- Psychological Issues
Crisis is defined by Webster as a “dangerous or worrying time: a situation or period in which things are very uncertain, difficult or painful, especially when action must be taken to avoid complete disaster or breakdown” and a “critical moment: a time when something very important for the future is decided.” Alternatively, in Chinese the concept of crisis is made of two characters; the first depicting a critical or dangerous situation, and the other and opportunity for change. With this in mind, exploring how to defuse a crisis as quickly as possible, prevent physical managements, and at the same time effect changes in future behavior will be discussed. How we handle the state of crisis can affect whether a client will grow or decline, and whether they gain more tools to effectively cope with stressors in the future.
We are applying what has come to be colloquially known what Rosenbluh (1981) referred to as psychological or emotional first aid when crisis support is performed in the inpatient or residential setting. First-line treatment needs to confined to the scope of the personnel on scene, and within the purpose of and appropriateness to immediate need – stabilization of emotional outburst, and ensuring client, peer, and staff safety. It is not the time for insight-oriented therapy, or deep discussions.
When a client is in crisis in the inpatient or residential setting, we have the ultimate power – to place hands on and physically restrain them if they present a danger to themselves or others. However, this is the choice of last resort for any number of reasons: the physical danger to both staff and the client, the resultant sequela and increased restrictions placed on the client, and most importantly the feeling of total helplessness, loss of dignity and future lack of trust in staff on the part of the client.
The question then becomes, how do we avoid these physical managements? Increased knowledge of what the client is going through, evaluating our own reactions, and measuring our responses are essential during the crisis. Before the crisis begins, developing trust, and acting honestly and truthfully, and showing empathy will contribute to the ability to communicate successfully during the crisis state. Another factor is to use creativity, and not to be fixed into a box of “my way or the highway” – tailor the crisis intervention to the needs of the individual. Finally, the quicker the crisis can be terminated, the less chance there is that it will escalate to a physical management. There are a number of attributes of a competent staff member performing competent crisis intervention.
The actual crisis for the client does not begin merely with a stressful situation in their environment. It is the result of their inability to effectively cope with that stressful situation, their view and perception of it. The more threatening and important that they see it as, the more critical it is. If they do not have any coping skills to deal with the situation either because their coping skills to not apply to it, it is too overwhelming, or they have exhausted them, and they are unable to explore or do other new skills, crisis results. Additionally, Lazarus (1980) suggested that failure to cope results from the inability to change the situation by problem solving, or being unable to manage the subjective components of the problem. Lazarus (1983) believes that the vulnerability to stress, adversity, and ability to cope varies individually and situationally, based on their three-part cognitive assessment of the situation, in which they look at the potential harm, threat, and challenge. They then look at their own available resources: internal, interpersonal, community, and spiritual (Wainrib & Bloch, 1998), to determine if they can meet the situation. If they determine they cannot, crisis ensues. According to Roberts (2000) there are five steps a person in crisis goes through:
The major task of psychological first-aid is to reestablish the client’s coping strategies and thus functioning. The seven major components of effective coping which can be enhanced, according to Slaikeu (1990) are: actively exploring reality issues and searching for information; freely expressing both positive and negative feeling and tolerating frustration; actively invoking help from others; breaking problems down into manageable bits and working them through one at a time; being aware of fatigue and tendencies toward disorganization, while pacing efforts and maintaining control in as many areas of functioning as possible; managing feelings where possible (and accepting them when necessary), and being flexible and willing to change; and trusting in oneself and others and having a basic optimism about the outcome. Overall, It is the clients perception of the event which is the most crucial part of the crisis, as it causes the most subjective distress, yet is the most easily and quickly altered (Kanel, 2003).
The Psychological effects of crisis include feelings such as increased anxiety, fear, helplessness, confusion, agitation, and disorganization. Early in this cycle, when they are beginning to have these feelings, before they escalate into severe mood changes, the emotional discomfort can make them receptive to outside help and influence, thus increasing the chance for teaching, and for change to be effected.
Soon after a person first enters the crisis state, they physically begin experiencing the general adaptation syndrome (GAS). The first stage is called the alarm reaction, in which adrenaline is released, and “fight or flight” is experienced. They will have an increase in heart rate, breathing pattern and perspiration, while their muscles tense. Their eyes dilate and their stomach may feel “funny” as it clenches. This state will either end when the crisis is ended, or the body becomes exhausted. In this case, the second state, called adaptation, long-term protection is the goal; during this phase hormones are released to increase blood glucose and raise the blood pressure. The third state, exhaustion, is one which will not be reached in the short-term crisis. Know this has a number of implications for us. The first is to remember the term “fight or flight” literally. Respect personal space, and don’t corner the client with them having any room to move or being able to see that they have an escape route. Just being able to see that there is a place to move to can decrease the claustrophobic reaction. Otherwise, if they don’t see that they have the option of flight, there is a good chance they may strike out and attempt to fight.
The way in which we communicate with the client is also important. Often, we can fail to effectively communicate due to a lack of clear communication goals and key messages to support them. We need to identify what we want to say, and what our ultimate desired outcome is before we begin. Then, we need to actively listen, and use problem-solving approaches. Active listening has the effect of inducing the client to actually listen to themselves more, evaluate and clarify their own thoughts and feelings. They also increase their ability to problem solve, become less defensive, more cooperative, and are able to accept other’s points of view more readily The practitioner needs to remain calm to convey acceptance, support, and confidence about a resolution to the situation. Empathy, when expressed, affects the client by making them less fearful of being criticized, and they become more realistic about their own point of view. Use of “I” statements will bring the client to a more equal level with the practitioner, and encourage communication. All together, these skills are classified as building rapport, and are the foundation of crisis intervention.
When a resolution is discussed, making promises that can’t be kept isn’t useful, it is detrimental. It may be beneficial in this situation, but in the future the client will be much less likely to believe the staff, and even may have their general treatment impeded due to a decreased level of trust. In order to resolve the situation, the person intervening always needs to find out what the clients perception of the crisis is. Without this, there is no way meaningfully communicate about the issue. If the practioner works off of what they have seen happen, or what others have told us, we start with strikes against us. If the staff intervenes early enough, before the client escalates, they can discuss with the client what coping skills have been tried, and possible alternate skills. Depending on the clients current level of functioning, either open-ended or limited choice questions can be used. Open-ended questions are preferred, as they reveal much more of what the client is truly thinking and feeling. However, if they are unable to communicate well, or are resistant to communicating, limited choice questions can also provide information. It is also important to evaluate non-verbal cues as well, such as body language, posture, facial expressions, hand position, mannerisms, and eye movements. The tone, rate, volume and quality of speech can be important indicators of mood as well. Saying “I understand” should be avoided as we really don’t understand, and because this also has the tendency to make people stop talking and we want them to talk more to allow us more information. Most practitioners have not undergone the same stressors and been in the situation that the client is in. Instead, use active listening techniques with eye contact, slight nodding of the head, saying “ok” or “alright.” Or “mm-hm” occasionally. When talking to the client, even if they are yelling at the staff, it is important to keep the voice calm, level, and at a low volume. Often, by talking softly, it has the effect of bringing the other person’s voice level down as well.
The intervention itself actually begins as soon as the client sees the practitioner coming toward them, or talking to them if they are already by them. The client will evaluate voice quality, tone, volume and sharpness. They will look at body language and facial expressions. The person who is walking calmly toward the client, and waits until they are near enough to speak to them in a calm, controlled voice starts steps ahead of the one who “stalks” to them with the frustrated or upset face while raising their voice so that they can be heard across the room. It continues, as discussed, by showing empathy while identifying the problem. We then take the next step in active listening, which is to give feedback on what we heard – state what we understand to be the clients view of the problem back to them to make sure it is what they are saying. There are two types of crisis expression generally that are encountered, and this will affect the rest of the intervention. The first is expressive behavior, which may be illogical, is highly emotional, and not have substantive or goal oriented demands. These are the clients who are also more likely to be self-destructive. This behavior comes from the need to express feelings and emotions, and is best responded to through active listening and not pushing them to make a snap decision until they have been able to express themselves, unless they are patently dangerous. The other behavior is instrumental in which recognizable demands are made, and they have clear objectives, that if realized will benefit the client. This responds best to problem-solving. Thus, in the case of instrumental behavior, or after a client with expressive behavior has begun to become less emotional and more open to a two-way discussion, brainstorming a solution is the next step in the process. The client is asked how the situation can be resolved, and honest feedback is given about their suggestion. Then, the staff’s suggestions on how the situation can be resolved are presented, and options are discussed.
Generally in the hospital or residential setting, there will be an existing relationship between the practitioner. Therefore, the quality of that relationship will affect the ability of the practitioner to work with the client during a crisis. Quality does not mean that the practitioner and client are friends. Instead it implies that the client believes the practitioner is trustworthy and credible. According to Covello (1993) the factors that are used when this is assessed are empathy and caring; competence and expertise; honesty and openness; and dedication and commitment.
Basic interviewing skills are essential in crisis management. Hersh (1985) notes that the assessment must be rapid and accurate, but Hoff (1995) tempers this with the warning that if an assessment is done incorrectly, it can be hazardous to both the client and the practitioner. This is due to the fact that it can result in an inadequate threat assessment, inadequate understanding of the nature of the crisis, or inaccurate level of treatment. The most important key to remember is that clients are more likely to reveal their thoughts and feelings when they trust the listener, and feel accepted. Three of the basic interventions which convey this are showing empathy, congruence, and unconditional positive regard. The other piece of basic interviewing is to actively listen to the client.
The skills of active listening begin with the knowledge that the practitioner will be listening the majority of the time, not talking, not asking questions. The body language is one of open acceptance. A slight lean forward, hands not crossed across the chest, legs not crossed if sitting is used to not “block” the body. Nodding the head once in a while shows that the listener is still interested. Verbally, the practitioner may use minimal encouragements, which are brief verbal replies that relate interest or concern. These may be as simple as “o.k.”, “yes”, or “I see”. An essential part of active listening is ensuring that the listener understands the speaker. This can be done through a number of communication techniques. Three of these are Paraphrasing, Emotion Labeling, and Mirroring. In paraphrasing, the listener will take what has been said, put it in their own words to say back to the subject, to ensure correct understanding. In emotion labeling, the listener “labels” emotions and explanations together. They may say “You angry because your mother told you she would not come see you this weekend”. The speaker then agrees, or can modify the label. Finally, in mirroring, the listener will repeat the last few words of what has been said, which may encourage more explanation, while showing interest. The listener, when needing information, should ask open-ended questions. These encourage the client to talk, and avoid simple answers. There are a total of seven of the communication techniques identified by Everly and Mitchell (1999), with the remainder being: silence, nonverbal attending, restatement, closed-ended questions. The listener also needs to use “I” messages, as they personalize the listener, instead of making them just an authority figure. Finally, the use of therapeutic silence, no matter how uncomfortable, is an effective technique used in active listening.
Oftentimes, before the practitioner can begin to have a meaningful dialogue with a client, they need to be able to calm them. They are several techniques available to do this (Slaikeu, 1990). The conversational methods include showing understanding, modeling calm behavior, reassuring, encouraging talking, using distraction, and using humor. The assertive methods, when the conversational methods don’t work include repeating and outshouting and physical restraint, and the alternative methods are using a trusted person and planned ignoring.
There are a number of models of crisis intervention, of which only the first few steps apply of any of them, as the first-line intervention is short-term, while the remainder of the model is aimed at continuing therapy. In Roberts Seven-Stage Crisis Intervention Model (Roberts 1991, 2000) the first state is to plan and conduct a thorough assessment including lethality, dangerousness to self and others, and immediate psychosocial needs. Include whether the person is a victim or perpetrator, whether the crisis situation is likely to reoccur in the immediate future, is the person under the influence of drugs or alcohol, is the person likely to self harm, and the person’s history and current level of mental health functioning and diagnoses. The second stage is to make psychological contact, establish rapport, and quickly make a relationship by conveying genuine respect, acceptance, reassurance, and a nonjudgmental attitude, while assuring them that they can be helped. In the third stage, examine the dimension of the problem in order to define it (making sure to include the last straw or precipitating event), investigating their previous means of coping, and focusing on the here and now, not the when and why. In the fourth stage, encourage the exploration of feelings and emotions, allowing the client to vent their feelings and emotions, incorporate active listening techniques that show empathy and reflection of the client’s view of the crisis situation, treating them in a nonjudgmental, supportive and accepting manner. Beyond these first four steps, regular therapy generally will be indicated to explore past coping strategies, and to generate new coping strategies, although with extra time available, these may be explored by a qualified first-line practitioner.
Golan (1978) gave us a three-stage plan for working with clients in crisis. Only the first stage is applicable to the front-line practitioner. The first phase of the first stage is formulation, and focuses on the precipitating factors: who what where, when, why, using open-ended questions to encourage the client to tell about what happened. Using statements that are subjective to encourage responses are also used, such as “you seem to be hurting.” Then, when the client has calmed down, making these same statements, directly relating to the incident are made, such as “you seem very angry with Tom.” While doing this, attempt to assess the sequence of events that led to the crisis situation, and how the client previously coped with the crisis situation. Finally, attempt to determine where the client is on a scale from complete disequilibrium to stabilization. Next the practitioner evaluates the problem with the client by making a decision statement about what they see as the most important problem, such as “I believe that you need to look at the relationship you are in with John.” The practitioner also asks what the client feels needs to be addressed first. Then, with the client, a single problem is decided upon to receive the focus of being worked on. Finally, a contract is set between the practitioner and client as to what will be done immediately by both parties, and what will be done to set up longer term help.
The best crisis is the one that is avoided. There are a number of ways to help prevent a crisis from occurring. The first is reinforcing calm and on-task behaviors. Behavior, whether is positive or negative can be maintained by attention. Therefore, when a person is showing appropriate behavior, reinforcement needs to be given consistently. Otherwise, negative behaviors will occur and be reinforced more often than the positive (Kennedy, 2000). One example of this is proximity control, or walking around a classroom or milieu and giving attention to those who are on task (De Pry & Sugai 2002). The next tool for prevention is knowing a clients triggers. Most clients will have a number of specific triggers that will lead to problem behaviors. The best way to deal with these triggers is to anticipate when a situation may occur which will include these triggers and give the clients options and choices. If they know there are options and choices other than reacting negatively, they have less chance of resorting to acting out (Clare & Im, 1999). Next, pay attention to anything unusual about behavior. Previous events that are troubling the client may be played out in their body language and key the practitioner in to talk to them. Previous events can cause them to trigger more easily, to not use coping skills as quickly or as effectively (Kennedy & Meyer, 1996). Also ensure that you do not escalate along with the client. When the practitioner loses control, both parties escalate from each other, and act inappropriately (Colvin, 2001). Offering chances to act appropriately is essential, as behavior is largely a choice. Much behavior is displayed based on their past experiences in order to get a certain desired result (Fox & Hoffman, 2002).
Finally, according to Everly and Mitchell (1999) the summary of what front-line practitioners need to remember is:
And the six steps Greenstone and Leviton (2002) urge those on the front-line to follow:
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