Existential Therapy

[Episode 7] In today's podcast, I talk about Existential therapy as an intellectual or philosophical approach to working with people. Although some authors have attempted to manualize Existential therapy (see Keshen, A. (2006). A new look at existential psychotherapy. American Journal of Psychotherapy, 60(3), 285-298), the existential approach is not known for specific techniques or procedures. Rather, its influence has been most notable in encouraging clinicians to focus on the ideas of freedom of choice, the responsibility that accompanies choice, and the notion that the inevitability of death is what gives life meaning.


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Transcript

Today, we're going to be talking about existential therapy.  Existential therapy is an insight-oriented therapy much like Freudian psychoanalysis or Adlerian personal psychology.  What distinguishes existential therapy from other insight-oriented therapies is that existential therapy is more of a philosophical or intellectual approach to understanding a person’s problems rather than a set of techniques.  Existential therapy emphasizes our freedom to choose what we make of our circumstances and believes that we are free and therefore responsible for our choices and actions.

In essence, as Gerald Corey (2005) writes, we are the authors of our lives. Gerald Corey identifies six key concepts associated with existential therapy.  The first is that we have the capacity for self awareness.  Now, the greater our awareness, the greater our responsibilities for freedom and Corey writes that awareness is realizing that we are finite, that we understand that time is limited.  We have the potential and the choice to act or not to act and that meaning is not automatic that we must seek it.  And finally, that we are subject to loneliness, meaninglessness, emptiness, guilt and isolation.

The second key concept is that because we're basically free beings, we must accept the responsibility that accompanies our freedom.  In other words, because we're free to choose we have to take responsibility for the choices that we make.

A third key concept is that we have a concern to preserve our uniqueness and identity.  We come to know ourselves in relation to knowing and interacting with others.  Our identity is the courage to be.  We must trust ourselves to search within and find our own answers. Corey writes that one of our greatest fears is that we'll discover that there is no core and no self.  Another key concept is that the significance of our existence and the meaning of our life are never fixed once and for all.  Instead, we recreate ourselves through our projects.  Our search for meaning must be pursued obliquely.  This means that finding meaning in life is by necessity a by-product of a commitment that we make to creating, loving and working.

Another way of thinking about this is that we can't directly seek meaning.  Rather, we have to engage in activities and it is through that engagement that we actually find the meaning in our lives.  Viktor Frankl talked about the will to meaning as our primary focus in life.  Frankl said that life in and of itself is not meaningful. The individual must create and discover that meaning.

Now, one of the themes here is that people are creating their own realities and this is a phenomenological approach similar to Adler but very dissimilar to Freud and this phenomenological approach assumes that we are actively involved in the creation of our own realities.  As a therapist, if we understand that our client is creating their own reality, it's therefore important for us to assess and identify what that reality is and the meanings that our client is making of his or her reality.

Final key concepts include anxiety as part of the human condition.  The existentialist believes that anxiety is a basic condition of life and they call this existential anxiety and they consider it to be normal.  In fact, life can't be lived nor can death be faced without anxiety.  Anxiety can be a stimulus for growth as we become aware of and accept our freedom.  We can blunt our anxiety by creating the illusion that there is security in life and if we have the courage to face ourselves in life, we might be frightened, but we will be able to change.

A final concept is that death is a basic human condition and awareness of death gives significance to living.  So, these are the six key concepts that Corey identifies in existential therapy.

One of the criticisms of existential therapy is that its concepts can be vague and hard to understand, so in the attempt to make it a little bit more clear what existentialist stand for I'm going to compare and contrast the existential approach to therapy with Freud’s psychodynamic approach.

Existentialism believes that we are free to make our choices and we're not hindered by the past or by biological drives.  In contrast, Freudian psychoanalysis believes that freedom is restricted by unconscious forces, irrational drives and past events.  In existentialism, anxiety can be useful.  In psychodynamic theory, anxiety or neurosis is not useful and is in fact pathological and something that needs to be addressed.

In existentialist therapy, techniques are antithetical to truly being there for the client.  This is one of the reasons why existential therapy is more of an approach rather than a prescription for therapy.  In Freudian psychoanalysis, techniques are essential to making the unconscious conscious and these techniques can include dream analysis, transference, counter-transference, interpretation, very specific things and it's specific because the therapist is considered the expert in interpretation and understanding the objective world of the client.

Now both existential and psychodynamic are insight orient.  In existential therapy, treatment is based on the here and now and explorations of the past seek to identify the origins of the world view.  Again, there we have this idea that our clients are constantly creating the way that they understand the world, so explorations of the past are simply a way of better understanding how our clients came to view the world that they do.

In psychodynamic therapy, change occurs by exploring the past.  In existential treatment, dream analysis sheds light on possibilities.  Dreams are commonly understood to mean I don’t know what's happening to me.  In contrast in Freudian psychoanalysis, dream analysis identifies unconscious content that symbolizes conscious issues.  This is a very different approach because again you have symbols that have objective meanings in psychodynamic frameworks
such as a cigar is sometimes not a cigar.

In contrast in existential therapy, dreams are seen more as close as to the meaning that people have made for themselves.  So, one clarifying example is that if we imagine that we're working with a war vet and the vet meets criteria for posttraumatic stress disorder, is having difficulty focusing on family relations, difficulty holding a job, has exaggerated sterile response, is increasingly focused on issues related to current conflicts around the world as presented on the TV and radio.

Psychoanalysis might say that the war experiences have triggered repressed pre-sexual experiences for the vet and that the impulses are in conflict with the super ego.  In contrast, in existential approach to therapy, you must say that without the focus on the Vietnam and posttraumatic symptomology, the vet’s world would be revealed as pointless and absurd.  If there were specific issues around building a family or future orientation that the vet was having a hard time addressing, existential therapy would probably say this is because the vet is not considering the future as viable and instead understanding that the imminence of death is causing serious questions as to the point of life.

Now, the therapist-client relationship is considered to be collaborative.  In fact, Corey describes it as a journey taken by the therapist and the client together.  The relationship demands that the therapist be in contact with his or her own phenomenological world.  That is, the therapist must be aware of the way that he or she is constructing their own world so that they understand that their client is constructing his or her own world and that those worlds are necessarily going to be somewhat different.

The core of the therapeutic relationship is respect and faith and the client’s potential to cope and sharing reactions with genuine concern and empathy.  Now, some therapeutic goals in existential therapy include giving attention to the client’s immediate ongoing experience with the aim of helping them to develop a greater presence in their quest for meaning and purpose.

Another goal is to recognize factors that block freedom.  A third goal is to challenge clients to recognize that they are doing something that they formally thought was happening to them.  So, again, this addresses the concept of freedom and responsibility.  If your client believes that child protective services is something that is happening to them, it's important for you to help them understand that in fact they are active participants in this world in this situation and that their choices and their decisions are components of the current situation that they're in.

No judgment on whether or not a confirmed case of abuse has merit, but I'm just saying that in existential theory that the important thing is to focus on helping your client understand their own action as being part of their world.  And finally, the goal – the final goal is to accept freedom and responsibilities that go along with that action.

The phases of counseling can be broken down into the initial, the middle and final.

In the initial phase, you really want to see how your client understands their world. Again, this is the phenomenological viewpoint.  In the middle phase, you can explore how your clients develop that view of the world and how that view of the world is affecting what's currently going on with them, how that emphasize or how that influences what it is that they see as their responsibilities, their actions, what they have choices over.  And finally, the last phase of counseling is geared towards understanding how clients can take what they’ve learned in making their lives more purposeful, intentional and grounded in meaning.

Some of the things to do during the assessment phase is to identify existential themes and these are themes related to responsibility, mortality, isolation and meaningless.  These are the big four that Yalom discussed in his classic 1980s text “dreaming like waking is a mode of existence or being in the world and special attention is paid to themes and dreams in making sure not to place emphasis on the therapist’s interpretation.”

So whereas in Freudian psychoanalysis, really it's the therapist that’s responsible for ultimately interpreting what a dream means not because the client is unconscious of the meaning.  In existential approaches, it's really the client that ultimately determines what a dream means.  Some assessment techniques are the use of objective and projective tests such as the Rorschach and the thematic apperception test, the purpose of life test.  This addresses individuals’ views of life goals, their world and their death and the experiencing scale which looks at feelings and self-awareness.

Because there are no specific techniques in existential therapy, application really looks like incorporating techniques and approaches that you as a therapist are comfortable using.  Just remember that as you use your techniques, the primary emphasis is on understanding the client’s current experience.  As you adapt interventions that you're really focusing on these issues of choice, freedom and responsibility and ultimately you're guided by the philosophical framework about what it means to be human.

Now, existential therapy has been applied to multiple areas.  Clients who are seeking personal growth are great candidates for taking an existential approach, career or marital failure, retirement, grief work and any transition from one stage of life to another.  Existential approaches are wonderful for working with teenagers and for whom the questions of what is my purpose, what is the meaning of my life, how am I to live the best life I can, all of these questions are classic teenage angst questions.

A final area of application is helping those who are struggling to find meaning in life and facing the anxiety of their eventual death.  An obvious group for this is older adults.  Existentialist philosophy and existential therapy have contributed a lot to social work practice and clinical work in general.  One of the big ones is that existential theory contributed the concepts of self-determination and personal responsibility.  It provided a perspective for understanding the value of anxiety and guilt and the role and meaning of death in treatment.

The existential approach really enables clients to examine the degree to which their behavior is influenced by social and cultural conditioning.  In his 2005 text, Gerald Corey in fact argues that the existentialist approach is perhaps the most culturally competent approach because it provides social workers with a framework for understanding the universal issues of freedom, choice, life and death and because it's not technique-bound there are no cultural limitations on how this approach is practiced.

However, one of the limitations of an existentialist approach is that it lacks systematic statements of principles and practices of therapy.  It uses vague and global terms and abstract concepts that can be very difficult to grasp such as the will to meaning.  Finally, it's not been subjected to scientific research as a way of validating its procedures.

Now, in a recent article, Aaron Keshen acknowledged the limitations of existential therapy primarily in its lack of empirically testable techniques or approaches.  In a 2006 article, he attempts to operationalize existential techniques.  If you want more information on his approach, his article can be found in the American Journal of Psychotherapy, volume 60, issue 3 and the article is called “A New Look at Existential Psychotherapy” and in this article he attempts to operationalize the issues of your actual purpose or your substituted purpose in life and then he applies those to issues of mental illness, substance abuse, personality disorders, things like that.


So, in conclusion, existential therapy is really a philosophical or intellectual approach that provides the therapist with a framework to understanding their client’s problems rather than providing a set of techniques for actually addressing the problems the clients come in with.  The main issues that existential approaches address are issues of freedom, the freedoms that we have to choose and the responsibilities that come with those choices.  The other main issues that are significant are issues of the meaning of life and the reality and acceptance of death.

References

Burke, J. F. (1989). Contemporary approaches to psychotherapy & counseling: The self-regulation and maturity model. Belmont, CA: Wadsworth Press.

Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed). Belmont, CA: Wadsworth/Thomson.

Keshen, A. (2006). A new look at existential psychotherapy. American Journal of Psychotherapy, 60(3), 285-298.

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APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2007, February 12). Existential therapy [Episode 7]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2007/02/existential-therapy.html

Behavior Therapy

[Episode 12] In this lecture, I focus on the concepts of stimulus and response, rewards and punishments, and how these concepts make operant conditioning such a powerful approach to behavior change. Also in this lecture I touch on classical conditioning, social learning theory and cognitive behavior therapy. The role of the therapist, client, expectations for treatment, implications for multicultural treatment, and the strengths and limitations of the approach are covered.

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Gestalt Therapy

[Episode 9] Today we're going to talk about the Gestalt therapy, which is part of the existential-phenomenological tradition. The Gestalt approach can be best summed up by the phrase, “the most important moment in a persons life is right now.” Gestalt is an experiential therapy that uses experiments and specific techniques to bring the client into the here and now. Through the experience of the here and now, the client is able to make contact with their environment. Contact is a fleeting experience, but it is during contact that we are in the here and now, and thus are in the process of self-actualizing. During the process of self-actualization we are able to make changes. In today's lecture I will will focus on some of the key concepts of Gestalt, the role of the therapist, the client’s experience and some of the innovative techniques attributed to Gestalt therapy. I’ll end with a brief discussion of the applications of Gestalt, the contributions and limitations of the approach.

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References

Burke, J. F. (1989). Contemporary approaches to psychotherapy & counseling: The self-regulation and maturity model. Belmont, CA: Wadsworth Press.

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

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APA (6th ed) citation for this podcast:

Singer, J. B. (Host). (2007, February 19). Gestalt Therapy [Episode 9]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://www.socialworkpodcast.com/2007/02/gestalt-therapy.html

Family Psychoeducation: Interview with Carol Anderson, Ph.D.

[Episode 27] In today's podcast, I speak with Carol Anderson, who along with Gerry Hogarty, developed a family-based approach to working with people with schizophrenia called Family Psychoeducation. Family Psychoeducation is only one of a handful of treatments that has been empirically validated to improve the lives of people with serious mental illness. According to the American Psychiatric Association, when people with schizophrenia are involved in family psychoeducation while taking medication, there is a significant reduction in relapse and unemployment. In today's podcast, Carol describes the 5 stages of psychoeducation, distinguishes between psychoeducation and other forms of family therapy, provides some anecdotes about family psychoeducation treatment, and provides some information for people interested in learning how to do family psychoeducation.

Theories for Clinical Social Work Practice: Interview with Joseph Walsh, Ph.D.

[Episode 52] Today's podcast looks at the relationship between theory and clinical social work practice. I spoke with Joseph Walsh, professor of social work at Virginia Commonwealth University (VCU), and author of the Brooks/Cole text, Theories for Direct Social Work Practice, which came out in a third edition in 2014. We talked about why social workers should learn practice theories, the differences between practice, developmental and personality theories, the difference between a theory and a model, and why there are so many different practice theories. We talked about how knowing theory makes for better social work practice and how being "eclectic" isn't about eschewing theory, but being well grounded in a few theories and making intentional choices about when and how to draw from them. Joe suggested that social workers in the field can contribute to theory refinement by thinking seriously about how well the theories they use work with the clients they serve. We ended our conversation with some information on resources for social workers who are interested in learning more about practice theories.

Embracing Therapeutic Complexity: Interview with Patricia Gianotti, Psy.D.

[Episode 138] Today's episode is an interview with Dr. Patricia Gianotti, Academic Director of The Institute for Advanced Psychotherapy at Loyola University Chicago. Patricia and I speak about the neurobiology of shame, why depth work is important, and how to think about human complexity in a therapeutic context. She emphasizes the impact of attachment failures on a person's sense of self and the role of shame in therapy. She explains the concept of loyalty contracts and how they shape individuals' beliefs and behaviors. She underscores the power of psychodynamic techniques in uncovering and addressing these dynamics. Throughout the conversation, she highlights the hope and resilience that can be found in therapy.

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The Institute for Advanced Psychotherapy at Loyola University Chicago offers a yearlong certificate program for licensed professionals, aimed at enhancing clinical skills through an integrative training method. The program incorporates advances in trauma and neuropsychological research within a framework rooted in attachment theory. Participants engage in onsite residencies that last three full days each, featuring hands-on training by nationally acclaimed faculty. In between residencies, distance learning continues through monthly 90-minute case consultation meetings and bimonthly live webinars. The program is approved for CEU Credit by the APA and NASW, and awards a total of 72 credit hours. To learn more, please visit https://www.luc-iap.com/

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

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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, Roberts and Ottens 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.

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[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.

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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