Crisis Intervention – A Primer

Crisis is a state of emotional turmoil or an acute emotional reaction to a powerful stimulus or demand, trauma expert Jeffrey Mitchell explains. There are three characteristics of crisis:
The usual balance between thinking and emotions is disturbed.
The usual coping mechanisms fail.
Evidence of impairment in an individual or group.
Crises may occur when individuals face actual or threatened death, serious injury or some other threat to their physical integrity, according to the International Journal of Emergency Mental Health. Individuals may also be victimized by witnessing these events occurring to others. Contradictions to some deeply held beliefs can cause crises.
Crisis intervention provides help for individuals or groups during a period of extreme distress. The intervention is temporary, active and supportive. Crisis intervention is most frequently provided by firefighters, police officers, emergency medical or search and rescue personnel, nurses, physicians and other hospital workers, communications personnel and community members.
Basics of Crisis Intervention
Three goals guide techniques used in crisis intervention:
Mitigate impact of event.
Facilitate normal recovery processes.
Restore adaptive function.
Crisis intervention techniques should also abide by the following seven principles:
Simplicity: In a crisis, people respond best to simple procedures. Simple things have the best chance of having a positive effect.
Brevity: Psychological first aid needs to remain short, from minutes up to one hour in most cases.
Innovation: Use creativity; specific instructions do not exist for every case or circumstance.
Pragmatism: Keep it practical; impractical suggestions can cause the person to feel more frustrated and out of control.
Proximity: Provide support services close to the person’s normal area of function. “The most important thing about proximity is that support must be given in a safe zone,” according to the book Prehospital Behavioral Emergencies and Crisis Response.
Immediacy: Provide services right away. Crises demand rapid interaction, and delays can undermine the effectiveness of support services.
Expectancy: Work to set up expectations of a reasonable positive outcome. The person or group in crisis should be encouraged to recognize that help is present, there is hope and the situation is manageable. It may be appropriate to tell the person or group that although the situation is overwhelming right now, most people can and do recover from crisis experiences.

Leading Crisis Intervention Models
Two leading crisis intervention models are: Albert Roberts’ Seven-Stage Crisis Intervention Model, as described in Brief Treatment and Crisis Intervention; and Mitchell’s Critical Incident Stress Management intervention system, as described by the International Critical Incident Stress Foundation and International Journal of Emergency Mental Health.
Other widely recognized models include Psychological First Aid, Mental Health First Aid and Stress First Aid.

Roberts’ Seven-Stage Crisis Intervention Model
Roberts identifies seven critical stages that clients typically pass on the road to crisis stabilization, resolution and mastery:

  1. Plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment.
    The biopsychological assessment should at least include the client’s environmental supports and stressors, medical needs and medications, current use of drugs and alcohol, and internal and external coping methods and resources. Assessing lethality must first determine whether a suicide attempt has been initiated and then can continue with the client’s potential for self-harm. Imminent danger must establish, for instance, whether the person is now a target of domestic violence, a violent stalker or sexual abuse.
  2. Make psychological contact and rapidly establish the collaborative relationship.
    Rapport is facilitated by the crisis worker offering conditions such as genuineness, respect and acceptance of the client. Traits, behaviors or character strengths of the crisis worker come to the fore to instill trust and confidence in the client. Strengths include flexibility, positive mental attitude, resiliency, reinforcing small gains, good eye contact, creativity and nonjudgmental attitude.
  3. Identify the major problems, including what precipitated the crisis.
    The crisis worker should determine what in the client’s life led to that person needing help. The worker should also try to determine which problems to work on first; these determinations can help understand the client’s coping style.
  4. Encourage an exploration of feelings and emotions.
    This stage involves the crisis worker allowing the client to express feelings, to vent and heal, and to explain the person’s side of the story about the current situation. Skills include active listening, communicating with warmth and reassurance, nonjudgmental statements and validation, and accurate empathetic statements. The crisis worker can, very cautiously, eventually work challenging responses into the dialogue, including giving information, reframing, interpretations and playing “devil’s advocate.” Challenging responses can help loosen clients’ maladaptive beliefs and consider other behavioral options.
  5. Generate and explore alternatives and new coping strategies.
    This stage can be the most difficult to accomplish. Achieving the goals in stage four means that the client likely has worked through enough feelings to have some emotional balance. Now, the crisis worker and client can put certain options on the table to ensure the client’s safety, such as a no-suicide contract or brief hospitalization, alternatives for finding temporary housing or considering the pros and cons of various programs for treating chemical dependency.
  6. Restore functioning through implementation of an action plan.
    An action plan helps provide concrete plans for ultimately restoring the client’s cognitive functioning. Many clients have trouble mobilizing and following through on an action plan; obviously, the action plan is critical for restoring the client’s equilibrium and psychological balance.
  7. Plan follow-up and booster sessions.
    The crisis worker should plan for a follow-up contact after the initial intervention to ensure the crisis will be resolved and to evaluate the client following the crisis. Follow-up contact should include physical condition, cognitive mastery of the precipitating event, assessment of overall functioning, satisfaction and progress with ongoing treatment, any current stressors and how those are being handled, and need for possible referrals
    Critical Incident Stress Management (CISM)The CISM is a comprehensive crisis intervention system that may be applied to individuals, small functional groups, large groups, families, organizations and even entire communities. It spans the entire temporal spectrum of a crisis. Mounting empirical evidence demonstrates that the CISM approach provides the tools for prevention and corrective treatment, the International Journal of Emergency Mental Health says.
    CISM has seven core components
    Pre-crisis preparation. This includes stress management education, stress resistance and crisis mitigation training.
    Disaster or large-scale incident, as well as school and community support programs including demobilizations, informational briefings, “town meetings” and advising staff.
    Brief small group discussions called defusings, which are provided within hours of a crisis for assessment, triaging and mitigating acute symptoms.
    Longer small group discussions known as Critical Incident Stress Debriefing (CISD). These structured group discussions are usually provided one to 10 days after a crisis to mitigate acute symptoms, assess the need for follow-up and, if possible, provide a sense of post-crisis psychological closure.
    One-on-one crisis intervention/counseling or psychological support throughout the full range of the crisis spectrum.
    Family crisis intervention and organizational consultation.
    Follow-up and referral mechanisms for assessment and treatment, if necessary.

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