Chapter 13:​ Working with People in Crisis​

Crisis

• Danger and opportunity​

• Psychological crisis​

• Single stressful situation or cumulative effect of many​

• Severity of stressor is subjective​

Psychological crisis

A person feels unable to cope with perceived challenges that threaten to overwhelm his or her normal coping mechanisms. The destabilization in a crisis provides an opportunity to restabilize at a higher or lower level of functioning. ​

Characteristics of Crisis Intervention​

Immediate​:

• Psychological first aid- intervention after a traumatic event to enhance one’s coping ability ​

  Brief​:

• Rapid assessment and intervention​

Characteristics of Crisis Intervention​

Specifically focused​:

• Clear, organized description of precipitant​

• Discussion of related reactions and interpretations​

• Action to meet urgent concrete or safety needs​

• Less exploration of history unless urgent need to do so​

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May require more frequent meetings and meetings of varying durations:​

• Shorter intervals to organize, calm, and relieve pressure​

• Increasing intervals as problems abate​

  May require more clinician activity than usual:​

• May inform, guide, structure, and advise more​

• May accompany client for support or take action on client’s behalf

What Clinicians Do in ​Crisis Intervention

Help the client tell the story​:

• Biological processes may distort memory or put it out of reach​

• Help clients find a medium of expression right for them​

• A coherent story helps people feel more capable and in control​

  Focus on safety and concrete needs​:

• Assist immediately with reestablishing resource base​

• Establish safety plans​

  Validate events and distress reactions​:

• Normalize universal human feelings in crisis​

• If feelings are culturally taboo, explore thoughts, actions, and bodily complaints instead​

• Explain reasons for exploring crisis reaction​

Critical Incident Stress Debriefing (CISD)​

• Immediate and brief post-trauma process​

• Education and validation of personal experiences​

• Prepare survivors for coping with complex after effects of trauma​

• Be careful not to re-traumatize​

• Debated usefulness

What Clinicians Do in ​Crisis Intervention

Help clients contain feelings and reduce stress​:

• Importance of expression and self-restraint​

• Demonstrate and practice stress reduction techniques​

• Minimize contact with stress-inducing people and situations​

• May volunteer to help others in crisis​

  Quickly establish a baseline of previous functional capacity:​

• Compare customary functioning with current resources and behaviors during crisis​

  Focus on effects on relationships and feelings of relatedness​:

• Help restore positive ties​

What Clinicians Do in ​Crisis Intervention​

Involve family and friends in the intervention​:

• Rich sources of information and support​

• Faith communities may offer non-stigmatized help and association​

• At times may be contributing to the crisis​

• Significant others may experience emotional contagion​

• Extend support to those who need it​

  Focus on strengths:​

• People in crisis can forget their strengths​

• Competence increased by exercising it on own and others’ behalf​

• Avoid directives, excessive control and action undermining that of clients​

Emotional contagion ​

The experience of absorbing another’s distress and subsequently becoming distressed oneself. Clinicians experience emotional contagion through empathy with their clients.

What Clinicians Do in ​Crisis Intervention​

Help the client make meaning of the events​:

• Bring gradual coherence to the narrative​

• Enlarge perspective and deepen understanding​

• Work within the client’s cultural framework​

• Enhance client’s locus of control​

• Work supportively with “Why me?” questions​

• Challenge self-blame and harsh self-judgments​

• Discuss alternative explanations, interpretations​

• Share stories of other survivors​

• See the crisis as one part of a whole life​

Locus of control

A psychological principle referring to one’s perception of personal power and place in the world, and the extent to which people see themselves as capable of effectively influencing outcomes and accomplishing desired goals. ​

What Clinicians Do in ​Crisis Intervention​

• Maintain here-and-now focus on present crisis​

• Check regularly for suicidal or other self-harming behaviors​

  -Signs of despair, hopelessness, and wishes to escape or rejoin lost ones​

  -Means and opportunity for self-harm​

  -Suddenly giving away possessions or money​

  -Suddenly presenting as strangely relieved and happy​

What Clinicians Do in ​Crisis Intervention

Use rituals and other marker events​:

• Ask about culturally based coping strategies​

• Restore agency, dignity, and connections​

• Anniversary reunions, permanent memorials, websites, quilts or other installations​

• Importance of kinship and reference group ties​

• Mutual aid strengthens all through support, coping tips, and shared caring​

• Advocacy groups can form to chance laws, institutions, and community norms

What Clinicians Do in ​Crisis Intervention

Prepare the client for ending​:

• Crisis bonding can be quite strong​

• Agreed-upon time limits ease the process​

• Work ends when functioning approximates pre-crisis levels or better​

  Provide follow-up and ongoing support​:

• Periodic check-ins to assess coping and well-being​

• Clients may reach out at important anniversaries​

Key Issues in Working with a Suicidal Client​

• Prepare for the unexpected​

• Use empirically supported assessment tools

  -Risk factors: increase a person’s chances of disease, injury, or harm in the future.

  -Warning signs (IS PATH WARM): events or behaviours that connate imminent risk of suicide over the next few minutes, hours,or days

IS PATH WARM

I: ideation

S: substance abuse

P: Purposelessness

A: Anxiety

T: Trapped

H: Hopelessness

W: Withdrawal

A: Anger

R: Recklessness

M: Mood change

Risk Assessment

• Goal of assessment is to predict risk and manage it​

  S pecificity​

  L ethality​

  A ctual availability of imagined method​

  P roximity of social helping resources​

• Protective factors- lower risk​

Key Issues in Working with a Suicidal Client​

• Directly address suicidal thoughts​

• Offer empathy and hope​

• Focus on immediate safety​

  -Emergency contact person​

  -Consult with supervisor or consultant​

  -Legal commitment​

  -Risk management- document in detail​

• Follow recommendations of consultants and supervisors​

• If a client commits suicide, get support​

Clinician Reactions to Working with​ Crisis, Trauma, and Suicide​

Negative reactions – dangers​:

• Emotional contagion​

• Secondary traumatic stress​

• Vicarious trauma- clinician experiences similar changes to traumatized individual​

• Shared sense of helplessness- de-value own skills​

• Distance or detach self from client​

• Feel contempt for the client​

• Take on too many assignments so can’t focus on client​

• Evokes crisis in our own lives​

Clinician Reactions to Working with​ Crisis, Trauma, and Suicide​

Positive reactions – opportunities​

-Vicarious resilience​

• Learn from clients about coping with adversity​

• Counters fatigue​

• Motivates to work with victims of trauma​

Clinician Reactions to Working with​ Crisis, Trauma, and Suicide

Positive reactions – opportunities (continued)​

-Vicarious traumatic growth- positive changes in clinician’s worldview​

• Increased faith​

• Ability to focus​

• Feel good about work​

• Work for social justice​