Perceived Crises Influencing Addiction

In a 2 – 3 page APA-formatted paper, address the following:

  • Provide a description of at least two factors outside an individual’s control that could result in a perceived crisis and explain how that perception might affect propensity toward addiction.
  • Describe a model of crisis intervention that might be most effective in addressing these factors and explain why.
  • Explain why that model might be more successful than other models.

Please use the attachments to complete the 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).

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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-

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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

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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.

The key issue is that normative or traumatic events have little objec- tive meaning—they are perceived in a wide variety of different ways by dif- ferent people, and the nature of this perception has a great deal to do with

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the individual’s response to the event as a challenge to be overcome or as a destabilizing crisis.

The Roles of Coping and Support

The nature of one’s coping mechanisms is a central issue. Coping refers to conscious and habitual methods of solving problems and adapting to de- mands from the environment. Researchers have found that coping can be categotized as active problem-focused, passive problem-focused, and passive avoidant (Koopman, Classen, & Spiegel, 1996). In the case of job loss, active problem-solving would include activities focused on obtaining a new job, handling financial matters, and related concerns. Passive problem-solving would include talking with others, quiet contemplation about job and finan- cial issues, and so forth. Passive avoidant coping involves activities that en- able the individual to avoid the problem, including escapes into drugs and alcohol. Some passive avoidant coping is not necessarily destructive, but a balance of coping mechanisms is most adaptive.

Social support is the third aspect of crisis. Numerous studies over the past 30 years have demonstrated the benefits of social support on both physi- cal and mental health (Cohen, 2004). Individuals in crisis who have a sup- port system and make use of it, in addition to the support inherent in the therapeutic relationship itself, tend to fare better in crisis situations.

AN INTEGRATED MODEL OF CRISIS AND EMERGENCY INTERVENTION

Now that crisis, crisis intervention, emergency, and emergency intervention have been defined, they can be combined into an integrated model to re- spond to both situations. This model is derived from the work of Aguilera (1998) and Puryear (1979), but with added elements of emergency interven- tion, which takes precedence over crisis intervention. Because a behavioral emergency involves the threat of danger or harm, it always has first priority. Similarly, crisis intervention takes precedence over routine outpatient treat- ment. If an outpatient comes on a routine visit while experiencing a crisis, the clinician must move away from normal psychotherapeutic activity and use the tools of crisis intervention (see Table 1.1).

If the client experiencing an emergency contacts a clinician or agency for the first time, the clinician’s response should be to arrange a face-to-face emergency intervention on an immediate basis. As noted previously, this emergency intervention should include an evaluation of the client’s situa- tion as well as a risk assessment of the potential for suicide or violence, an in- session intervention to try to lessen the risk, and a carefully thought out disposition to ensure safety and provide continuity for subsequent care. Many

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TABLE 1.1 Goals of Emergency Interventions Versus Crisis Interventions

Type of intervention Treatment goals

Emergency An immediate response to perceived imminent risk Management to prevent harm or death Resolution of the immediate risk within a single

encounter Crisis A response within 24 to 48 hours

Therapy to develop or reestablish psychological equilibrium

Resolution within 4 to 6 weeks

times emergency interventions are carried out in a hospital emergency de- partment, and many agencies and private practitioners routinely refer or even take emergency clients to hospital emergency departments.

Crisis intervention, however, requires a rapid but not immediate re- sponse. Much of the crisis intervention litetature of the 1960s and 1970s advocated an immediate response to crisis, but this was because of the con- text of that time. When long-term psychoanalytic psychotherapy was the only treatment available, months-long waiting lists were not uncommon; therefore, immediate attention was not to be taken literally. Newer guide- lines suggest seeing a client in crisis within 24 hours (Puryear, 1979). An emergency requires literally an immediate response.

As noted earlier, this model of crisis intervention focuses on perception (i.e., meaning), coping, and support. In the initial session, the clinician pro- vides a safe atmosphere, uses active listening, and is an empathic, nonjudgmental listener. In most cases, open-ended questioning will allow the client to tell his or her story. In this first session, the clinician should listen for the availability and use of support systems, assess the client’s coping mechanisms and notice which mechanisms are constructive and which are destructive, and form some preliminary understanding of the meaning of the event to the client. In rare cases of traumatic stress the client may not be able to remember the entire event because of dissociative amnesia (Koopman, Classen, Cardena, & Spiegel, 1995); in some instances, the client may feel the need to avoid discussing certain overwhelming aspects of the situation.

During the first session and periodically throughout the subsequent ses- sions of the crisis intervention, the clinician must investigate the possibility of a behavioral emergency. Any reason to believe that the client may be potentially suicidal, violent, or a victim of violence constitutes a behavioral emergency, and at that point the crisis intervention is delayed until the emer- gency is resolved. A risk assessment is carried out. The details of this proce- dure are beyond the scope of this chapter, but chapters 2 through 9 of this book discuss them in depth. An emergency intervention also includes an in- session attempt to decrease the risk of danger by means of a variety of stan-

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dard therapeutic techniques. Such techniques include active listening, ex- plicit empathizing, negotiating conflicts with significant others, offering hope, and pointing out the realistic consequences of fantasized actions. As dis- cussed earlier, the emergency intervention includes a specific disposition based on the outcome of the risk assessment, modified by the in-session interven- tion. If by the end of the session the risk is judged to be low or moderate, the focus can shift back to the crisis intervention. If the risk continues to be high, the session may culminate in a hospitalization or other concrete method of containment and security.

If the risk is low or moderate and the crisis intervention can proceed, certain other aspects must be explored. First is to ascertain that the situation is, in fact, a crisis. As discussed earlier, a crisis is a period of psychological disequilibrium in which the individual experiences anxiety and depression as well as functional impairment. This means the clinician must get a sense of the client’s baseline level of functioning to ensure that this petiod of dis- equilibrium is an acute episode, not a chronic state. Some individuals who function in a state of constant crisis are not really in crisis at all, because a crisis is defined as different from an individual’s baseline. Certain clients with borderline personality disorder, alcohol dependence, or drug dependence can appear to be in crisis, but the chaos they experience is their baseline state. Various questions regarding the individual’s functioning prior to the current situation will usually reveal the quality of his or her baseline, espe- cially in terms of impulse control, maturity of relationships, and integrity of ego boundaries (Gerhart, 1990; James & Gilliland, 2005). Crisis interven- tion, with its rapid intensity of involvement and active style, is not appropri- ate for these clients and will frequently promote regression (Callahan, 1996; Golan, 1974).

Another important aspect of crisis intervention is the instillation of hope. The clinician must project an attitude of calm optimism, which was described by Puryear (1979) as follows:

You are attempting to convey by your entire approach your attitude that the client is a capable, decent person who has been temporarily over- whelmed by extreme stresses, and who will use your help to cope with these stresses and get back on the track, (p. 49)

In fact, the instillation of hope may be one of the most crucial and key ele- ments of crisis intervention.

Subsequent sessions in crisis intervention build on the assessment of coping, support, and perception that was conducted in the first session.

• Coping. In each subsequent session, the clinician discusses the client’s attempts to cope with the situation and reinforces con- structive methods of coping while gently confronting and at- tempting to undermine maladaptive activities. The clinician

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must be careful, however, because certain coping activities, such as drinking excessively, are usually accompanied by denial and defensiveness. Too intense a confrontation will invariably pre- cipitate a loss of the therapeutic alliance and possibly the cli- ent leaving treatment. Support. In each session, the clinician directly provides support and attempts to enlarge the client’s support system. Most people have at least one or two others they can call on for support and the issue is frequently the client’s reluctance to use this sup- port, rather than the lack of it. For certain traumatic events and stressful situations, including medical illnesses, support groups are available. Perception. The clinician elicits the client’s perception of the meaning of the event and gently confronts grossly inaccurate depictions such as “I’ll never get another job” or “I’ll never find anyone else to love again.” In crises precipitated by trau- matic stress, patients often feel they will never be able to func- tion adequately again. Although chronic PTSD sometimes fol- lows traumatic events, it is also true that many people survive enormously devastating losses and continue to live productive

lives.

There are other meanings that some people attach to traumatic events, as described earlier in the discussion of basic assumptions. For instance, a young male patient suffered serious facial bums when the machine he was working on exploded; he later concluded that he was being punished for using drugs and disrespecting his mother. He maintained this belief despite several discussions with his therapist. Similarly, in March 2005, a Chicago judge’s husband and mother were murdered; the parishioners at their church were distraught that this could happen, saying, “Don’t all these good deeds mean anything?” (Cholo &. Ciokajlo, 2005). It is not always possible to in- fluence patients to change the meaning of a horrific event, but when the meaning is particularly malignant or destructive an attempt should be made.

Throughout the course of the crisis intervention, the clinician wotks to enlarge the patient’s support system, promote adaptive coping, and create a more positive and affitming meaning when possible.

In addition, when the precipitating event is traumatic the clinician should also pay attention to the four clusters of symptoms of ASD (Ameri- can Psychiatric Association, 2000). Although many people experiencing a crisis due to traumatic stress do not meet criteria for ASD, these symptom clusters are a helpful way to conceptualize traumatic reactions. These are (a) reexperiencing phenomena, including flashbacks and intrusive images and thoughts; (b) purposeful avoidance of reminders of the event; (c) disso- ciative phenomena, including partial amnesia, numbing of emotional respon-

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siveness, a sense of disconnection from life, and so on; and (d) autonomic reactivity and increased tension and anxiety (American Psychiatric Asso- ciation, 2000). The presence of these reactions in the immediate aftermath of a ttaumatic event does not necessarily signal a negative outcome—many individuals substantially recover during the 1st month or so. Crisis interven- tion treatment does not necessarily resolve these reactions but does work toward a new emotional equilibrium with fewer intrusive thoughts, a reduc- tion in dissociative reactions, and decreased anxiety. Some of this improve- ment is probably directly due to openly discussing the event and one’s reac- tions to it with a nonjudgmental, sympathetic listener. This process can be conceptualized from the cognitive-behavioral perspective as exposure thetapy (Rothbaum, Meadows, Resick, & Foy, 2000) or from the psychodynamic perspective as mastering the trauma (Marmar, 1991). Note that this process goes on over a number of sessions, as opposed to the single session of psycho- logical debriefing.

BEHAVIORAL EMERGENCIES THAT ARE NOT PART OF CRISES

A final consideration is that of behavioral emergencies that ate not a part of a crisis. As noted earlier, most emergencies (e.g., potential suicide, potential violence, victim of violence) take place in the context of a crisis. For example, a middle-age man loses his job and experiences a crisis. A week later he becomes suicidal, or perhaps he becomes violent toward his former boss. These situations are behavioral emergencies in the context of crises, which happen frequently. In less common situations, however, emergencies can arise in times of stability. Individuals with borderline personality disor- der or alcohol or drug dependence often experience chaotic and impulse- ridden lifestyles. In these cases, impulsive suicide attempts can atise during a time of relative stability; borderline patients are sometimes described as hav- ing stable instability.

Similarly, patients with antisocial personality disorder and perpetrators of domestic battery can become violent not only during the decompensation of a crisis but also during a time of normal, stable functioning.

These acts of potential or actual suicide or violence are behavioral emer- gencies without crises. The appropriate therapeutic approach is to conduct an emergency intervention, as described earlier, but not crisis intervention. If the risk of harm is low or moderate, the patient can be referred to or con- tinued in routine outpatient treatment; if the risk is high, hospitalization or some other form of containment is the ideal disposition. Either way, this approach avoids the regression that comes about when crisis intetvention— with its rapid, intense involvement—is inappropriately applied to a person with a stable personality disorder or substance dependence disorder.

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C O N C L U S I O N

Clearly differentiating between a crisis and a behavioral emergency leads to clarity in action and avoids some of the pitfalls of inappropriate interven- tions. In this chapter I provided definitions for crisis to accompany this book’s overall focus on behavioral emergencies and presented a model (not yet em- pirically tested) to integrate the understanding of b o t h situations. I encour- age readers to make use of these concepts in their clinical practice.

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