, discusses an overall approach to multicultural counseling, multicultural approaches within crisis counseling, and finally, provision of an overview, general approaches, case studies, and exercises with regard to age, gender, sexual orientation, and ethnicity.

Chapter 9, Self-Care, provides an overview, definition, and approaches to self-care as it relates to the counselor, along with case studies and exercises.

Acknowledgments

I have had many great teachers in the counseling field: mentors, supervisors, colleagues, and students of mine. Thank you for all the time and energy you put into teaching me the essentials of counseling and crisis counseling, and for teaching me the power of having compassion for the suffering of others by not only sharing your own stories of suffering but also encouraging me to draw on and learn from the experiences of my own suffering.

In particular, I want to thank the courageous clients I have had the honor of being with in their moments of crisis. To these clients I say: Thank you for trusting me in your sacred space, on your hallowed ground, within your soft spots. You taught me the most important lesson of all: Kindness, a balance of the head and the heart, makes all the difference in life, especially when the volume of life is turned up loud as it is in a crisis. As a result of this lesson, all that is left for me in this world is to practice, to live, to breathe out kindness each day of my life, both personally and professionally. From my work with you, I learned there is nothing more important for me to do in a day than practice kindness. My motto has truly become: If it cannot be done with kindness, then it is not worth doing at all.

Additionally, I want to thank the people at John Wiley & Sons who helped me write this book and supported me on the journey: Lisa Gebo, my first editor, who planted the seed of this book; Isabel Pratt, my second editor, who showed me patience and delighted me with her intellect, humor, and delightful personality; and Marquita Flemming, my third editor, with whom I have had the joy of working on a previous book with Wiley. Marquita’s knowledge, precision, enthusiasm, and support never cease to amaze me. I also want to acknowledge the other Wiley employees who worked hard with me on this book and made it an enjoyable experience because of their delightful personalities and intellect: Judi Knott and Heather Dunphy in marketing, Kim Nir in production, and Sherry Wasseeman as editorial assistant.

George Dennis, my computer teacher, again helped me with this book—especially as my computers had crises of their own. George continues to remain a kind, smart, patient, and honest friend of mine. Leila Weinstein, my friend and colleague, assisted me with literature reviews, rewrites, and many miscellaneous details that allowed this book to occur. I especially acknowledge Dr. Betty Gridley, my statistics teacher and mentor, who generously and kindly gave her time and energy to assist me in the development of test questions.

I also thank Susie Greene, Kathleen Kasprick, Alice Krueger, Pat Mitchell, Laurie Percival Oates, Rod and Marilou Steinmetz, and Sue Sweeting, who remained steadfast friends, showing me kindness, compassion, and support and providing me with safe havens on the journey of this book. In addition, I thank my Saturday-morning coffee-drinking buddies, who encouraged me and believed in me and this work.

To Sonny Sweet, former director of the Watauga chapter of the American Red Cross, who encouraged me and others in our work as disaster mental health workers at local, state, and national levels: Thank you.

To the employees of the Paul H. Broyhill Wellness Center—Jodi Cash (director), Paul Moore (assistant director), Michael Darling (personal trainer), and all the rest of my friends who work there and work out there—for encouraging me and supporting me every day with their friendship, laughter, and love: Thank you.

Thank you also to the owners of the Higher Ground Coffee Shop in Boone, North Carolina, Matt and Gloria Scott, who let George and me work on the book for hours in their shop and shared their support and humor with me.

And last on the list, but first in my heart, my husband and best friend, Ron Hood, who continually gave me his love and support by reading every word of every draft of this book and giving up precious evening and weekend time to let me work. My thank you remains the same: “Thank you, Ron, for being with me on this life path. I love you.”

CHAPTER ONE

Introduction/Overview

Learning Objectives

1. To learn an overview of the philosophy of crisis counseling.

2. To understand the history of crisis counseling.

3. To develop awareness of areas related to crisis counseling, such as helpful characteristics of counselors and interagency collaboration.

Personal Reflections on the Overall Book

Whoever can see through all fear will always be safe.

—Tao Te Ching

A few comments regarding this book’s philosophy and approach toward crisis counseling need to be presented in this opening chapter. While sometimes this type of information is provided in the preface of a book, it is included in the introductory chapter of this text because of how significantly the underlying philosophy of this book influences each chapter and the general framework of the book.

The motivation for this book stems from my experiences with crisis counseling during 35 years of clinical work. These professional crisis counseling experiences have been augmented recently by my work as a disaster mental health worker with the American Red Cross. This work began in response to the 9/11 attacks in New York and has expanded over the past 10 years to local and state disasters. These combined clinical experiences have resulted in the guiding question used to write this book: “What information is essential to assist mental health professionals in doing crisis work?” This book has evolved from that question and focuses on the goal of the crisis counseling captured in the Tao Te Ching quote at the start of the chapter: to help the client see through the fears of the crisis and feel safe enough in counseling to make the best life-enhancing decisions possible.

In order to assist the client in seeing through the crisis and feeling safe enough to make life-enhancing decisions, the counselor is metaphorically acting as a lighthouse for the client; the client can focus on the guidance of the counselor as the tumultuous waters of the crisis are navigated. As we each think of personal or professional crises we have navigated, we know the power of a caring person simply staying with us through the journey. There is a deep, abiding, sustaining connection offered by the counselor to the client in a crisis situation when the counselor is able to be present with the client and reach out with compassion in response to the client’s suffering. The counselor also needs to: (a) help clients proactively respond to the crisis situation, in order to give them a sense of self-control (empowerment); (b) assist clients in getting back into some aspects of their daily routines (activities, rituals), in order to be reassured that the world is a safe place; and (c) provide them with a safe place to vent, where the counselor is listening to the client’s storyline (the crisis) but not becoming lost in it to the point of feeling helpless him- or herself or of being drawn to rescue the client and thereby encourage unnecessary dependency of the client on the counselor.

This book, then, is an attempt to provide the reader with practical, hands-on crisis counseling information that will assist clients in crisis and help them heal in their recovery from the crisis. The book can be used as a primer, a handbook presenting an overview of crisis counseling that can be used in clinical work. This can be particularly useful to the reader, because while all clinicians need to be ready to do effective crisis counseling, many of us do not do this work full time. Instead, we have a tendency to integrate this approach into our clinical work when situations arise with clients that require us to have a crisis counseling mindset and crisis counseling skills. Different factors, such as internal client factors (e.g., specific mental health diagnoses that result in the client going in and out of crisis states) or external factors (e.g., life situations such as divorce or natural disasters) may influence the necessary shift to a crisis counseling emphasis in clinical work. To apply effective, timely interventions that operate in the best interests of the client, the reader needs to be prepared to quickly shift to a crisis counseling perspective, often relying solely on his/her clinical judgment under the adage of “the buck stops here.”

Because crisis situations require thoughtful clinical decisions that need to be made quickly, the book is designed to expose the reader to an overview of aspects of crisis counseling that one might use infrequently, at best, in clinical work. This approach is intended to help hone the reader’s assessment and treatment approach and to enhance the skills that might be required in the crisis counseling situation. The self-reflective aspect of the book (questions, case studies, exercises, etc.) is designed to assist the reader in developing or enhancing his/her crisis counseling mindset by creating an interactive experience between the book and the reader.

This interactive approach is meant to help the reader understand his/her own crisis counseling strengths and weaknesses with the goal of enhancing his/her effectiveness. This self-assessment involves knowledge of critical components, such as: (a) current evidence-based, practical crisis counseling approaches and techniques; (b) operation as an “environmental stress manager” for the client; (c) development of internal and external resources that facilitate client resilience; and (d) self-care approaches that result in the reduction or elimination of burnout.

Finally, the term “counselor” is used throughout the text to describe the mental health professional reader. Readers may identify with different mental health professions and use different labels to describe their work. The term counselor has been chosen by the author as a term that represents the application of crisis counseling skills. While it is true that there are emphasis differences in crisis counseling among professionals (due to orientation and training), there are also similar themes and approaches that bridge these differences. While I have attempted to be sensitive to these variances, the reader is asked to acknowledge any limitations of the terminology used in this book and to not allow these limitations to block the potential usefulness of the text.

Definitions of Crisis, Crisis Counseling, and Crisis Intervention

There are numerous definitions for crisis (James, 2008). Typically, the crisis is made up of an event that occurs before the crisis, the client’s perception of the event, and the client’s previous coping strategies not being enough in the situation (Roberts, 2005). It is a state of upset-disorganization that is temporary and has the potential for either a “radically positive or negative outcome” (Slaikeu, 1990, p. 15). Essentially, the various definitions state the same components of a crisis: the client’s perception or experience of an event/situation as being intolerable and going beyond their resources and coping abilities. There are three components of the crisis: an event, the client’s perception, and the failure of the client’s typical coping methods (Kanel, 2007). As human beings we are, at least temporarily, unable to find relief in the crisis situation (Hoff, Hallisey, & Hoff, 2009).

When the individual does reach out for assistance, the reaching out can, obviously, include counseling. There are two main components to crisis counseling: first-order intervention (psychological first aid) and second-order intervention (crisis therapy) (Slaikeu, 1990). The first-order intervention of crisis counseling (psychological first aid) has been defined by the National Institute of Mental Health (2002) as making sure clients are safe, stress-related symptoms are reduced, clients have opportunities to rest and recover physically, and clients are connected to the resources and social supports they need to survive and recover from the crisis. The term “psychological first aid” originated in a description of crisis work in response to an Australian railway disaster (Raphael, 1977). It is considered the basic component of crisis intervention (James, 2008).

The goal at this stage of psychological first aid is to break up the behavior cycle that is dysfunctional and help the person return to their previous functioning level. Slaikeu (1990) breaks this stage into five components: psychological contact, problem exploration, solution exploration, concrete action taken, and follow-up. Overall assessment of the client can be done through the BASIC personality profile (Slaikeu, 1990) as described by Miller (2010, p. 100):

1. Behavioral. This area focuses on the client’s behavior in terms of strengths and weaknesses as well as behavioral antecedents and consequences.

2. Affective. The counselor assesses the client’s feelings about these behaviors.

3. Somatic. The counselor assesses the client’s physical health through sensations experienced.

4. Interpersonal. This area focuses on examining the quality of various relationships in the client’s life.

5. Cognitive. The counselor assesses the client’s thoughts and self-talk.

When counselors respond, they are intervening in the crisis. In this intervention, counselors are basically assessing the crisis situation at that moment, stabilizing the person, and assisting in the development of a plan to help them move out of the crisis mode. In crisis intervention, the counselor tries to reduce the crisis impact by immersing him- or herself into the client’s life and assisting in the development of resources. This involves crisis therapy along a continuum that includes assessment, planning, implementation, and follow-up; the crisis intervention is woven into the context of therapy (Hoff et al., 2009).

Counseling interventions in therapy need to be sensitively timed for the client, because the crisis is both a danger and an opportunity. It is dangerous in that the client may resort to destructive behavior (suicide, homicide), but it is an opportunity because the client may reorganize him/herself and his/her life by reaching out for assistance and thereby developing new knowledge and skills. It is in this development of new knowledge and skills that the counselor can be immeasurably significant in the client’s life; this is where therapy can have a long-lasting impact. A well-designed, sensitively timed intervention that is idiosyncratically matched to the individual client and his/her situation can change a life forever.

History of Crisis Intervention

Crisis intervention work has been around since 1942, when the staff of Massachusetts General Hospital responded to the Cocoanut Grove nightclub fire in Boston, where 493 people died (Lindemann, 1944). In their work with survivors and families of the victims, the hospital staff studied their acute and delayed reactions and clinically addressed psychological symptoms (survivors) and the prevention of unresolved grief (family members) (Roberts, 2005). In addition to Lindemann, Gerald Caplan (1961) also worked with these survivors and was a pioneer in defining and developing theory related to crisis (stages). Rapoport (1967) added to Lindemann’s and Caplan’s work by showing that an event led to a crisis and by describing the nature of the event more precisely, as well as emphasizing the importance of the intervention—particularly in assessment (Roberts, 2005).

This work continued into the 1960s, when suicide prevention (e.g., 24-hour hotlines) and community mental health (e.g., mental health clinics, managing psychiatric patients on medication on an outpatient basis) became popular concerns in the United States. Crisis intervention strategies and research grew out of these concerns (Kanel, 2007). Three major grassroots movements impacted crisis intervention: Alcoholics Anonymous (AA), activism by veterans from the Vietnam War, and the women’s movement (James, 2008). The impact came because these three groups of people needed help and were not receiving it. Crisis intervention strategies and research, then, became even more widespread, as there were increased concerns about money and limited resources that could not meet the demands of the population. Since the 1960s, additional crisis management has focused on specific areas, such as domestic violence (hotlines, shelters), child abuse (hotlines, referral networks), and rape crisis programs (Roberts, 2005).

In recent years, crisis intervention has become even more of a core component of the helping professions due to the impact of violent incidents on helping professionals in all areas of the United States because of (a) increased access to information, and (b) violence expressed in terrorist acts in public settings (e.g., the attacks on the Twin Towers, school shootings, etc.). A crisis in one part of the United States can easily set off a secondary trauma in another part of the United States. For example, although the 9/11 terrorist activity took place in New York, Pennsylvania, and Washington, DC, and Hurricane Katrina was physically localized to the southern part of the United States, the impact of these traumas throughout the United States was widespread because of the visual images and information spread through television and the Internet. Additionally, the impact of disasters such as 9/11 and Hurricane Katrina does not remain localized to one specific area, since many individuals needed to relocate themselves in response to the disasters. Finally, shootings such as the ones that occurred at Virginia Tech show that helping professionals are increasingly working with individuals impacted by crises in their communities; the helping professionals need to be prepared to do crisis intervention work at a moment’s notice.

The history of crisis intervention work and the current context of this work (increased opportunities for exposure to crisis work) speak again to the focus of this book. This book has an overall goal of providing mental health professionals and students in training in the mental health professions with readily applicable theoretical and practical research-based crisis intervention approaches. Ready access to the essentials of crisis counseling work can assist these individuals in their very important work with the clients in their communities. All counselors will do crisis counseling work, whether it is brief work of a few sessions, working with clients who are in continual crises, and/or working with clients on an ongoing basis who experience a crisis during their therapy.

Helpful Characteristics of Counselors

While there may be numerable counselor characteristics that can be helpful in a crisis situation, this section will elaborate on five: life experiences, poise, creativity and flexibility, energy and resiliency, and quick mental reflexes. These are drawn from James’s (2008) list of helpful counselor characteristics.

Life experiences means the crisis counselor has emotional maturity that stems from life experiences. Our training as mental health professionals teaches us how to work with clients, whether we have personally experienced their specific crisis or not. Emotional maturity developed through learning from our life experiences can enhance the depth and sensitivity with which we treat our crisis clients. Those of us who have experienced the same type of crisis as our client need to be aware of our countertransference issues that stem from personal and professional biases and “wounds” and work with those issues through consultation with colleagues, mentors, supervisors, and/or personal therapy.

In terms of poise, it is important to stay calm, stable, poised, rational, and in control, because in a crisis the client can be out of control and/or might present material that can be shocking and threatening. Here the counselor is acting as the rudder for the client in the storm of the crisis; the client can pick up on the emotional state as well as the physical presence of the counselor. Therefore, the counselor needs to find ways to reassure him/herself in the crisis in order to remain stable for the client. Specific suggestions to the counselor are made in Chapters 3 and 9 of this text with regard to disaster mental health work and self-care. In the overall practice of self-care, the counselor will have the balance and internal resources to be of maximum benefit to the client in the crisis. Or, in terms of the metaphor stated previously, the counselor will be a stable rudder for the client’s boat in the storm. Such stability makes an impressive impact on reducing the crisis. In a 9/11 crisis situation, I saw a counselor calmly approach a hostile, belligerent client. In a steady, calming voice and manner, the counselor said, “Friend, I do not think this approach is going to take you far in this situation.” Immediately the client calmed down in the situation, making the crisis more manageable.

Creativity and flexibility are major assets and encourage divergent thinking. The more creative and flexible counselors can be in a crisis situation, the more effectively they can meet the needs of the client. If the counselor becomes caught in a formula approach to a crisis situation, then the counselor’s response can be an automatic, rigid one that does not meet the unique needs of the client or the possibly changing dynamics of the crisis situation. Rather, if the counselor can approach the crisis with a tentative plan for how to address it, combined with a readiness to let go of that approach if it does not work, then the counselor can be more effective, because a more comfortable intervention fit can evolve for the client through a natural process. For example, a counselor may approach a crisis situation in which the client has been given a terminal illness diagnosis. The counselor may assume the client will want to discuss issues related to death. However, the client may be in a place of denial and may be interested only in discussing how to fight the illness; he or she is unwilling to discuss death at all. The counselor may need to shift the focus of the session to discussing the “battle” first, and then gently but quickly explore the underlying fears related to death.

In terms of energy and resiliency, we need to have energy and be organized, direct, and systemic in the actions we take, which means we need to practice self-care to promote our own resiliency. Energy, self-care, and resiliency are discussed more extensively in Chapter 9. To have physical and emotional energy, we need to care for ourselves. The practice of self-care can provide us with resiliency, which is required in the intensity of addressing crises. Clients in crisis will sense when a counselor is balanced, resulting in a helpful contagion effect that may calm the client. When we care for ourselves as mental health professionals, the result is that we are calm and steady in facing the crisis situation, providing the sense that “someone is in charge here.” I was told by a mental health worker in a crisis situation where other workers had been having “meltdowns,” “Oh, no, you won’t have a meltdown—you take care of yourself too well on an ongoing basis.”

Quick mental reflexes are critical because the issues in a crisis are steadily emerging and changing. This is very similar to creativity, flexibility, energy, and resiliency. We need to be able to think divergently and be resilient in order to have quick mental reflexes. The nature of the crisis situation calls for us to be able to make quick decisions. This is why I advocate that my students and trainees interested in crisis work have licensure and experience as counselors before doing this type of work, because it is truly work where “the buck stops here.” One needs to be comfortable making decisions quickly and often alone in the context of the crisis. There may be time and opportunity for consultation with colleagues, mentors, and supervisors, but we cannot count on it.

This section on characteristics of the counselor is not meant to be discouraging to the reader. No crisis counselor is perfect all the time, nor do any of us handle the crisis perfectly throughout. Rather, we act in the best interest of the client and continually assess the client and the situation for what appears to be the approach that reflects caring for the client’s welfare. Rather than focusing on avoiding making a mistake or being flawless, it is more important for us, if and when we make a mistake, to recognize it and recover from it. Most importantly, we need to be human beings with our clients in a crisis situation, for whom everything feels tumultuous. Such humanity can be an umbilical cord of hope for our clients.

Interagency Collaboration

We need to discuss briefly the subject of collaboration with other agencies, because client crises often mean that other agencies will need to be involved somewhere in the process of the intervention—whether it be in terms of referral, assessment, treatment, or follow-up. The same characteristics described above as being helpful with clients are also helpful in working with other agencies: life experiences, poise, creativity and flexibility, energy and resiliency, and quick mental reflexes. Other agency personnel may be almost, or sometimes more, out of balance than the client in the crisis, and through their behavior they may exacerbate the crisis. Or the counselor may approach or interact with the other agency personnel during the crisis in a manner that fuels the crisis.

In crisis situations, emotions tend to run high and just one comment, behavior, intervention, or the like can inflame a crisis through deterioration of a professional relationship. That is why the counselor needs to learn how to remain calm when others are not calm. In Chapter 3, this approach is titled “environmental stress manager.” This means that the counselor needs to be able to read his/her own stress levels, those of the client, and those of the surrounding crisis situation, and then intervene on these stressors present in each area—that is, manage the stress. Counselors should not assume that others will pick up on stress indicators and respond to them. Rather, the counselor needs to be cognizant of the skills developed through his/her training to recognize, address, and minimize these indicators. For example, a supervisor at a disaster mental health site had not been caring for herself on a regular basis, but had focused almost exclusively on others. As a result, after a few days on the site, she was very critical and sharp in her dealings with other agencies. Her fellow counselor team members successfully encouraged her to take more breaks, which ended up in her approaching other agencies in a more collaborative manner and reducing the stress in the environment.

Summary

This chapter presented an overview of crisis counseling: philosophy, definition, and history. Finally, it addressed the importance of helpful counselor characteristics and interagency collaboration.

Questions

1. What is the philosophy of crisis counseling as presented in this book?

2. Describe the history of crisis counseling.

3. What are typical reactions (professional, client) to crisis situations, and what makes interagency collaboration so critical to crisis counseling?

Exercise

Write out your philosophy of crisis counseling work in a few sentences. Make sure to address these questions: What is your main focus? How does your current (or anticipated) job/clientele impact your philosophy of crisis counseling? What do you see as your main strengths and weaknesses in this type of work?

Case Study 1.1

You have a client who requires the assistance of a number of agencies (social services, church, health department, etc.) in dealing with a crisis situation Your client is very distraught, but is willing to contact these agencies to obtain assistance and willing to have you talk with them regarding her situation (she has signed consent forms). You have a history of working with helping professionals at the local health department; you are aware that they do not like to work with clients in crisis mental health situations, and generally, they have not been cooperative with you in the past.

1. How would you approach this situation with the health department?

2. What would you tell your client, if anything, about the history of your experiences in working with the health department?

3. Would you warn your client about some of the barriers she may face in approaching them? If so, what would be your general strategy?

Suggested Readings

Bein, A. W. (2008). The Zen of helping: Spiritual principles for mindful and open-hearted practice. Hoboken, NJ: Wiley.

This book has ten chapters that address a mindfulness approach in counseling clients in general.

Briere, J., & Scott, C. (2006). Principles of trauma therapy. Thousand Oaks, CA: Sage.

This book is divided into two sections: trauma effects and assessment and clinical interventions.

Greenstone, J. L., & Leviton, S. C. (2002). Elements of crisis intervention (3rd ed.). Belmont, CA: Brooks/Cole.

This short book has 11 chapters that briefly cover basic approaches and strategies in crisis work with focused chapters on children, families, hotline workers, loss, legal implications, and disasters.

Hoff, L. A., Hallisey, B. J., & Hoff, M. (2009). People in crisis: Clinical and diversity perspectives (6th ed.). New York, NY: Routledge.

This book is an overview of crisis work. It is divided into three sections: understanding crisis intervention, specific crises, and suicide/homicide/catastrophic events.

James, R. K. (2008). Crisis intervention strategies. Belmont, CA: Thomson Brooks/Cole.

This book provides an overview of crisis intervention. It has four sections: theory and application, handling specific crises, workplace, and disaster. There is a specific chapter related to addiction.

Kanel, K. (2007). Crisis intervention (3rd ed.). Belmont, CA: Thomson Brooks/Cole.

This book has 12 chapters that cover general crisis information (definition, history, ethical/professional issues) as well as chapters on multicultural concerns, the ABC model, and addressing issues related to crisis, such as danger, developmental crises, loss, illness and disabilities, substance abuse, PTSD/community disasters/trauma, and abuse (child, spousal, sexual assault).

Roberts, A. R., & Yeager, K. R. (2009). Pocket guide to crisis intervention. New York, NY: Oxford University Press.

This brief book has 33 chapters, each of which, in a few pages, covers major topics of crisis work. It may be thought of as a type of CliffsNotes or a primer of crisis work.

Shea, S. C. (2002). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. Hoboken, NJ: Wiley.

This book has three sections: an overview, suicidal ideation, and assessment. It has helpful appendices on assessment documentation, safety contracts, and suicide prevention Web sites.

Web Sites

Mental health professionals can contact the following Web sites for information on mental health counseling in a crisis context with regard to their professional organizational affiliation.

American Association for Marital and Family Therapy: www.aamft.org

American Counseling Association: www.counseling.org

American Psychiatric Association: www.psych.org

American Psychological Association: www.apa.org

National Association of Social Workers: www.naswdc.org

Co-occurring Disorders

Substance Abuse and Mental Health Services Administration (SAMHSA): www.mentalhealth.samhsa.gov

This Web site provides a variety of information and resources on substance abuse and mental health.

Crisis

Crisis Prevention Institute: www.crisisprevention.com

This Web site provides information on training professionals working with potentially violent people.

National Organization for Victim Assistance: www.trynova.org

This Web site offers information on the rights of victims and services available to them.

General

Department of Health and Human Services (DHHS): www.hhs.gov

This Web site provides information on various aspects of American health concerns. A connecting Web site, www.phe.gov/preparedness, provides information specifically focused on public health emergencies, including crises such as disasters and trauma.

National Institute of Mental Health: www.nimh.nih.gov

This Web site provides information on understanding and treating mental illness and offers helpful publications for the mental health professional.

Suicide

American Association of Suicidology (AAS): www.suicidology.org

One can join this organization. The Web site has facts, warning signs, support groups, crisis centers, a bulletin board (members only), and a bookstore.

American Foundation for Suicide Prevention (AFSP): www.afsp.org

This Web site has statistics and suicide survivor information.

SA/VE: Suicide Awareness Voices of Education: www.save.org

This Web site has suicide prevention education, advocates for suicide survivors, and information on developing a group for suicide survivors.

Suicide Prevention Action Network (SPAN) USA: www.spanusa.org

If You Are Thinking About Suicide . . . Read This First: www.metanoia.org/suicide

This Web site attempts to reduce the stigma around having suicidal thoughts so that the reader is open to receiving help.

CHAPTER TWO

Crisis Theories, Domains, and Intervention Models

Learning Objectives

1. To learn specific theoretical models, domains, and intervention models related to crisis counseling.

2. To apply two general interventions of crisis counseling.

3. To apply these theoretical models, domains, and intervention models to specific crisis situations through the use of case studies and exercises.

The world is but a resting place.

—Ancient Proverb

Counselors need to have a theoretical framework through which to view a client’s problem. This is especially important in a crisis counseling situation, in which the counselor often does not have much time to reflect on his/her theoretical views. In such a situation, the counselor needs to almost go into “automatic pilot” regarding a theoretical orientation, because the crisis situation simply needs to be addressed as quickly, thoroughly, and adequately as possible. Such a focused, efficient, yet humane orientation means that the counselor would be well-advised to examine and explore his/her crisis counseling theoretical perspective prior to doing the work of crisis counseling.

While some counselors have jobs that are specifically crisis-focused, and their training for these positions may involve an exploration of theoretical models, domains, and intervention models, many counselors do not have opportunities for such training. At the same time, crisis intervention is seen as a core part of counseling (Hoff, Hallisey, & Hoff, 2009). As a result of these two realities (possibly limited training and required knowledge), this chapter will attempt to assist the counselor in this self-examination process regarding crisis-related theories, domains, and intervention models as a preparation for this type of work.

The theoretical framework (theory, domain, intervention) of the counselor assists the counselor in knowing which factors of the crisis need to be punctuated to adequately address the crisis—which parts of the client’s story are drawn into the foreground or dropped into the background. This emphasis guides the counselor through the assessment and treatment aspects of the crisis counseling with regard to the focus on, the priority of, and the intervention on issues; it helps the counselor understand the world of the crisis and attempt to be a part of making the “world as a resting place” for the client. In general, a counselor’s theoretical framework acts as his/her rudder. In the navigation of what may be substantial, fragmented, and intense information regarding both the crisis situation and the client’s response to it, this rudder is essential. Metaphorically, while a rudder (theoretical framework) is helpful to a boat’s balance in the water (general counseling), the sailor (counselor) relies on it even more when the waters are tumultuous (crisis counseling).

Regarding the framework of crisis counseling related areas (theories, domains, and interventions), an overall framework is presented in Figure 2.1 based on James’s work (2008). A part of this framework is also based on Janosik’s (1984) levels of crisis theory described in James’s work (2008).

Figure 2.1 Crisis-Related Theories (James, 2008)

The framework presented in Figure 2.1 has two main components: crisis theories (which include domains) and crisis intervention models. The theories examine the phenomenon of the crisis, while the intervention models focus on the helping response. The reader is encouraged to choose a core theory, domain, and intervention model from which to view the phenomena of and intervention on the crisis. The reader may also elect to choose one or two adjunctive theories, domains, and intervention models to find a balance between being flexible in applying crisis theory to the crisis situation of the client and organizing the fragmentation of the crisis situation to serve the best interests of the client.

Three tables are provided in this chapter to assist the reader in creating a framework that includes theories, domains, and intervention models. Following each table is a case study and exercise(s) to assist in the integration and application of this crisis counseling framework to the reader’s overall counseling perspective.

Crisis Theories

A counseling theory is made up of ideas and explanations that require the counselor to prove the theory’s fit to the client’s situation (Johnson, 2004). The theory reflects both the personal and professional view of the counselor and is shaped by the populations with whom the counselor has worked and is working currently. In general counseling, no theory explains all counseling problems and required approaches. The same is true for crisis counseling: no one theory explains the phenomenon of crisis adequately. Therefore, the counselor needs to be flexible in drawing upon and applying crisis theory in the same way a counselor would need to be when practicing counseling in general. Such flexibility is very important in crisis counseling so the counselor can readily adapt approaches to fit the uniqueness of the client and the uniqueness of the crisis situation.

The difficulty in choosing a crisis counseling theory may in part be connected to the reality of the numerous crisis counseling theories that exist, as well as the different frameworks developed to organize them. No theoretical discipline can rightfully claim that crisis theory stems solely from it; therefore, crisis counseling theory comes from an “eclectic mixture drawn from psychoanalytic, existential, humanistic, cognitive-behavioral, and general systems theories” (Kanel, 2007, p. 18). To learn more about the overall theories mentioned in this chapter, the reader is referred to general counseling theory textbooks (such as Corey, 2009) and to the resources developed by the respective experts in each of these theoretical orientations. The crisis theories are sorted as Basic, Expanded, and Applied.

Basic Crisis Theory

As stated in the history of crisis counseling in Chapter 1, Lindemann (1944) and Caplan (1961) helped professionals understand the basic theory and counseling interventions of crisis counseling. Although their work was different in emphasis, both normalized clients’ crisis responses and provided short-term intervention techniques that can be used by the counselor. It is this work, discussed both here and in Chapter 1, that makes up basic crisis intervention theory anchored in a psychoanalytic perspective. This psychoanalytic perspective is presented in Table 2.1 in the “Expanded Crisis Theory” section.

Table 2.1 Expanded Crisis Theoretical Models

Expanded Crisis Theory

Expanded crisis theory evolved because of the limits of basic crisis intervention theory (it did not account enough for the social, environmental, and situational factors that can contribute to a crisis). Thus, crisis counseling expanded from solely psychoanalytic theory to the inclusion of six other types of theories: systems, ecosystems, adaptational, interpersonal, chaos, and developmental. Table 2.1 summarizes each theoretical perspective and its view of the nature, causes, and resolution of crisis.

Case Study 2.1

Your client presents with a work situation that has evolved into a crisis because of the current economic problems and politics in the workplace. He is married, has children, and describes himself as a “regular, middle-class, middle-aged guy.” He does not know what to do, because his work situation is becoming more abusive due to politics that are hampering the completion of his job responsibilities: for example, people (co-workers, supervisors) are not providing him with necessary information and yet are blaming him and giving him consequences for not meeting his job responsibilities. As a result, he is having to work longer and has less time for his family. This has resulted in problems within his marriage and him being more short-tempered with his children. He wants to leave his career (he has been unhappy with it for a number of years), but does not know how he could find another job in the local area given the current state of the economy. He does not feel suicidal, but he has recently been placed on antidepressants and high blood pressure medication by his general physician. He describes himself as in a crisis and unable to see his way out, which is why he has come for counseling for the first time in his life.

1. Which expanded theory is most complementary to your view of counseling and seems to fit his crisis situation the best?

2. How does this expanded theory explain the cause and resolution of the crisis?

3. How would you approach the assessment and treatment of the client based on your choice of expanded theory?

Exercise 2.1

Choose one expanded theory that complements your view of counseling in general and one applied theory that does the same. Write out the pros and cons of the use of this theory in a crisis situation.

Applied Crisis Theory (Domains)

In applied crisis theory, James (2008) discusses the presence of four areas: developmental, situational, existential, and ecosystemic. The first three of these areas are based on Brammer’s work (1985) and the fourth is a domain added by James (2008). Although theorists will use different domains to understand the crisis (James & Gilliland, 2005), the first two categories (developmental, situational) are most commonly used to understand the domains of the crisis and are typically labeled maturational/developmental and situational/accidental (Halpern & Tramontin, 2007). The reader may want to explore these two areas (maturational/developmental and situational/accidental) in more depth in Hoff et al.’s (2009) three chapters on life passages, health status and self-image, and occupational and residential security. Table 2.2 summarizes these crisis domains in terms of their views and definitions of crisis.

Table 2.2 Applied Crisis Theory (Domains)

DomainView of CrisisDefinition of CrisisDevelopmentalNormalA shift in development that results in abnormal responses (e.g., graduation)Situational“random, sudden, shocking, intense, and often catastrophic” (James, 2008, p. 13).An uncommon, extraordinary event that an individual cannot predict or control (e.g., rape)ExistentialInner conflicts/anxieties in relation to basic human existence issuesConfrontation of the void, the emptiness with regard to living (e.g., meaning of life)EcosystemicDisaster results that stem from nature or humansA consuming disaster in terms of a group of people who are victims of an event (e.g., a flood)

Case Study 2.2

Using the same case study as in the expanded theory section (p. 17):

1. Which applied theory domain fits this crisis situation?

2. How would you integrate the expanded theory and applied theoretical domain you chose?

Exercise 2.2

Discuss with a colleague how the four applied theoretical domains of crisis counseling can be integrated into your expanded theory of crisis counseling.

Exercise 2.3

Write out your experiences with crisis counseling populations in terms of how you would use your expanded crisis theory. Then add in your experiences in working in the four domains and write about how this expanded crisis theory may have assisted in your assessment and treatment of these clinical populations.

General Crisis Interventions

Before discussing crisis counseling intervention models, we will address a couple of specific interventions, because they can be viewed as overall bridges between theory and application in crisis counseling work. These two interventions are psychological first aid and multimodal therapy. Each can be used in the various crisis intervention models. As discussed in Chapter 1, Slaikeu (1990) separates them into two main intervention components in crisis counseling: first-order intervention (psychological first aid) and second-order intervention (crisis therapy).

Psychological First Aid (PFA)

This intervention strategy of crisis counseling was discussed in Chapter 1 and will be discussed again in Chapter 3. In Chapter 1, it was discussed in an overview of crisis counseling; in Chapter 3 it will be viewed in the context of disaster mental health counseling specifically with regard to treatment.

Using Slaikeu’s (1990) perspective, first-order crisis counseling intervention is psychological first aid (PFA), where the goal is to disrupt the client’s dysfunctional behavior and help him/her return to his/her previous functioning level. The term began in a description of crisis work that was done in response to an Australian railway disaster (Raphael, 1977).

PFA has been described as an acute intervention that is one part of a mental health continuum of care (Everly & Flynn, 2006). It is viewed as the basic component of crisis intervention, as it provides physical and psychological support to the client in a manner that is not viewed as invasive. It has been used professionally in different ways that can be confusing; therefore, it may be understood more easily as being like physical first aid: preliminary care ranging from minor care that needs no additional treatment to serious care that can be addressed temporarily until medical professionals arrive on the scene (Jacobs & Meyer, 2006).

PFA has been described as: (a) having five components (psychological contact, problem exploration, solution exploration, concrete action taken, and follow-up; Slaikeu, 1990), (b) defining duty components (problem definition, client safety and support; James, 2008), and (c) being a general approach to assisting clients (safety, stress symptom reduction, physical rest and recovery, connection to resources and social supports; the National Institute of Mental Health [NIMH], 2002). It has also been described as a set of eight core actions that attempt to reduce the initial distress of the trauma by supporting the short- and long-term adaptive functioning of the client (Ruzek, Brymer, Jacobs, Layne, Vernberg, & Watson, 2007):

1. Contact and engage the client

2. Provide safety and comfort

3. Stabilize the client

4. Gather information

5. Provide practical assistance

6. Connect with social supports

7. Provide information on coping supports

8. Connect the client with collaborative services

Finally, PFA can be placed in Stage 1 (Acute Support) of a three-stage model of treatment (Housley & Beutler, 2007). In this stage, the counselor’s goals with regard to the client are to reduce distress, increase understanding of his/her personal reactions to the crisis, reduce negative coping, and increase knowledge of resources (when needed, how to access). In the provision of acute support, the counselor is establishing rapport with the client, adapting the counseling to fit the client’s needs, providing helpful information, supporting the client’s positive coping skills, making sure resources are available to meet basic needs, and exploring the existence and use of social networks.

Case Study 2.3

Your client is quite emotional during your first few minutes with him. You are concerned about obtaining accurate information in the assessment because of the extent of the anger being expressed. You are not concerned about violence, but more concerned that you cannot follow your client’s train of thought and accurately capture the story of the impact the crisis has had on him.

1. In terms of applying PFA, which aspect(s) of it would you focus on initially?

2. How would you focus on these aspects as a reflection of your view of crisis counseling and your general therapy approach?

All of these perspectives on PFA underscore the importance of using it as a baseline of assistance in crisis counseling work. Although it is technically an intervention strategy, without this strategy, crisis counseling would simply not occur or would be ineffective in its delivery and application. Counselors need to learn how to use PFA as they work with clients in all types of crisis.

Exercise 2.4

Find a colleague with whom you can discuss the following questions:

1. Which aspects of PFA do you view as your strengths in crisis counseling?

2. Which aspects of PFA do you believe you need to strengthen?

3. Are these views of your use of PFA based on clinical experiences? If they are, share one of the highlights of both areas with your colleague. If not a part of your clinical experience, share with your colleague what you anticipate to be a strength or a weakness.

Multimodal

One of the developers of the Multimodal therapy approach was Lazarus (1976, 1981). Lazarus (1981) uses the acronym BASIC ID to describe seven modalities of personality: behaviors (B), affective processes (A), sensations (S), images (I), cognitions (C), interpersonal relationships (I), and biological functions–drugs (D).

This BASIC ID framework can be used to both assess and treat the client in crisis therapy. This acronym can be memorized and used by the crisis counselor to ensure that a balanced assessment and treatment approach is done. For example, a client may have a very strong Affective orientation during the crisis intake, or a tendency for expressing affect in crisis therapy. The counselor can use the acronym (BASIC ID) as a mental checklist to make sure that the other areas are adequately discussed and explored in the assessment and then expressed in the treatment plan. The use of such an acronym in the assessment and treatment process can assist the counselor in appropriately addressing the client’s welfare.

Case Study 2.4

Your client’s physical concerns (Sensations) dominate the counseling session. You believe that it is important to hear the client’s story because the physical concerns are core to the crisis. Yet you realize that in order to complete an accurate, overall assessment, you need to address the other areas of the BASIC ID profile (behaviors, affective processes, sensations, images, cognitions, interpersonal relationships, biological functions–drugs). How would you approach the client in a way that would both allow the client the experience of being heard and yet ensure that a complete assessment is done? What would be your concerns about exploring other areas with the client? How would you address those concerns in your approach, whether directly or indirectly, with the client?

Exercise 2.5

Write down your first thoughts to the following questions:

1. What approaches would you use to explore the cognitive domain of a highly affective crisis client?

2. How would your counseling approach be different if you had a highly cognitive crisis client who was resistant to exploring his/her affective domain in response to the crisis?

Crisis Intervention Models

As stated earlier, no single crisis intervention model captures all crisis intervention approaches. However, as stated in the previous section on crisis theories, the intervention model:

Reflects the counselor’s personal/professional viewsIs shaped by the populations with whom the counselor has worked and with whom he/she is currently workingCan be flexibly used to fit the unique factors of the client and the crisis

Table 2.3 organizes five crisis intervention models to assist the reader in determining the model or models he/she wants to use in crisis counseling. These five models are: equilibrium, cognitive, psychosocial (Belkin, 1984; Leitner, 1974), developmental-ecological (Collins & Collins, 2005), and contextual-ecological (Myer & Moore, 2006).

Table 2.3 Crisis Intervention Models

Case Study 2.5