Monday, January 29, 2007

Crisis Intervention and Suicide Assessment: Part 1 - History and Assessment

[Episode 3] This is part one of a two-part series on Crisis Intervention. In this lecture, I provide a brief overview of the history of modern crisis intervention and crisis theory. I discuss two approaches to crisis assessment, Myer's Triage Assessment Model and the Dilation-Constriction Continuum model.


Please visit: http://www.socialworkpodcast.com/2007/02/crisis-intervention-and-suicide.html for the second part of Crisis Intervention and Suicide Assessment.

Download MP3 [34:31]



Transcript

CRISIS INTERVENTION 01-64


[00:00:13]

Today’s topic is Crisis Intervention and we're going to be looking at three areas of intervention. We're going to start out by taking a look at crisis assessment: what you do to figure out what's going on with the affective, behavioral and cognitive functioning of your client. We're going to follow up with crisis intervention. As with all interventions, you start with the assessment and then you move on to what you actually do to resolve the problem at hand. And we're going to end with a discussion on suicide assessment and risk assessment.

Suicide assessment is a separate category of assessment, but it's also used during the crisis assessment to establish lethality, because safety is important for both the clinician and the client. Although people have certainly experienced crises, for probably since time began, there is an actual date that people point to as the modern beginnings of crisis intervention: November 28th, 1942 -- 492 people died in a fire in the Cocoanut Grove Nightclub in Boston.

A Boston psychiatrist, with an interest in emotional responses to bereavement, grief and loss, Dr. Erich Lindemann, interviewed survivors or relatives of those who died in the fire. And his description of the acute grief reaction became the foundation for understanding how people respond to crisis. He found that most people who survived the fire, or family members who lost someone in the fire, demonstrated remarkable coping skills. The survivors who had dealt with previous crises and those who had completed a cycle of grief fared better than those who had not resolved past problems and who did not complete the cycle of grief.

He also found that the human capacity to cope with problems, which is not innate but gained through experience, often falters at the time of crisis, like the sudden loss of a loved one. Perhaps most importantly, Lindemann’s work set the stage for understanding crisis as a normal event. That is, something that’s not pathological or not representative of an underlying moral or cognitive failing of the person. Normal in the sense that everyone is susceptible to experiencing a crisis.

This is a significant departure from the predominant beliefs of the time influenced by Freud and the other psychodynamic theorists that suggested that personality problems were the result of deep-seated, unresolved issues. But in fact, with the Coconut Grove fire, Dr. Lindemann found that in fact people that were otherwise healthy (functioning people) found themselves completely debilitated by the crisis event. So in 1944, Dr. Lindemann proposed the following foundational ideas about crisis.

People in crisis can be receptive to major life changes. Crisis intervention can be accomplished in a relatively brief period of time and this was also a significant departure from the psychodynamic paradigm of the day. Third, people in crisis can be helped significantly through supportive networks with friends, para-professionals and religious leaders. And finally, an adaptive resolution to a crisis situation can result in enduring positive change.

So, how do we define crisis? There are as many definitions of crisis as there are authors that write about crisis. Some of the contemporary authors that I've drawn from for this lecture are: James and Gilliland, Hal Roberts, Kristi Kanel, Jennifer Hillman, Wainrib and Bloch and some others.

In Chinese, the pictograph for crisis is comprised of the words danger and opportunity. And it's safe to assume that almost every crisis imaginable has some element of danger, either physical or psychological, as well as the opportunity for growth and change. All crises have some sort of precipitating event and there are a variety of events that people have identified as contributing to the perception of a crisis.

The first kind is a situational, and that’s a specific incident and actually for service providers. A situational crisis [00:05:00] can include what they call vicarious traumatization or secondary trauma as a result of working with somebody in crisis. The second type is a developmental crisis, such as the kinds that Erikson talks about in his Eight Stages of Psychosocial Development. The third could be an environmental event and this is different than situational or developmental in that environmental events specifically affect groups.

Types of environmental events include natural disasters, such as hurricane Katrina; human made, such as Three Mile Island; political disasters, such as what's happening in Iraq right now; a biological disaster, for example AIDS; and economic disasters, for example recessions or factories closing, jobs being outsourced. A fourth type of event could be an existential event such as a mid-life crisis. And finally there's a compound, or as James and Gilliland talks about, a trans-crisis and that’s when an event that in and of itself might not have precipitated a crisis, actually triggers a prior crisis response.

For example, a woman who experienced childhood rape goes into a crisis state when her own daughter gets raped. So, in addition to there being a precipitating event, that event is actually perceived as a threat, danger or loss. If your client does not perceive the event as a crisis event, then it's not a crisis. For example, I had a client who was raped and for her the actual act of being raped did not precipitate a crisis. She did not see that as a crisis situation in part because she had experienced rape before and had coping mechanisms for that experience. For her, the crisis event was the loss of her place to stay. If I was just going to guess between losing a place to stay and being raped, my guess would have been rape as precipitating event, but for my client, in fact, it was losing her shelter. And so this is a good example of why it's important to be very careful when you listen to your clients to make sure that you are identifying their precipitating event and find out what they perceive to be the crisis event.

Once you do that, then you need to identify whether or not their coping strategies are overwhelmed and insufficient. And finally, once you’ve identified the precipitating event, and you realized that it's been perceived as a threat, and you recognize that coping strategies are overwhelmed, then the last criteria is that the person is in a state of disequilibrium, and that there's an opportunity to intervene that can result in the person returning to the same or a higher level of functioning than before the crisis.

So, what crisis is not: crisis is not disaster management. In a 2005 article, Robert [inaudible] [0:08:15] clarified that disaster management actually focuses on the event, such as hurricane Katrina, rather than the psychological needs and responses of those who experienced the disaster. Disaster management includes rescue services and reestablishing infrastructure; for example: food, running water, shelter, etc. and can be a necessary precursor to crisis intervention because it provides safety and basic needs. But disaster management does not constitute crisis intervention, because disaster relief workers do not assess whether an individual has perceived the disaster event as a crisis. Only some people will find that their coping skills will be overwhelmed by the event and for those people crisis intervention is appropriate.

Crisis is also not stress and trauma, although they have some overlap and follow along a continuum that ends in crisis, according to Domez and Hilarsky. Stress is defined as pressure or strain that is ameliorated through typical coping and stress often occurs multiple times a day. Now trauma is defined as unresolved pressure or strain that can be either physiological or psychological, that a person understands to have injured his or her worldview.

One way of understanding this idea of trauma as injuring a worldview is to look at issues of cultural diversity. Recently, a number of authors have argued to recognize the role of continuous class, gender and racial or color-based aggressions including acts [00:10:00] of exclusion, victimization and intimidation and injustice. Weaver (1996), talks about collective trauma experienced by Native Americans as a result of systematic genocide perpetrated by Americans in the U.S. government over centuries. Now these traumas, while they might injure somebody’s worldview, again do not meet the criteria for crisis.

So again, disaster management, stress, and trauma are not crises.  So how do you define a crisis? One definition is that crisis is instability or disorganization resulting from an acute or chronic perceived stress. It is the failure to adequately employ typical coping skills. So now, we’d like to talk specifically about crisis intervention.

Some major assumptions of crisis intervention, according to Jennifer Hillman in 2002, are that everyone is susceptible to crisis reactions and so you will work with a diversity of clients in a diversity of settings. For example, you work with kids, adults; you work out in the field, in offices; wherever the crisis happens. Number two: client and worker’s safety is a prerequisite for crisis intervention, and this is one of the reasons why we're going to be talking about suicide assessment and risk assessment at the end of this podcast. Third: crisis intervention is brief and time-limited. It is suggested that crisis intervention lasts somewhere between 6 to 12 weeks. The focus is on the present in a single issue. In such a short period of time and with such limited coping skills, the worker with limited time, doesn’t have the ability to accurately and fully address multiple issues. And the client, with limited coping skills, doesn’t have the resources to actually deal with more than the one precipitating event in addressing that.

Now, the worker in crisis intervention is active, but avoids being directive. Another assumption of crisis intervention is that treatment needs to be flexible. Techniques are drawn from multiple perspectives and modalities, such as individual family therapy and group therapy. And finally, as we've said many times, the final assumption of crisis intervention is that it is an opportunity for change.

Now the goal for treatment for crisis intervention is to restore the client at least to the pre-crisis level of functioning. Green and his colleagues in 2005 suggested that people are uniquely open to significant change during a crisis and therefore, crisis intervention should leave people at a higher level of functioning than prior to the crisis. The second general treatment goal is to resolve the central single, or focal, issue rather than addressing multiple goals.

The treatment relationship should be active. For example, the crisis worker takes charge and provides structure and, when necessary, safety. But not necessarily directive, meaning that the crisis worker makes decisions about how the client lives their life. The treatment relationship is also intensive. And by intensive I mean that the treatment relationship lasts as long and is as frequent as necessary to resolve the crisis situation. And this could be five hours one day, six hours the next day; it could be multiple times over a 24-hour period.

Techniques are eclectic. Cognitive behavioral therapy, reality therapy, etc. are particularly valuable because of the emphasis on the here and now in quantifiable change.  But the most important thing for the clinician to know is that crisis intervention is flexible. And you can use most techniques that you are comfortable with in terms of assessment, eliciting feelings, treatment planning, identifying goals and really getting at the heart of the issue for the client.

Some of the limitations for crisis intervention include limited empirical evidence to support crisis assessment intervention techniques, due in part to practical and ethical issues of obtaining consent from participants during crisis situations. The risk of coercion is high if somebody comes to you immediately following a rape and you say: “Great, I'd love to provide services. Would you be willing to participate in our research study?”

This doesn’t mean that research can't happen in crisis situations. It just means that ethical issues are important to consider and is one of the reasons why there is limited current research on crisis intervention. In 2002, Jennifer Hillman noted that we don’t know if the most effective crisis intervention comes from peers or professionals. For example, volunteers are the most common [00:15:00] crisis workers on hotlines and receive more training than most licensed professionals.

And furthermore, she notes, it's unclear if group or individual intervention is most effective. Another limitation of crisis intervention is that it does not resolve underlying issues, for example: deep seated personality issues or relationship problems. Nor does it resolve broader social issues, for example: discrimination, prejudice, unemployment, poverty, violence, etc. By design, crisis intervention will not address long-term psychological problems.

The relationship of crisis intervention to traditional social work is that it requires the same basic attending and listening skills, support and empathy, careful assessment and working agreements as used in non-crisis treatment. And as with all clinical work, the most important component of crisis intervention is the relationship between you and your client. What makes crisis intervention different, however, is that it's more active, faster-paced, more focused in shorter term than other forms of intervention.

It's one of the few clinical situations where you won't have time to look up how to do something or how to proceed. Therefore, I recommend memorizing the steps involved in crisis intervention and suicide assessment. Memorizing this framework will enable you to provide a higher quality of professional service to your clients, as well as limit your risk for future liability.

After we come back from a short break, I will review two types of crisis assessment, two types of crisis intervention and I'll end with suicide assessment.

[00:16:43]

Break

[00:17:11]

Today, I'm going to talk about two models of crisis assessment. The first one is Rick Myer’s Triage Assessment Model; I highly recommend his book on Triage Assessment for Crisis Intervention. Dr. Myer does a wonderful job of operationalizing how to assess affective, cognitive and behavioral functioning and I believe that it's useful in both crisis and non-crisis situations.

So, you have those three domains and they're rated on a scale of 10 (which is severe impairment) to 1 (which is no impairment). Rather than having 10 distinct levels of impairment, the triage assessment model divides impairment into six levels. That would be: no impairment, minimal, low, moderate, marked and severe; and each of the levels of impairment has their own characteristics. Now, when you do the assessment, you start with the most severe ratings and work down.  So, for example, when you first meet a client, you start with the most severe rating and decide: “Does my client meet this category?” And if the answer is no, then you move down to the next less severe category.

And the purpose is to establish severity ratings for affect, behavior, and cognition. Affect is divided into three emotional groupings: the first is anger-hostility, the second is anxiety-fear, and the third is sadness-melancholy. Now, there might very well be more emotions that your client expresses and feels. These are three broad categories that most emotions can fit into. And during a crisis situation it might not be as important to distinguish the minutia of the emotional expression as the broad overall category, because that’s what's going to help you determine what your intervention will look like.

So the first one, anger-hostility might sound like somebody saying: “I'm outraged, furious, irritated. I'm enraged. I'm exasperated. I'm pissed off. I feel violated.” Anxiety-fear might be evidenced by someone saying: “I'm panicked. I'm terrified. I feel scared. I'm tense. I'm jumpy. I'm stressed. I'm afraid. I'm anxious.” Finally, sadness-melancholy, somebody might say: “I'm depressed. I feel hopeless. I'm miserable. I'm hurt. I'm lonely. I'm discouraged. I'm blue, dismal. I just feel pathetic.”

I'm going to go through some brief examples of the ratings for the affect and I'm not going to go through the ratings for all of the categories because it would just take too long. And over a podcast, it's pretty boring to listen to somebody ramble on and on. So, we're going to start out with the most severe rating, [00:20:00] which is, I said is, what you want to start out with, and that’s decompensation or depersonalization. For example, the client may be in shock, unable to talk, unable to express any emotions.

On the other hand, the client might be hysterical and unable to regulate any expression of affect. Now moderate impairment, which will be level 6 and 7, the affect might be incongruent with the situation. There might be extended periods of negative mood. The client might have to exert serious effort to control emotions that are related to situations other than the crisis. For example, reacting to a situation at work with the same emotional content that they're reacting to the crisis situation with.

The last rating that I'll go over would be minimal impairment, and this would be somebody who gets a 2 or a 3. What you would see is that the affect was appropriate to the situation. Emotions would be substantially under the client’s control and the affect of reactions wouldn’t interfere with day-to-day emotional expression. When asked, a client would be able to regulate their emotional expression, associated specifically with the crisis.

Behavior. Behavior is divided into three categories: approach, avoidance and immobility.  Approach are active efforts to resolve crisis-related issues. Behaviors can be positive or helpful or they can be negative or unhelpful, with regards to the resolution of the crisis.  So for example, a client might say: “Well, what if I did this?” or “If I ever get my hands on him or her, I'm going to get them.” You can have a client say: “That doesn’t work.”  All of these indicate that the client is actually doing something to resolve the crisis. If, in the example of hurricane Katrina, somebody is filling out paperwork for a FEMA trailer or to get food stamps, then that would be an approach behavior that would be positive. If however, they were seeking revenge on, I don’t know the National Weather Service, that would be an approach behavior that would not actually help them address whatever crisis situation they might find themselves in.

Avoidance is the second category. Now, these are efforts to flee crisis-related problems.
So again, with approach, they are behaviors that are directed towards resolving the crisis.  Avoidance are efforts to flee crisis-related problems and this could look like your client blaming others, lying, hiding evidence. Some phrases that they might use could include: “People tell me I have to face it sometime” or “I can't take it anymore” or “You know this will never work.” These are all things that clients can say to indicate that the behaviors that they're engaged in are actually in the effort to avoid the crisis resolution.

Now the third category is immobilization. And this is the lack of attempts to approach or avoid, or they can be self-canceling behaviors that mitigates successful crisis resolution.  So, lack of attempts to avoid or approach could sound like somebody saying: “I don’t know where to start” and “I'm not sure what to do.” Self-canceling behaviors could be that the person is approaching the situation in one way and then engaging in another behavior that actually cancels out the first behavior.

You might get clued into this if somebody says: “You know, nothing seems to work here.” So, for example, if somebody is filling out paperwork for a FEMA trailer, that would be an approach behavior. But could ultimately end up being immobilizing if they never actually turn it in.  So, you would have filling out the paper, which is good; and not turning it in, which doesn’t actually help them resolve their crisis situation. And they would be self-cancelling behaviors.

The next area is cognition. Now, assessment of cognition is slightly different than affect and behavior because thoughts and beliefs about the future, past, and present are assessed within the context of four-life dimensions. And these would be the physical, psychological, social, and moral-spiritual. And these four dimensions correspond with the traditional social work assessment, which covers the bio-psycho-social-spiritual assessment domains. So, this should be familiar to social workers.

There are three types of cognitions that you're going to want to assess for within each of the four domains. The first one is [00:25:00] threat. And threat looks at potential for harm in the future. For example: “I don’t know what will happen. What should I do? How long can I bear this?” These are all things that clients can say that let you know that they're thinking about the future. They could be thinking about the future in any one of the four-life dimensions.

It could be physical, which is: food, water, shelter, financial, etc. Psychological, this includes: self-concept, issues of identity and self-esteem. And also social, which would be: relationships with friends, co-workers. And then finally moral-spiritual, which includes: issues of integrity, values, religious beliefs, etc. So if we think about future threat in terms of cognition, you would want to assess whether there are concerns about the future with regards to the physical domain.

For example, a client would say: “What should I do to get shelter? What should I do to get water? Where can I find food?” During hurricane Katrina, and I know I keep coming to this-back to this example, but during hurricane Katrina, you had people who were looting stores for food. Well, those were approach behaviors that were probably triggered as a result of concerns, thoughts about: Where am I going to gather food? as opposed to any deep seated psychopathology. This is what people do in a crisis.

So you have thoughts about the future, which in this model is called threat. You also want to assess if there are thoughts about the past and those are called loss and those would be perception of injury or actual harm. Some phrases could include: “If I only had (something)” (whatever that would be) or “I really miss my dog” or “I wonder what would have happened had I actually heeded the warnings and left New Orleans.” Again, you can have loss for any of the four-life domains, so let's take for an example: social.

If somebody says: “You know, I really miss my dog.” That would be a social relationship. They could also say: “You know, I really miss being able to go to work in the morning. You know, paling around with my co-workers, standing at the water cooler. I really miss that.” And for this client, this is really a sense of loss, of perhaps identity, which would be psychological.

And the final one that you're going to want to assess for among those four domains is this idea of current violation, something in the present which Myer refers to as transgression. And some examples of that might sound like: “You know, no one should have to take this. Why is this happening to me?” or “Why doesn’t it stop?” And again, those can all happen within the life domains. So, transgression in the moral domain could sound like: “Why would God let this happen at all? Why doesn’t God make this stop?”

The point of addressing these three different time frames in cognition, among the four different life dimensions, is that it helps target whatever it is that you're going to do in the intervention. Now, for all three: the affect, the behavior and the cognition; it's important to identify what is the most important or the most significant issue to address in affect, behavior and cognition. You'll create a single rating for affect, for behavior, and cognition and you'll add those up and you'll have your overall crisis assessment rating. And this is what's going to help you determine what to do for your intervention.

The second crisis assessment model that I'm going to talk about is the Dilation-Constriction Continuum Model. Lillibridge and Klukken first developed this model, or talked about this model, in 1978. And this model proposes that people’s affective, behavioral and cognitive functioning can be assessed along a continuum of dilation and constriction. This metaphor is pretty easy to understand if we think about dilation and constriction as it relates to the human eye and the way that the eye reacts to the presence or absence of light.

So when light is not present, when it's dark, pupils open or dilate to let more light in. And when it is bright out, pupils get smaller or they constrict to keep light out. In the dilation-constriction continuum model of emotions, emotions can be more open, they can be more dilated or more closed. If the pupils dilate and constrict in response to the light, all is well.  However, if the pupils stay dilated when it is bright or constricted when it's dark, then the eyes are not properly functioning. And as with the eyes, dilation and constriction of emotions, behaviors and cognitions can be an adaptive and protective and helpful response. But at the extreme these functional adaptations [00:30:00] can interfere with successful crisis resolution.

For dilated affect, it looks like somebody is over-emotional or has uncontrollable emotion and the worker’s response is to focus on specific feelings and work with cognitive material. Now, it's important to work with cognitive material when somebody is over-emotional because that takes them out of the emotional experience, not dismissing their emotional experience. But it takes them out of their emotional experience to the point where they can actually address the situation at hand, which again in a crisis situation is key.

On the other end of the continuum, you have somebody whose affect is totally constricted. They would be holding in their feelings, for example, and the crisis worker would then help with emotional expression. One way to help people access their emotions is simply to close their eyes as they're talking about a situation or discussing a situation. It blocks out external stimuli and helps them focus inwards.

Behavioral assessment dilation could look like excessive behavior, acting out or inappropriate behavior and the worker’s response would be to use reality-oriented and problem solving approaches to identify and encourage the client to use more appropriate behaviors. The opposite end of the continuum would be constricted behavior and that might look like paralyzed, immobile or withdrawn behavior. And the worker’s response would be to stimulate movement and help the client to do things for themselves.

Finally, for the cognitive domain, cognitive dilation could look like disorganized, chaotic or confused thinking and the worker’s response would be to help clarify, identify specifics and identify problems that the client can work on. And constricted cognition would look like preoccupation with solutions, ruminating or obsessing. For example, if a client has been displaced because of a hurricane and the thought: I need to get back home to save my photo albums, that’s all I have left, that it keeps going through their mind over and over and over again such that they think about it for, I don’t know, say a couple of hours a day. Or they're thinking about it so much so that they can't actually think about other things that might be more important in that very moment for resolving whatever crisis it is that they're experiencing.

And so the worker’s response is to identify alternatives and to identify workable solutions. So, the Triage Assessment Model and the Dilation-Constriction Continuum Model, they're not mutually exclusive. They do not contradict each other. They are two different ways of assessing affective, cognitive and behavioral domains. The bottom line is that it really doesn’t matter which model you use as long as you're able to adequately assess the affective, behavioral and cognitive functioning of your client in crisis.

The Dilation-Constriction Continuum Model has a fairly easy metaphor and can be easy to keep in mind when you're working with a client. The Triage Assessment Model takes much more training, but it is much more sophisticated and provides things such as final ratings and detail when looking back on a crisis situation. So, use whichever one you want. They can piggyback. They're good to go with each other, just as long as you're able to assess those three domains.

This is the end of Part 1 of Crisis Intervention and Suicide Assessment. We've reviewed a brief history of Crisis Intervention and we've talked about two different models for assessing folks in crisis: the Triage Assessment Model and the Dilation-Constriction Continuum Model. Join us in our next podcast where we're going to talk about Roberts’ Seven Stage Model of Crisis Intervention and we're going to end with a discussion of Suicide Risk Assessment.

[End of Audio]
[00:34:16]

Transcription generously donated by Kelsi Macklin.


References

Corey, G. (2005). Theory and practice of counseling and psychotherapy (7th ed). Belmont, CA: Wadsworth/Thomson.

Greenstone, J.L., & Leviton, S.C. (2002). Elements of crisis intervention: Crises and how to respond to them (2nd ed.). Pacific Grove, CA: Brooks/Cole

Lukas, S. (1993). Where to start and what to ask: An assessment handbook. New York: W. W. Norton & Company.

Myer, R. A. (2000). Assessment for crisis intervention: A triage assessment model. Belmont, CA: Wadsworth Publishing.

Roberts, A.R. (Ed.). (2005). Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). New York: Oxford University Press

Wainrib, B. R., & Bloch, E. L. (1998). Crisis intervention and trauma response: Theory and practice. New York: Springer Publishing Company.




APA (6th) citation for this podcast:

Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 1 - history and assessment [Episode 3]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/01/crisis-intervention-and-suicide.html

2 comments:

Savannah Smiles said...

I have two college classes right now that require us to listen to a podcast and write a learning summary write up weekly. For those in class that have a learning disability, or simply don't do well with listening to podcasts, it would really help if more or the podcasts were transcribed. I know that some of the more recent podcasts have been transcribed, but for those in the archives that graduate professors are still using, it would help to have them transcribed as well.
Love the podcasts! Keep it coming!

Amanda Shady said...

I completely agree with Savannah. The podcasts are great however when trying to write a paper while listening to them can easily become overwhelming and frustrating. You can easily lose your place if you go back because you missed something you needed to hear. Having a transcription of it would make it easier to follow along as well as easier to comprehend for those who understand things better reading what is also being said.