Contributing To Community Recovery

Reflect on the ways in which government and community organizations might contribute to addiction counseling using the case scenario below

You are the director of a local addiction treatment center in a small Midwestern town of 20,000. A tornado has struck the community, cutting a path of destruction through the entire town and causing hundreds of thousands of dollars in property damage. More devastating, the tornado has resulted in a huge loss of life, including the deaths of over 100 children who were in the local elementary school. Many families are left homeless and grieving over the loss of their property, businesses, friends, and loved ones. The loss of such a large number of children has a particularly serious impact on the emotional well-being of the town’s citizens.

Please use the attached reading resources to complete assignment.

1 EMERGENCY INTERVENTION AND CRISIS INTERVENTION

JAY CALLAHAN

In this chapter I provide a foundation for understanding behavioral emergencies and crisis situations. Clinicians frequently use these concepts in ambiguous and ill-defined ways and often use them interchangeably. The lack of clear definitions leads to confusion and hesitation in clinical decision making. Understanding the distinction between a behavioral emergency and a crisis is an important clinical task and can provide clear guidelines about how to proceed in intense and difficult situations.

BEHAVIORAL EMERGENCIES

As described in the Introduction, a behavioral emergency is a situation that requires an immediate response to avoid possible harm. The three major behavioral emergencies are suicidal behavior, violent behavior, and inter- personal victimization. The appropriate clinical response to a behavioral emergency is an emergency intervention. Although different chapters in this book describe different types of behavioral emergencies, a consistent con- cept of intervention applies across all types. An emergency intervention is a

13 http://dx.doi.org/10.1037/11865-001 Behavioral Emergencies: An Evidence-Based Resource for Evaluating and Managing Risk of Suicide, Violence, and Victimization, edited by P. M. Kleespies Copyright © 2009 American Psychological Association. All rights reserved.

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single interview conducted on an immediate basis. Its goals are threefold. The first goal is to evaluate the status of the patient and the potential for harm. The second is to intervene in that situation if possible, to reduce the risk of harm. Sometimes simple and straightforward clinical interventions such as providing nonjudgmental active listening and working to clarify a crisis situation can have a major impact on the patient and reduce risk. Some- times this intervention can make the difference between the need for inpa- tient versus outpatient treatment. The third goal is the plan, or disposition— what should be done next? In the context of behavioral emergencies, containment or hands-on prevention—hospitalization, intensive residential treatment, continuous family watch, and so forth—is sometimes necessary.

CRISES

The concept of a “crisis” is much less clear, and the word crisis is used to describe a wide variety of situations in the psychological and mental health literature. Sometimes it is used as a synonym for emergency. For instance, Johnson et al. (2005) described a crisis as a situation justifying psychiatric admission, specifically one in which psychological deterioration has occurred and the potential for harm exists. This essentially defines a crisis as identical to an emergency. Similarly, Halliday-Boykins, Henggeler, Rowland, and DeLucia (2004) studied youth psychiatric crisis, which they defined as a situ- ation that required emergency hospitalization. Kulic (2005) described a “cri- sis intervention semi-structured interview” that is to be used “with clients in crisis situations who may require emergency psychiatric care” (p. 143).

The term crisis is sometimes used also to define any serious or chronic problem. For instance, Castro-Blanco (2005) wrote “Youth Crisis in the Schools,” in which he discussed a variety of mental health-related problems adolescents may experience, including depression, anger and aggression, and anxiety disorders. These are certainly problems, but they are not necessarily crises. Similarly, in her book on crisis intervention, Kanel (2007) included a chapter on substance abuse. Drugs and alcohol can certainly precipitate cri- ses, but the disorders of substance abuse and dependence are not crises in themselves. In fact, chronic substance dependence becomes part of an individual’s homeostasis and is used in an attempt to cope with life problems.

The term crisis intervention is also used to describe intervening in poten- tially violent situations, which would actually be emergency intervention. Several well-advertised corporations (e.g., Crisis Prevention Institute, Thera- peutic Crisis Intervention) offer training for mental health professionals and paraprofessionals in crisis intervention, by which they describe de-escalating and calming agitated and threatening clients.

In other words, there is much confusion about what constitutes a behav- ioral emergency and what constitutes a mental health crisis. Many mental health

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clinicians use these terms interchangeably, without making a distinction between them. Many publications in psychological, medical, social work, and related literature also interchange the terms crisis and emergency rather indiscriminately.

Despite this confusion, however, a consensus appears to be forming to define crisis in the traditional way that was originally formulated in crisis intervention writings of the 1960s and 1970s (Caplan, 1961; Golan, 1978; Rapoport, 1965). This definition regards a crisis as a loss of psychological equilibrium or a state of emotional instability that includes elements of de- pression and anxiety. A crisis is precipitated by an external event; it is not a state of endogenous distress. A crisis is also a state of the individual, not the stressor or the precipitating event. The crisis is not the sexual assault, or the bombing, or the airplane crash; the crisis is the state of disequilibrium that may follow one of these stressful events. A crisis implies an inability to cope— a problem of adaptation becomes a crisis because normal coping mechanisms are insufficient, including both primary and secondary (i.e., back-up) meth- ods. In a crisis, an individual’s inability to function at his or her usual level is termed functional impairment. During a crisis, an individual is often more will- ing to try new coping methods or accept assistance from others than he or she would in normal circumstances (Aguilera, 1998; Callahan, 1994; Golan, 1978; Roberts, 2005; Slaikeu, 1990). A key element in an individual’s vul- nerability to crisis is the appraisal or perception of the event, along with the person’s perception of her or his ability to cope with that event (Aguilera, 1998; Golan, 1978).

It is frequently pointed out that the Chinese pictogram for crisis is made up of the juxtaposition of the two pictograms that represent danger and op- portunity (Aguilera, 1998). Arising from the danger of stressful life circum- stances, a crisis can be an opportunity for the development of new and con- structive coping mechanisms and psychological growth.

Many systems for categorizing types of crises have been proposed, in- cluding developmental or maturational (i.e., crises emerging from normal de- velopmental phases in life) and situational (i.e., arising solely from unpredict- able stressful situations; Caplan, 1964). Part of this conceptualization includes the idea that most people negotiate these developmental stages without fall- ing into a crisis and that most situational stresses do not trigger a crisis for most people. Many people are very resilient in these situations.

Probably the simplest and most useful categorization is that of dividing crises into those precipitated by normative stress versus traumatic stress. Normative stress is caused by ordinary, commonplace events, such as a job loss or threat of loss, illness of a family member, a flat tire on the morning of a major presentation, or the breakup of a romantic relationship. Traumatic stress, however, is made up of events that involve the threat of life and death. At one time these life-threatening events were described as “outside the range of usual human experience” (American Psychiatric Association, 1987, p. 259).

EMERGENCY INTERVENTION AND CRISIS INTERVENTION 15

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However, a number of contemporary epidemiologic studies have found that traumatic events are surprisingly common. In a nationwide study of indi- viduals 15 to 54 years old, 19% of the 2,812 men surveyed said they had been threatened with a weapon, held captive, or kidnapped; 35.6% said they had witnessed someone being badly injured or killed. Over 9% of the 3,065 women surveyed said they had been raped, and 15.2% said they had been involved in a fire, flood, or natural disaster (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995, p. 1050). A subsequent national epidemiologic survey confirmed these findings (Kessler, Berglund, Dernier, Jin, & Waltets, 2005). Thus, unfortu- nately, these events are not outside the range of usual human experience. Because of these findings, this phrase was deleted from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 4th ed.; American Psychiat- ric Association, 1994).

Crises are substantially similar whether they are triggered by normative or traumatic stress. In both cases, the individual is thrown into a state of emotional disequilibrium, displays symptoms of anxiety and depression, and has difficulty coping. One difference is that many crises precipitated by trau- matic stress meet criteria for acute stress disorder (ASD; American Psychiat- ric Association, 1994), whereas crises precipitated by normative stress usu- ally do not because the stressor does not meet Criterion A (i.e., “an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”; American Psychiatric Association, 1994, p. 427). Another difference is that normative stress rarely causes the dissociative symptoms that are characteristic of ASD. Diagnostically, nor-, mative crises can often be diagnosed as episodes of major depression, sub- stance abuse disorders, or adjustment disorders.

Traumatic Stress Versus Posttraumatic Stress Disorder

Because ASD often becomes posttraumatic stress disorder (PTSD), an- other common misconception is that crisis intervention is an appropriate treatment for PTSD. This is not the case. Crisis intervention is the treat- ment of choice for a crisis precipitated by traumatic stress, but the crisis is only the initial period of dysfunction.

Various authorities have described the self-limiting quality of a crisis— that it is not possible for a person to continue in the high-arousal state of crisis indefinitely. After about 4 to 6 weeks, the individual inevitably finds a new homeostasis (Golan, 1978; Parad & Parad, 1990). This new equilibrium is often the same level of functioning that was present prior to the crisis; however, in some circumstances the individual might end up functioning at a higher or lower level than previously. These outcomes are often based on how overwhelming the original precipitating event was to an individual, and traumatic events are obviously more overwhelming than normative ones. Another important variable is the nature of the help received, if any. Some

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individuals receive thoughtful and competent support (i.e., professional or personal) that enables them to adopt new coping abilities; therefore, they are more capable of dealing with future stress after recovery.

Crisis intervention, however, is appropriate only during the period of crisis—usually 4 to 6 weeks. If the dysfunction continues after the crisis is over, which is not uncommon, longer term treatment is indicated. If an indi- vidual with PTSD comes for professional help 3 or 6 months after the trau- matic event, he or she is no longer in crisis. Some adaptation has occurred, and the period of disequilibrium has passed. The individual is no longer in crisis, and crisis intervention is inappropriate.

Type 1 Versus Type II Trauma

Terr (1994) described the distinction between Type I and Type II trauma in children, and the distinction is useful for adults as well. Type I is the single traumatic event—the single blow. Examples include rape, assault, natural disasters such as Hurricane Katrina and the 2004 tsunami in Southeast Asia, a motor vehicle accident, or the terrorist attack of September 11, 2001. Type II trauma consists of a series of traumatic events over a period of time that are linked together and perpetrated on victims who are in a situation of physical or psychological captivity. Examples include combat, being a prisoner of war or being held in a concentration camp, many cases of domestic violence, and child abuse and neglect. Type II traumas always include physical or psycho- logical captivity; otherwise, the victim would find a way to escape from the traumatic situation. Individuals who have experienced Type II trauma settle into a new, usually lower level of functioning long before they escape or are able to receive professional assistance. Therefore, they are rarely in a state of crisis when they come to professional attention and require long-term treat- ment for PTSD (and possibly other posttraumatic disorders), rather than cri- sis intervention.

RECENT TRENDS IN THE CRISIS INTERVENTION LITERATURE

Traumatic stress has become the new focus of crisis intervention in the early years of the 21st century. This trend began in the 1990s with the devel- opment and popularity of critical incident stress debriefing (CISD) and the oc- currence of a number of natural and man-made disasters, including Hurri- cane Andrew in 1992 and the bombings of the World Trade Center in 1993 and the Murrah Federal Building in Oklahoma City in 1995. The terrorist attacks of September 11, 2001, however, significantly shifted the focus of crisis intervention to an almost total preoccupation with traumatic stress and disasters. Although some literature continues to explore crises resulting from normative stress, most of the 21st-century crisis literature is about trau-

EMERGENCY INTERVENTION AND CRISIS INTERVENTION 17

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matic stress, acute stress disorder, disasters, and critical incidents (e.g., see Bronisch et al., 2006; Chemtob, Nakashima, &. Carlson, 2002; Despland, Drapeau, & de Roten, 2005; Reyes & Jacobs, 2006; Ursano, Fullerton, & Norwood, 2003).

Resilience

A particular focus of this recent literature is a new appreciation for resilience and even posttraumatic growth. That is, previous literature empha- sized the assumption that a sufficiently overwhelming traumatic event pro- duced extensive psychopathology in virtually everyone (Bonanno, 2004). This viewpoint may have developed from thinking about PTSD as essen- tially a normal adaptation to overwhelming stress, as opposed to a mental disorder. Epidemiologic data, however, have clearly shown that many people who experience traumatic events do not develop PTSD, and a National In- stitute of Mental Health (NIMH; 2000) consensus document states that “a sensible working principle in the immediate post-incident phase is to expect normal recovery” (p. 2). The National Comorbidity Survey, cited earlier in this chapter (Kessler, Sonnega, et al., 1995), studied a nationally representa- tive sample of over 5,000 individuals from 15 to 54 years old and found a lifetime prevalence of traumatic events of 60.7% for men and 52.1% for women. Over half of the population of the United States from age 15 to age 54 has experienced one or more traumatic events. However, in many or most instances the traumatic event did not lead to PTSD. The overall lifetime rate of PTSD in this sample was 5.0% for men and 10.4% for women (Kessler, Sonnega, et al., 1995). Studies of specific traumatic events have found simi- lar results. For instance, a study of hospitalized survivors of car accidents found a rate of ASD of only 28% (Bryant, Harvey, Guthrie, & Moulds, 2000), and a study of 1991 Gulf War veterans found “minimal psychological dis- tress” in a sample of 775 returnees (Sutker, Davis, Uddo, & Ditta, 1995, p. 447). Not only do victims of trauma survive, in some cases victims experi- ence positive emotions and psychological growth (Calhoun & Tedeschi, 2006; Fredrickson, Tugade, Waugh, & Larkin, 2003).

Controversy Over Critical Incident Stress Debriefing

One of the most controversial issues of the late 1990s and early years of the 21st century is CISD. Originally used in the military, CISD is a single session group crisis intervention technique that emphasizes emotional venti- lation, discussion of typical symptoms of traumatic stress, and advice on how to deal with stress (Mitchell & Everly, 1995). CISD has become extremely popular and is one of a number of intervention models that are described as psychological debriefing. CISD was developed primarily by Jeffrey Mitchell (1983), a Baltimore paramedic who went on to get a doctorate in psychol-

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ogy. Over the past 20 years numerous CISD and CISM (i.e., critical incident stress management) teams have sprung up around the United States; many of these focus on first responders (i.e., firefighters, police officers, paramed- ics), but others serve the public. The vast majority of these teams are volun- tary organizations consisting of trained police officers, firefighters, paramed- ics, emergency medical personnel, and mental health professionals.

The controversy centers on whether CISD is an effective intervention in the aftermath of a traumatic event. Advocates argue that a single debrief- ing 24 to 72 hours after a traumatic event (or critical incident) can substan- tially reduce subsequent symptomatology and distress (Mitchell, 1983). Ran- domized controlled studies are few (Kaplan, lancu, & Bodner, 2001), and findings are equivocal. However, most of the evidence shows little or no effect for psychological debriefing (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994; Hobbs, Mayou, Harrison, & Worlock, 1996; Lee, Slade, & Lygo, 1996; Marchand et al., 2006; Rose, Brewin, Andrews, & Kirk, 1999; Stallard & Salter, 2003). In two studies the intervention group, which re- ceived debriefing, did more poorly than the control group (Bisson, Jenkins, Alexander, & Bannister, 1997; Mayou, Ehlers, & Hobbs, 2000). However, most of these studies have focused on psychological debriefing, which often differs in a variety of ways from Mitchell’s (1983; Mitchell & Everly, 1995) CISD. Many of these studies conducted individual, not group, debriefings, and most did not use the seven-stage structure that is characteristic of CISD.

Nonetheless, critics of debriefing point out that CISD not only is of questionable efficacy but also does not fulfill one of Mitchell’s earliest claims— that it prevents or mitigates the later development of PTSD (Mitchell & Everly, 1995). Furthermore, several studies seem to suggest that CISD can even be harmful, probably by interfering with some individuals’ natural means of coping with extreme stress (Bisson et a l , 1997; Mayou et al., 2000).

Other difficulties with CISD have been identified. A common practice in the 1990s was to mandate debriefings for police officers and firefighters after certain extreme traumatic events. This practice was based on the belief that few individuals would come forward, despite a clear need to do so, be- cause of the fear of appearing weak in front of their peers. For example, the entire Oklahoma City Police Department was ordered to undergo CISDs in the aftermath of the Federal Building bombing in 1995. It is not surprising that most reacted negatively to this mandate (Callahan, 2000). An NIMH consensus conference strongly recommended that all interventions be vol- untary (NIMH, 2002).

The debate has become contentious, with advocates on both sides ar- guing about which studies are methodologically rigorous enough to be trusted. One meta-analysis found that “multicomponent CISM are effective inter- ventions” (Roberts & Everly, 2006, p. 10), but one author of this meta-analysis is a former chairman of the board of Mitchell’s International Critical Inci- dent Stress Foundation and thus not a neutral observer. One descriptive re-

EMERGENCY INTERVENTION AND CRISIS INTERVENTION 19

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view found that “debriefing might be an effective intervention” (Kaplan et al., 2001, p. 824). Otherwise, most meta-analyses have found no evidence in support of CISD (McNally, Bryant, & Ehlers, 2003; Rose, Bisson, & Wessely, 2004; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002).

Many experts are now calling for practitioners to use psychological first aid, a flexible and individualized approach that emphasizes education, reas- surance, avoidance of discussing the details of the event, and active inter- vention for only those showing serious symptoms after 3 to 4 weeks—not 3 to 4 days (McNally et al., 2003; Young, 2006; van Emmerik et al., 2002). In 2001, NIMH sponsored a consensus workshop on early psychological inter- vention for victims of mass violence. The consensus was that in the after- math of mass violence, the evidence supports the provision of psychological first aid, screening for morbidity, and follow-up for only specific individuals at risk (NIMH, 2002).

This controversy has highlighted the fact that the published work on crisis intervention is almost wholly concerned with traumatic stress, disas- ters, and mass violence. In the past decade, little has been written about crisis intetvention with normative stress, developmental and maturational crises, and situational stress. Although this development is understandable given the events of the past decade, the field of crisis intervention must not ignore the impact of normative stress on people’s lives.

A MODEL OF CRISIS INTERVENTION

Although the majority of the attention in recent years has gone to cri- ses precipitated by traumatic stress, other kinds of crises occur. People lose jobs, family members become ill, and separation and divorce continue to take place. In many of these instances, the stress precipitates a crisis.

There are many models of crisis intervention. In addition to older mod- els by Golan, (1978), Dixon (1979), Puryear (1979), and Hoff (1989), newer models have been proposed by Slaikeu (1990), Janosik (1994), James and Gilliland (2005), and Kanel (2007). Roberts’s seven-stage model (2005) is not new but has received renewed attention in recent years. This chapter focuses on a model developed at the Benjamin Rush Center for Problems of Living in Los Angeles, as described by Aguilera (1998; see Figure 1.1). This model describes crisis intervention as brief psychotherapy initiated during a crisis (i.e., a period of psychological disequilibrium caused by an external stressor). This treatment consists of one to six sessions during the crisis pe- riod of a few days up to 4 to 6 weeks. In this model, a crisis develops because an individual has difficulties in one or more of the following three areas: (a) his or her coping mechanisms, (b) the availability of adequate social sup- port, and (c) the meaning or perception of the event. Poor coping mecha- nisms, lack of support, and a malignant perception of the event will more

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Inadequate Coping Mechanisms

Unavailable or Inadequate Social

Support

Malignant Meaning 1 or Perception of the

Event

\ ; \ /

\

/

Crisis

/ /

\

Teach Constructive, Flexible Coping

Mechanisms

Enlarge Support System

,

\

\

> /

/ / \

/ \ Encourage Benign Perception of the Event

/

Resolution of Crisis: New Emotional

Equilibrium

/

Figure 1.1. Modified model for crisis intervention. This figure was created per the model developed at the Benjamin Rush Center for Problems of Living in Los Angeles, as described by Anguilera (1998).

likely lead to a state of crisis. More constructive and flexible coping, varied sources of support, and a more benign perception of the event will often lead to an individual weathering a stressful event without experiencing a state of crisis (Aguilera, 1998).

The Role of Perception

The perception or meaning of the event is a key element. This charac- teristic has also been called apfraisal in the early literature on stress and cop- ing (Lazarus, 1980). The impact of a stressful event, either normative or trau- matic, is significantly affected by its appraisal. One person’s overwhelming stressor is another person’s challenge. A divorce, although sttessful for al- most everyone, can be overwhelming for one person and merely upsetting for another.

Despite this significant subjectivity, traumatic stress is usually more likely than normative stress to lead to a state of crisis for most people. At first glance it appears that traumatic stress has a more universal or objective mean- ing. However, even death or the threat of death has diverse meanings to different people.

In general, accidents of nature are perceived as less stressful than trau- matic events caused by human error. Trauma caused by human malevolence is the most stressful of all, in part because of the difficulty comprehending that a person could do such terrible things to other people. The events of September 11, 2001, are obvious examples.

Cultural aspects also influence the meaning of traumatic events. As noted by McNally et al. (2003),

certain norms and beliefs may lead survivors to think that they are irre- versibly damaged by the trauma, thereby increasing their risk for PTSD. For example, many Kosovar women who were raped during the recent

EMERGENCY INTERVENTION AND CRISIS INTERVENTION 21

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Balkan conflict regarded other people’s response to their trauma—namely, the belief that they were defiled by the experience—as the worst part of their rape trauma. Culturally based beliefs that worsen the implications of a trauma may complicate treatment, (p. 74)

Many traumatic events lead to a search for explanation. Even though the survivors and victims understand the conventional explanation for a trau- matic event, such a conventional explanation is often insufficient. For ex- ample, in a memorial service commemorating the 60th anniversary of the liberation of the Auschwitz concentration camp of World War II, a survivor of the camp took the microphone and cried, “Why? Why did they bum my people? Why?” Millions of words have been written about the Holocaust, and yet for a survivor, the search for explanation continues (Fried, 2005).

One explanation for this phenomenon is what Janoff-Bulman (1985) called violations of basic assumptions about life and the world. In the aftermath of a traumatic event, an individual’s basic beliefs about how the world oper- ates are shattered, and a crisis ensues. These assumptions are (a) a belief in personal invulnerability (i.e., “I never thought this could happen to me”), (b) a perception of the world as meaningful and comprehensible, and (c) a positive view of the self (Janoff-Bulman, 1985). Part of the view that “It’ll never happen to me [or my family]” is a belief in a meaningful, and even controllable, world in which events occur for understandable reasons. In- deed, “at a fundamental level, we also believe we are protected against mis- fortune by being good and worthy people” and that “people deserve what they get and get what they deserve” (Janoff-Bulman, 1985, p. 20). Obviously, this is problematic: When trauma strikes many individuals wonder, “What did I do to deserve this?”, and of course there is no answer.

The alternative to this distressing situation is to not find any meaning, which is even more difficult for most people. Many people believe that “ev- erything happens for a reason,” which leads them full circle back to “I must have done something to deserve this.” Obviously, this is a more malignant meaning to attribute to a traumatic event and makes the crisis more severe and intense. The clinician’s role in this dilemma is to engage the patient in a discussion of meaning, keeping in mind that in many instances patients are resistant to changing long-held belief systems.

The function of guilt in the aftermath of a traumatic event is a similar phenomenon. Guilt serves the purpose of giving people the illusion of con- trol. If the victim of a date rape resolves to stop dating entirely or a person hurt in a subway crash refuses to ever take the subway again, each has done something to assure themselves that the terrible event will not happen to them again. Of course, this is a false sense of security, but it is preferable to feeling out of control.