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[Episode 6] In this lecture, I discuss key elements of Adler's Personal psychology and how this approach contrasts with Freud's theory. The contrast between Adler's and Freud's approaches can best be summed up in the quote "We are pulled by our goals, rather than pushed by our drives."
[Episode 5] In this lecture, I discuss key elements of Freud's theory of personality and how that translated into his approach to therapy. The central goal of Freudian psychoanalysis is to make the unconscious conscious.
Transcript
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In today’s podcast, we're looking at two of the major figures in psychodynamic therapy: Sigmund Freud and Alfred Adler. Sigmund Freud, of course, the father of psychoanalysis and Alfred Adler, developer of individual psychology. These two men had a lot in common, as did their approaches to therapy. In fact, the most common element to their therapies is that they were insight-oriented. These men believed that insight into why you do things is actually the key to making changes and living a happier, more successful life. The way that these men conceptualize change was very different and that’s what we'll be talking about in today’s podcast.
In Freudian psychoanalysis, which is also called Id Psychology, the goal of treatment is to make the unconscious conscious. For example, let's say you're working with a man who has a confirmed case of physical abuse against his children. His explanation as to why he beat his children is that they deserved it. However, during your treatment you discovered that this man hates his boss. He also hates his abusive father. It becomes clear that his boss reminds him of his abusive father.
But your client was unaware of this connection. That is, he was not conscious of the connection between his emotions towards his father and his boss. Although his boss certainly has some characteristics of his father, you're able to point out to him that he’s employing a defense mechanism called displacement, where he is redirecting his feelings about his father to his boss. However, because he cannot act out his aggression towards his boss for fear of losing his job, he then displaces his anger on his children.
Freud would say that he is displacing his anger as a way of protecting himself, ultimately against addressing his deep-seated anger towards his father. In this example, by making your client aware of his unconscious anger, he’s able to gain insight into his behaviors and thereby he’s able to make not only situation-specific changes, but more importantly, changes in his personality. Now, this concept is key in understanding Freudian psychoanalysis.
Without a belief in the existence of an unconscious, Freud’s techniques and his approaches to treatment really make no sense. So, we're going to start out by talking about the topographical model: that is the conscious, the pre-conscious and the unconscious. Freud believed that the mind was divided into three layers.
You have the conscious layer, which was just a thin sliver on top and these were thoughts and ideas that we're aware of. So for example, if you ask me for a telephone number and I'm able to bring it up and say: “Oh yeah, the telephone number is 555-1212.” That telephone number is in my conscious. If you ask me for a phone number and then I have to think about it for a little bit, but I eventually come up with it, then Freud would have said that that phone number was in my pre-conscious (that was somewhere in between the conscious and the unconscious). I knew that it was pre-conscious and not unconscious because I was consciously able to recall it.
Information or data that we’re consciously able to recall can't be unconscious in Freud’s structure. By unconscious, I mean that these are things we're not aware of, also known as repressed material. The clinical evidence that Freud used for postulating the existence of the unconscious included: dreams, slips of the tongue, post-hypnotic suggestion, material derived from free association, material derived from projective techniques (such as ink blots, Rorscharch’s, things like that) and the symbolic content of psychiatric symptoms.
In Freudian theory, personality development hinges on the successful resolution of each phase of development. Erikson shares this concept with Freud, but for Freud it is psychosexual development and particularly inadequate resolution of a particular phase of psychosexual development can lead to neurotic behaviors, such as phobias. Now, in adulthood, the inadequate resolution of particular [00:05:00] phases is directly linked to unconscious wishes and impulses that seek to satisfy conflicting internal drives.
The structure of the personality, as it develops, starts out with the id. The id is the demanding child and is ruled by the pleasure principle. An easy way to think about the id is to think of a 1-year-old, somebody in the oral stage. That child is ruled entirely by: what feels good, what's going to soothe it, what's going to make it full, what's going to allow it to go to sleep, what's going to calm it. The 1-year-old child doesn’t think too much about: "Well, maybe I should give mom a break because I kept her up all night screaming."
The 1-year-old child is interested in getting fed when he wants to get fed or going to the bathroom when she wants to go to the bathroom. So people who are ruled by pleasure principles are considered to be dominated by the id. That is their personality is dominated by the id. In contrast to the id, the super ego is the judge and this is the part of our personality that’s ruled by the moral principle. The moral principle is: do what's right. And the moral principle isn't necessarily good for us.
That is if we rule (if we lived entirely by the moral principle), then we wouldn’t necessarily be any better off than somebody who lives entirely by the id or the pleasure principle. So in order to have a balance between the id and the super ego, Freud postulates that there is the ego (sometimes thought of as a traffic cop) and the ego is ruled by the reality principle. This is where the ego takes into consideration some of the pleasure principle, some of the impulses of the id as well as some of the ideas of what's just and moral (imposed by the super ego) and then takes all that information into consideration and compares it to what is necessary in this situation in a realistic manner.
So it's not realistic to do everything you want all the time nor is it realistic to act god-like. We have to be real and that’s how we connect with other people. Now, ego defense mechanisms are defense mechanisms that are used by the ego. They're normal behaviors, which operate on an unconscious level, which tend to deny or distort reality. These defense mechanisms help individuals cope with anxiety and they prevent the ego from being overwhelmed.
So for example, denial is a classic defense mechanism. Denial is when the ego says: “No, that didn’t really happen.” Then you have the most fundamental defense mechanism of repression. And repression is literally when material is pushed into the unconscious so that we're not even aware of it. Now, it's common for people to say: “Oh, I totally repressed that.” But that’s actually an inaccurate use of the Freudian concept of repression. If we're conscious of repressing something, then it can't be unconscious. Instead what we're actually talking about is suppression: “I suppressed the memories of the party from the other night.” That would be suppression.
Finally, ego defense mechanisms can have adaptive value if they do not become a style of life to avoid facing reality. The therapeutic goals for Freudian psychoanalysis are to make unconscious motives conscious, because only then can an individual exercise choice. And when that happens, this ego can be strengthened so that behavior is based more on reality and less on instinctual cravings (that will be the id) or irrational guilt (which would be the super ego).
Essentially, psychoanalytic treatment revolves around uncovering and interpreting unconscious impulses and defending against them. Now Freud is famous for his psychoanalytic techniques and the reason why these techniques are so important is that in psychoanalysis the therapist, [00:10:00] the analyst, is the expert. The analyst is the expert in interpreting the material that the client brings up. And the reason why the analyst has to be the expert is because by theory the client is not aware of what it is that they're doing.
So for example, if I'm sitting in my therapist’s office and I'm free associating (which is one of Freud’s famous psychoanalytic techniques) and I'm talking about my work and I list a whole string of words that I associate with work and a whole bunch of ideas, I'm not necessarily going to be able to identify what unconscious material is being brought up. It is up to the therapist to say: “Uh-huh, it seems like this is what's going on.” And that’s the interpretation piece of psychoanalysis.
For this reason, classically trained psychoanalytic therapists had to go through their own psychoanalysis. So some of these psychoanalytic techniques include free association, (which I was just talking about) and this is when the client reports immediately without censoring any feelings or thoughts. Another technique is interpretation. In an interpretation, the therapist points out, explains and teaches the meanings of whatever is revealed.
Now Freud believes that we can only get in touch with the unconscious by interpreting what it seems to be indicating in our dreams, waking fantasies, slips of the tongue and so on. Freud believed that you could communicate on two levels at the same time, the conscious and the unconscious. For example, if you're having a professional conversation (that would be a conscious act) and engaging in intimate body language (that could be unconscious flirting) then you're accessing both your conscious and your unconscious simultaneously and only a trained psychoanalyst could point out what the unconscious material is. That’s why the traditional therapeutic relationship had to be expert-driven rather than collaborative.
A third psychoanalytic technique is dream analysis and dream analysis is called “the royal road to the unconscious.” During your dreams: images appear, ideas, scenes out of a movie will pop up in your head. And Freud believed that these were not realistic in the sense that, if I'm driving a car, it doesn’t actually just mean that I'm driving a car. There is important information in these images that are symbolic of something that’s going on in my unconscious.
Freud also believed that certain symbols were universal. For example, bodies of water always represented the unconscious in Freudian theory. So, if I was floating on a lake, I would be floating on my unconscious and that lake could be calm or it could be choppy and these would mean things in Freudian psychoanalysis.
Now transference is when the client reacts to the therapist as she does to an earlier significant other. Transference allows the client to experience feelings that would otherwise be inaccessible. In the analysis of transference, the therapist is able to achieve insight into the influence of the client’s past.
Countertransference is the reaction of the therapist towards the client that may interfere with objectivity. And remember in Freudian psychoanalysis, the analyst is considered to be a blank slate and objective, so these ideas of transference and countertransference are really key and very important. And I believe that these are two of the concepts that are actually most useful to draw on from traditional Freudian psychoanalysis.
For example, if you're working with the client and they start to talk to you as if you are their father or you are their grandson or possibly you are their girlfriend, they're somebody other than who you are, then Freud would say that they are transferring unconscious material onto [00:15:00] you.
Now one easy explanation for why this happens is because most of the time therapists do not spend a lot of time talking about themselves, in their lives, in the therapy room and so clients have to do something. They have to create some image of the therapist and when this happens, oftentimes they project information from their own lives. Now, this can be really useful if you're working with, say a woman who’s been in an abusive relationship, and she starts to interact with you as if you are an abuser. Now assuming that you're an ethical clinician and you are in fact not abusive, you can use this material to work in the moment with the client about these feelings and really work on these issues in a here and now way.
Although this isn't traditionally psychoanalytic, it is a modern adaptation of the concept of transference. If however, you're working in a session with a client and you find yourself looking at her as if she’s your daughter or perhaps your mother or even possibly if she were your lover, then that could suggest countertransference, reactions that you're having towards your client. And unless you're aware of these and are dealing with these actively, they can certainly interfere with your ability to provide a professional service to your client.
The last psychoanalytic technique that I'll talk about is resistance; and this is anything that works against the progress of therapy and prevents the production of unconscious material. These days in social work we don’t necessarily think of clients as being resistant. Resistant clients were traditionally conceptualized as clients who are actively trying to sabotage treatment. Today, if a client says: “That treatment is not working for me “or “I don’t want to do that,” we first look to ourselves and find out if we're doing a poor job of treatment matching for our clients.
The assumption is that if we find the right thing, if we've done our job at collaborating with our clients on identifying goals and developing treatment plans, then our clients will actually engage in the treatment, rather than saying that they don’t want to do it. In contemporary psychoanalysis, the relationship tends to be collaborative and although problems are grounded in the past, the focus is on alleviating current problems. Contemporary psychoanalysis also incorporates modern therapy techniques.
A modern day adaptation of Freud’s individual psychoanalytic therapy is psychoanalytic family therapy. Rather than emphasizing instincts and drives, the focus is on attachment objects and their role in individuation and personal growth. Now, the contributions of Freudian psychoanalysis are almost immeasurable. The concepts and ideas are so interwoven into our everyday lives that it's hard to really distinguish what is psychoanalytic and what is just the way we think about things.
For example, it's not uncommon to hear somebody complaining of somebody having an anal personality. It's also not uncommon to hear jokes that refer to some of the core concepts that Freud developed, as in this joke about Freudian slips. This joke was told to me by a British friend of mine:
Patience says to his doctor: “Doctor, I had a Freudian slip last night. I was eating dinner with my mother-in-law and I meant to say: ‘Please pass the butter.’ But instead I said ‘You silly cow, you’ve completely ruined my life.’”
Now what's true is that even though our everyday speech is full of concepts developed and popularized by Freud, Freudian psychoanalysis (or at least the traditional form of psychoanalysis) has fallen out of favor in contemporary psychotherapy. Although it was the dominant model through the 1970s, it is a long-term, insight-oriented therapy that doesn’t fit with our contemporary understanding of what people’s problems are, what solutions they're looking for, and perhaps most importantly, how managed care pays for services.
Even still, Freudian psychoanalysis (and particularly its modern day derivatives) contains ideas that are useful to anyone who’s involved in a therapeutic relationship, including those ideas of transference, countertransference and defense mechanisms.
In the next section of this podcast, we're going to talk about Alfred Adler, who took a very different approach to understanding people’s problems and therefore [00:20:00] what the solutions to those problems are.
[Episode 4] This is part two of a two-part series on Crisis Intervention. In this lecture, I discuss individual crisis intervention within the context of Roberts's Seven-Stage Model of Crisis Intervention, and the most popular group crisis intervention model currently in use, Critical Incident Stress Debriefing. The podcast ends with a detailed review of suicide assessment.
Now that you’ve assessed the affective, behavioral and cognitive domains of your client, we're going to move to the intervention model for today’s lecture. And although there are a variety of intervention models, including James and Gilliland (they have a 6-stage intervention model) and Hillman (has a 14-stage model of intervention), I'm going to talk today about Roberts’ 7-stage model for crisis intervention. And I'm going to talk about it because it provides a useful framework for crisis intervention, but it's not prescriptive to the point where it can't be modified to be used in either a single session or over multiple sessions. And Congress in 2000 (the author Congress, not the governmental body, but Elaine Congress) noted that it is, its flexibility enables it to be used in a culturally competent manner.
On the first stage is the assessment of safety and lethality and when we talk about suicide and risk assessment later, you'll get a better idea of specifically how to do that. But suffice it to say that in Stage One, you want to make sure that you are safe, that the client is safe, that the surroundings are safe. So you want to identify whether the client is at risk for harm to self or others or whether someone or something is putting the client at risk.
In Stage Two, that’s the rapport building stage and Roberts notes that that often happens concurrently with Stage One. As you're establishing safety, you're building a rapport and rapport, as I mentioned in the beginning of lecture, is the foundation for any clinical intervention (crisis intervention included). The Third Stage is problem identification. This is where you really identify what the precipitating event was and what problem the crisis intervention will focus on.
In Stage Four, you address feelings and emotions and this is where your assessment of affective, behavioral and cognitive domains is useful. You can implement Myer’s Triage Assessment at this stage or you can use it throughout. In Stage Five, you generate and explore alternatives. Now, similar to the problem solving method, generating and exploring alternatives is an area where the crisis worker can be more active in the crisis intervention model without necessarily being directive.
Being directive in Stage Five would look like presenting the client with a list of possible actions that they could do or solutions to the problem. Active would be collaborating with the client to identify things that they could use. One technique in particular that’s very congruent with social work perspective is using a very solution-focused approach in Stage Five. For example, when you're generating and exploring alternatives, you can review exceptions or use the miracle question or use other techniques that enable the client to think about times when they have actually been successful in resolving issues and thereby drawing on those successful opportunities as a way of reminding them of things that they can do in the current situation.
In Stage Six, you develop an action plan and again the action plan is very specific. It's concrete. It's measurable and it usually has a very short time frame. When I was doing crisis intervention in Austin, Texas, our crisis plans often lasted no longer than 24 hours without meeting again. And so they would include things like: When I leave here I will drive my child home. We will do this, this and this and this and this. It was very prescriptive. It provided structure and it was organized and it enabled me to review with the parents and the children the plan to find out exactly where it worked and where it didn’t, both as a way of helping me gather information, but also as a way of letting the family know exactly what it was that they were and were not doing to resolve whatever crisis was at hand.
And the Final Stage is follow up, and this looks like the referral stage for most traditional treatments because crisis intervention is short term and does not address long term intrapsychic or interpersonal or social problems (social environmental problems). [00:05:00] The need for a referral is great and it is expected that in fact you will be referring your clients out once the crisis has been resolved. So for that reason, follow up is a significant part of crisis intervention.
In different cultures, follow up can look like different things. If you have a family from the dominant culture that does not demonstrate underlying psychopathology and once they’ve reestablished prior coping skills, they're fairly easily able to address their activities of daily living. Then referrals can be fairly traditionally professional and say: “Here’s a phone number. We’d like you to follow up with them.” They agree to it and then you check up and you say: “Did you call?” It's great.
In families that might not be from the dominant culture, for example let's say you have a Latino family that has recently immigrated to the United States: follow up might be more personal. For example, making personal introductions, (assuming that consents have been signed) and really being more active in the follow up to make sure that both the information has been transferred to the new clinician, but also that there's that sense of trust that the family can have in the new provider.
Those were the Seven Stages of Roberts’ crisis intervention model. And again, it's a very flexible and very useful framework to have in mind when doing crisis intervention. And Roberts discusses this model in numerous articles and publications and books most recently in the third edition of the Crisis Intervention Handbook and also in an article that he wrote for the journal Brief Treatment in Crisis Intervention.
A second approach to crisis intervention that’s commonly used with groups is Critical Incident Stress Debriefing (CISD) or Critical Incident Stress Management. Everly and Mitchell are the main authors and proponents of this model. Critical Incident Stress Debriefing is typically used with first responders, for example: firefighters, EMS workers, police officers and it follows a group format. The CISD occurs no later than one week after the critical incident and the debriefing is run by a first responder who’s trained in the model.
And so again, if we think back to Hillman’s critique of the current research on crisis intervention, the question is: Is a peer who has been trained actually better than a licensed professional doing crisis intervention? If you have a police officer that has been trained in Critical Incident Stress Debriefing and they run a group with other police officers who have been involved in a critical incident, then it is possible that they would be more effective in this particular type of crisis intervention.
The CISD centers on the workers and is sensory-based and it encourages the participants to report on what each of them saw during the critical incident, what they heard and what sort of physical and emotional feelings they had, as well as what they smelled and tasted. After a critical incident such as a multi-car pile-up with fatalities on a highway or a shooting or some other critical incident that first responders are involved in, this type of debriefing can have the effect of reducing anxiety, letting people know they're not “crazy.”
Also important in these debriefings is that information about the event is shared. Crisis situations are fast-paced and people are not always sure that what they're experiencing is actually true. And so if during a fire, a floor collapses and a firefighter falls three or four storeys and the other firefighters are called in for Critical Incident Stress Debriefing, some information can be shared about the nature of the fire, how it developed, what other people were doing at that time. And in this way, it can actually provide concrete information that can be useful for individuals in reducing anxiety and addressing this critical incident.
In the protocol for Critical Incident Stress Debriefing is that the trained mental health professional is a silent observer of the proceedings and his or her purpose is to identify first responders who might benefit from individualized crisis intervention and/or ongoing psychotherapy. So, again, Roberts’ model is typically used with individuals or families and if you're in a group situation, the most commonly used approach is the Critical Incident Stress Debriefing Model by Everly and Mitchell.
The final area we're going to cover today in our discussion of crisis intervention is suicide assessment and this is a special instance of crisis intervention, so don’t go anywhere. We'll be back after this [00:10:00] brief pause for the cause.
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Break
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Now, the purpose of suicide assessment is to determine the lethality and severity of suicidal behaviors. It's also to predict risk of imminent harm to self. Empirical evidence does not support that we know how to predict future suicidal behaviors. However, the courts and the public expect mental health professionals to be able to predict future behaviors.
The third purpose of suicide assessment is to gather information used for crisis planning and intervention and treatment and management of suicidal behaviors. Now, this is of course is only if suicidal behaviors are present and you won't know that if you do not do a crisis – rather if you do not do a suicide assessment. Because suicidal attempts are higher with people who have psychiatric disorders than in the general population, anytime you're working in a psychiatric setting, either outpatient or inpatient, and you're working with people with a diagnosis, it is important to do suicide assessments so that you can determine whether past suicidal behaviors have been present. If so, what those triggers were and/or if there is current suicidal ideation.
So, the basic suicide assessment covers three areas. It covers ideation (and those were thoughts), intent (which is how serious the thoughts are and how serious the person is about dying by suicide). And the third area is the plan (how, with what, when, access to the means, etc. etc.). During the suicide assessment, it's important to use the words kill and die and specific words like that, so that your client knows you're not afraid of the topic and they’ll be more likely to confide in you and also that you can gather more accurate information.
The father of suicidology, Edwin Shneidman, suggested that people choose suicide because it's a means to end intolerable psychic pain. And if you ask people if they want to hurt themselves, which is the more mild way of addressing suicide assessment that people who were not trained sometimes do, if you say – if you ask people if they want to hurt themselves, somebody who’s actively suicidal might honestly say no because in fact they do not want to inflict more pain on themselves. They do not want to hurt more. In fact, they want to end their pain. They want to end the hurt and that is why they're suicidal.
So, that’s just one example of – or one reason why it's important to be specific when talking with clients about suicidal ideation and why it's important to use the words such as: “Do you want to kill yourself? Have you thought of dying?”
Ideation: “Do you have thoughts of killing yourself? If so, how frequent do you think of killing yourself? Every hour, a couple of times a day, weekly or never? How long are your suicidal thoughts? What is the longest time period in which you’ve consistently thought of killing yourself and what is the shortest? And answers can range from you know: “It just flashed into my mind and then it was gone” to you know, “I was thinking about it constantly for eight hours. I just couldn’t get it out of my head.”
In intensity: “How strong or weak are these thoughts? Do they interfere with your activities of daily living?” For example: “Are you afraid to go into the kitchen because your suicidal thoughts are so intense that you're afraid you're going to do something like grab a knife from the kitchen and cut yourself?”
The intent areas, how serious and one way of using scaling questions for this area is to say: “On a scale of 1 to 3, how badly do you want to die?” When you're talking with someone who’s actively suicidal, it's not necessary to give a 1 to 10 scale, which can be difficult to interpret and also it can be a little overwhelming. But a 1 to 3 scale is not cognitively complex and also if somebody says that on a scale of 1 to 3, 1 being “I'm not serious at all” and 3 being “I'm totally serious,” if they give you 1, 2 or 3 then you pretty much know what they're talking about and you can ask more detailed questions at that point.
The third area is the plan: “Do you have a plan? Is your plan general or is it detailed? How will you do it? Do you have access to the means?” And that could be to the materials or the specific weapons. [00:15:00] “And when are you planning on killing yourself?” I've worked with a number of children who in response to that question would say: “Well, there's a party this weekend and so I'm not planning on killing myself until Monday.” Well, that was important and significant information for me to have because even though they might have had a detailed plan and they might have frequent thoughts, it provided information about how serious they were imminently ending their life.
After you talk about ideation, intent and plan, it's useful to talk about prior attempts, because prior attempts have been reported to be the single best indicator of a future death by suicide. So, you want to ask: “How recent was your prior attempt?” and because there's usually a limited time to discuss suicidal ideation with a client either because you're in a crisis situation or because that’s not the primary focus of your work with the client. Shawn Shea, who wrote a wonderful book on The Practical Art of Suicide Assessment, he suggests that the most valuable thing for a clinician is to find out what the most serious prior attempt was, as opposed to getting an exhaustive history of all the prior attempts.
And by getting details on the most important prior attempt, then you gather information on triggers, on what kept the person alive, how long it lasted, things like that. So, other questions to ask are: “Do you know somebody who has recently died by suicide? Do you have friends or family members who have died by suicide? Have you told anyone about your ideation, intent or plan?” Finally, you can ask the client who do they talk to when they're really down, when they're having thoughts of killing themselves, and this can give a lot of information about their social support or lack thereof.
It also provides information about resources for the clinician about who they can contact in the event of a suicidal emergency that would enable them to breach the limits of confidentiality and go outside of the client-therapist relationship.
At the end of the suicide assessment, you should be able to establish a severity rating. Rudd and his colleagues in 2001 recommended a five-level severity rating ranging from 1 (which is nonexistent) to 5 (which is extremely severe). The least and most severe ratings are relatively easy to establish and have clear plans of action.
Number one: nonexistent, there's no identifiable suicidal ideation. Number five is: there is extremely severe suicidal risk. And this looks like frequent, intense and enduring suicidal ideation, specific plans, clear subjective and objective intent, evidence of impaired self-control, severe dysphoria and symptomology and many risk factors and almost no protective factors.
The middle ratings are: mild, moderate and severe. Mild risk would look like: suicidal ideation of limited frequency, intensity and duration, no identifiable plans or intent, mild dysphoria and symptomology, good self-control, few risk factors and identifiable protective factors. Moderate suicidal risk looks like: frequent suicidal ideation with limited intensity and moderation. So, again, the distinction between mild and moderate is you have limited intensity and duration, but you have frequent ideation for the moderate, but for the mild it is limited ideation, frequency and intensity and duration. For the moderate, you also have good self-control, limited dysphoria and symptomology, some risk factors and identifiable protective factors.
Severe suicidal risk looks like: frequent, intense and enduring suicidal ideation, specific plans, no subjective intent, but some objective markers of intent for example: they talk about specific lethal methods, they know that the method is available and there are some limited behaviors in preparation for death by suicide. There's evidence of impaired self-control, severe dysphoria and symptomology and multiple risk factors present and few if any protective factors.
In summary, the big three areas to cover in a suicide assessment are suicidal ideation (that is thoughts of suicide), suicidal intent (that would be motivation to die by suicide) and plan (which looks at how and when somebody is going to try to kill themselves). Another area that’s also useful is prior attempts and prior attempts are useful because the best predictor for a future attempt is a past attempt.
Ultimately, the purpose of gathering information [00:20:00] about intent, ideation and plan is to be able to determine the client’s risk for imminent harm to self. Once you have a severity rating, such as the one developed by Rudd, Joiner and colleagues, you're able to quickly and easily identify what the next step is in terms of a treatment plan. This has the obvious benefit of providing safety for the client and has the less obvious, but no less important benefit of providing the clinician with solid clinical evidence to support their decision.
Well, that’s it. Congratulations. You’ve made it through Crisis Intervention. Today, we've talked about crisis intervention, crisis assessment and suicide assessment and all of these are invaluable skills for social workers. In fact, they're some of the few skills that you really want to memorize because well, during a crisis you don’t really have time to look things up.
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Transcription generously donated by Kelsi Macklin.
Simpson, S., and Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicidal risk assessment. Journal of Psychiatric Practice, 10(3), 185-189.
Singer, J. B. (2006). Making stone soup: Evidence-based practice for a suicidal youth with comorbid ADHD and MDD. Brief Treatment and Crisis Intervention, 6(3), 234-247.
Weller, E. B., Young, K. M., Rohrbaugh, A. H., & Weller, R. A. (2001). Overview and assessment of the suicidal child. Depression and Anxiety 14,157-163.
Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 2 - intervention and crisis assessment [Episode 4]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/02/crisis-intervention-and-suicide.html
[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.
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.
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Break
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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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Transcription generously donated by Kelsi Macklin.
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
[Episode 2] This is the second part of a two-part lecture on diagnosis and assessment. In the first episode I reviewed the history of the DSM and the multiaxial system. In this lecture, I discuss the Bio-psychosocial-spiritual (BPSS) assessment as the means for providing context for the client's presenting problems. I discuss the purpose of each of the four life domains and how the information is used in social work practice. Emphasis is placed on solution-focused approaches to assessment. I end with a brief description of traditional format for organizing observations about the client - the Mental Status Exam.
[Episode 1] This is the first part of a two-part lecture on diagnosis and assessment. The Bio-psychosocial-spiritual (BPSS) assessment and the DSM diagnosis are the two most common types of assessments made by social workers. In this lecture, I briefly review the history of DSM diagnosis, from the creation of the first ICD in 1900 to the most recent text revision of the DSM-IV in 2000. I discuss the multiaxial system and provide examples. I transition from DSM diagnosis to the BPSS assessment by discussing the similarities and differences between the two assessments.
[Episode 6] In this lecture, I discuss key elements of Adler's Personal psychology and how this approach contrasts with Freud's theory. The contrast between Adler's and Freud's approaches can best be summed up in the quote "We are pulled by our goals, rather than pushed by our drives."
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