Crisis Theory and Intervention

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Crisis Theory and Intervention

• SOW6425 Assessment and Planning
• Professor Nan Van Den Bergh

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THE NATURE OF CRISIS

• A crisis is the perception of an experienced
  event as an intolerable difficulty
• A crisis is an upset in a steady state. ( from
  a previous equilibrium)
• A person experiencing a crisis may be lacking
• knowledge about how to manage the situation
  (cope)
• ability to focus and utilize her or his strengths
• A crisis often results when we face a serious
  stressors
• Biological ( illness, disability, loss of prior
  physical functioning)
• Psychological (a sense of loss of esteem, self
  worth) important relationship ending)
• Social (ending of valued relationship/s)
• Economic (economic insecurity, poverty, layoff,
  etc )

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STAGES OF A CRISIS

• There is a sharp and sudden increase in the
  persons level of tension.
• The person tries to cope, but fails, experiencing
  stress
• tension increases and contributes to the sense of
  being overwhelmed.
• The crisis resolves (normatively within 4 to 6
  weeks)
• negatively (with an unhealthy coping solution)
• positively (with successful management leading to
  enhanced sense of personal competence)
• With prior level of functioning intact

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A PERSONS RESPONSE TO A CRISIS

• The growth pattern - the client recovers from the
  event and then develops new skills and strengths.
• The equilibrium pattern - the client returns to
  the pre-crisis level of functioning
• The frozen crisis pattern - the client does not
  improve. New coping strategies may be harmful
  such as
• Withdrawal
• Self destructive behaviors
• Violence

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TYPES OF CRISES

• Developmental crises occur in the normal flow of
  life as significant changes in life status
• college graduation
• marriage/committed partnership
• birth of children
• midlife career change
• retirement from work
• Situational crises refer to extraordinary events
  that a person has no way of forecasting or
  controlling
• physical injuries
• sexual assault
• loss of a job
• the death of a loved one

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Types of Crises (cont.)

• Existential crises are characterized by inner
  conflicts related to
• searching for a sense of meaning and purpose in
  life
• Experiencing remorse over past life choices,
• questioning of ones basic values or spiritual
  beliefs

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STRESS, COPING, AND ADAPTATION

• Stress is the emotional, cognitive, physiological
  and behavioral result of an event in which
  environmental or internal demands exceed a
  person's coping capacity.
• Psychological stress can be experienced as
• Harm effects of a damaging event that has
  already occurred (victimization)
• Threat potential for harm in the future (layoff,
  bankcruptcy)
• Challenge appraisal of opportunity, not harm
  (downsizing)
• Coping is a persons efforts to master the
  demands of stress. It includes
• thoughts, feelings, and actions that constitute
  those efforts.
• Adaptation involves adjustments the person makes
  in biological responses, perceptions, or
  lifestyle.

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BIOLOGICAL COPING - THE GENERAL ADAPTATION
SYNDROME

• Alarm - the body becomes aware of a threat
• Resistance - the body attempts to maintain or
  restore homeostasis.
• Endorphins and specialized cells of the immune
  system fight off stress and infection
• Exhaustion - the body terminates coping efforts
  because of its inability to physically sustain
  the state of disequilibrium.
• Cumulative wear and tear of stress episodes can
  gradually depletes the immune system.
• Outcomes include some physical and emotional
  disorders.

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PSYCHOLOGICAL COPING

• Problem-focused coping to change the stressful
  situation (cognitive problem solving strategies)
• This method is appropriate when we view the
  situation as changeable or controllable via
  taking action.
• In emotion-focused coping (distancing, avoidance,
  and reappraisal of the threat)
• The external situation does not change, but our
  behavior or attitudes change with respect to it.
• Psychologically, the primary coping method
  employed is denial and repression (emotional
  numbing)

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Relational Coping

• Relational coping takes into account actions that
  maximize the survival or others
• Research has shown that within stressful
  situations, rather that fight or flight women
  may be more likely to gather the brood
• Oxytocin is produced

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SOCIAL SUPPORT

• Social support interpersonal interactions and
  relationships that provide people with
  assistance or positive feelings of attachment
• Family
• Friends
• Neighbors
• Material support food, clothing shelter,
  transportation, other tangible items or services
• Instrumental support services provided by
  casual contacts, such as grocers, hairstylists
• Support clusters - distinct categories of people
  such as the nuclear family, extended family,
  friends, neighbors, school peers, work peers,
  church associates, recreational groups

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HOW SOCIAL SUPPORT AIDS COPING

• Nurtures and promotes an ordered worldview
• Promotes hope
• Promotes timely withdrawal and initiative
• Provides guidance
• Provides communication channels with the social
  world
• Affirms personal identity
• Provides material help
• Modulates distress through reassurance and
  affirmation
• Ensures adequate rest
• Mobilizes other personal supports

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Clinical Aspects of Crisis Assessment

• Rapid establishment of a constructive
  relationship
• acceptance,
• empathy
• verbal reassurance
• Eliciting and encouraging the clients expression
  of feelings
• reduces anxiety,
• promotes return to focusing,
• assists re-establishing a sense of calm
• Assessment is rapid but thorough enough to result
  in a well-crafted plan.

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Aspects of Assessment (cont.)

• Assessment includes
• Investigating precipitating factors of the crisis
• Determining the meaning of the precipitating
  event to the client
• Clarifying the clients capacities for adaptive
  functioning
• Determining the clients potential and actual
  support systems

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ASSESSMENT QUESTIONS

• What factors can the client identify relative to
  the onset of the crisis?
• What is the current quality of the clients
  affective, cognitive, and behavioral functioning?
  
• Which areas appear to be the most adversely
  affected?
• Is the client self-destructive?
• Does the client require immediate medical or
  psychiatric attention?
• How does the clients current level of
  functioning compare with pre-crisis functioning?

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ASSESSMENT QUESTIONS (Cont.)

• Has there been significant trauma, illness,
  pathology, or substance abuse in the clients
  past?
• What are the clients strengths? Areas of life
  stability?
• What are the clients realistic alternatives for
  managing the distress?
• What are the clients formal, informal, and
  potential support systems?
• Are there financial, social, or personal
  impediments to the clients progress?

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Crisis Interventions

• Two unique features of crisis interventions
• Social worker's short term and intensive
  involvement with client ( and others if needed)
• Workers active use of the environment in
  establishing linkages plus concrete and social
  support
• Crisis interventions are adapted from other
  practice theories ego psychology, cognitive,
  behavioral, solution-focused, narrative,
  structural family therapy
• Intervention is present-focused
• Clinical case management will almost always be
  provided

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Three Major Clinical Case Management Tasks in
Crisis Intervention

• Forge relationship and make positive connection
• Nature of the relationship will depend upon
  characteristics of the client
• Highly interactive
• Formal and distant
• Facilitate client moving from dependence to
  greater self-sufficiency
• Alter the client's physical environment to
  facilitate improved adjustment to crisis

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Skills Needed for Clinical Case Management in
Crisis Intervention

• Recognize a clients fluctuating competence
• Develop a realistic view of the client's
  strengths and limitations
• Continue to reinforce client's strengths so the
  s/he can acknowledge and utilize them
• Adjust levels of support to maximize a clients
  capacity for self-efficacy
• Facilitate client moving from dependency to
  greater self-sufficiency
• Determine the biological and psychological
  reaction to the crisis

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Skills Needed for Clinical Case Management in
Crisis Intervention (cont.)

• Help the clients significant others cope with
  the crisis situation
• Appreciate the effects of social factors on a
  clients sense of competence
• Appreciate a client's conscious and unconscious
  motives for behavior
• Maintain relationship boundaries during
  often-intensive work
• Provide agency, but not, personal phone number
• Clarify need to maintain appointments, not just
  drop in
• Provide information on how to access emergency
  services

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INTERVENTIONS FROM EGO PSYCHOLOGY

• Ego-sustaining techniques help clients become
  mobilized to resolve their crises and to
  understand their motivations and actions more
  clearly
• Sustainment
• Exploration-description-ventilation
• Person-situation reflection
• Education
• Direct influence
• Structuring (Partializing)

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Interventions From Ego Psychology (cont.)

• Restoration of cognitive functioning techniques
• Worker utilizes reflective statements regarding
  nature of crisis and its meaning to client
• Normalizes the clients experiences based on the
  nature of the crisis and its meaning to the
  client
• Affirms the clients capacity to make lemonade
  out of lemons

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INTERVENTIONS FROM BEHAVIOR THEORY

• Classical conditioning
• Systematic desensitization surrounding responses
  to cues reminding client of crisis event
• Operant conditioning
• Providing reinforcements for changes in client
  behavior related to attempts to manage crisis
• Modeling
• Covert Social worker guides client through a
  process of imagining resolution of the crisis
• Behavioral rehearsal Worker role plays client
  engaging in a crisis resolution task
• Life skills training
• Navigating systems
• Stress management training
• Breathing
• Progressive muscle relaxation

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Intervention Strategies From Cognitive Theory

• Cognitive restructuring
• the ABC review (event/thought/feeling)
• the point-counterpoint techniques (costs and
  benefits of current beliefs)
• Cognitive coping via education and skills
  training
• self-instruction internal cognitive framework
  for instructing themselves on how to cope with
  problem situations
• communication skills training attention to
  clients social, assertiveness and negotiation
  skills
• Use of I messages
• Active listening skills
• Make specific requests of others

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Crisis Intervention Strategies From Cognitive
Therapy (con.t)

• Problem solving structured five step method for
  clients who dont have to eliminate cognitive
  distortions
• Define the problem
• Brainstorm solutions
• Evaluating the alternatives
• Choosing and implementing an alternative
• Role play this for trial run.
• Evaluate the implemented option

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Solution Focused Strategies and Crisis
Intervention

• Focus on solutions and exceptions
• Identify and amplify clients strengths
• Builds positive feelings and hope
• What will be different for you when our
  collaboration on resolving this crisis has been
  successful?
• Ask strengths-reinforcing coping questions
• How have you been able to manage this crisis so
  far?
• Explores exceptions to the client's feelings and
  behaviors
• Are there times when you think you can stand up
  to this crisis? How so?
• Ask miracle question
• If you were to wake up tomorrow and this crisis
  has been resolved, what would be the first things
  you would notice.?
• Elicit solution-focused tasks
• Between now and the next time we meet, I would
  like you to call at least one of the people we
  have identified as your supports, on a daily
  basis

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Narrative Theory and Crisis Intervention

• Many crises that people experience may be
  complicated by life narratives that exclude
  possibilities for a successful resolution
• Feeling hopeless, helpless, worthless, unlovable,
  incompetent..etc.
• Normalizing and strengthening
• Encourages client to describe how s/he
  understands and approaches the crisis situation
• Anyone who is given a cancer diagnosis finds it
  difficult to be task-focused, initially
• Affirms clients resources for dealing with
  crisis
• Consider all of the challenges you have met
  through your life to date raising a family,
  having a job, caring for your parents..and your
  capability to do that is based on your own
  strengths!
• Reflecting (deconstructing)
• Helps client analyze assumptions about self and
  world to uncover ideas that are represented by
  the crisis ( Im not able to because I am
  a.. )
• Helps client identify vales that underlie her/his
  beliefs about crisis and social conditions that
  contribute to clients assumptions about the self
• Because you have had a mastectomy, you dont
  believe that anyone could ever find you desirable
  as a woman.

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Narrative Theory and Crisis Intervention(cont.)

• Enhancing changes (Reconstructing)
• Help client to give up stories that result from
  rigid narratives
• Being a desirable woman is more than wearing
  lingerie and being sexually attractive.
• Consider alternative stories about the past,
  present and future
• You can join that army of breast cancer
  survivors who see themselves as strong, proud
  and awesome women!
• Celebrating and connecting
• Help client to make plans to sustain the new
  narrative and new self after crisis resolution
• You have so many opportunities to expand your
  social network by getting involved with all the
  breast cancer support and advocacy activities
  within our community..
• You are more than your hair..

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TOPICS FOR DISCUSSION

• Share examples of crises that you or people you
  know have experienced.
• What was the nature of the crisis?
• How did the person (or group) respond, and what
  factors seemed to influence the response?
• Psychological stresses can be categorized as
  involving harm, threats or challenges.
• Identify examples of each of these stress
  perceptions as they are seen in clinical
  practice.
• How does the way in which the situations are
  perceived influence clients reactions?
• Are client perceptions generally realistic in
  this regard?
• In this chapter crisis intervention strategies
  are described from the perspective of six
  clinical practice theories.
• Consider the types of client presentations that
  would be suited to each of these intervention
  perspectives.

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ROLE PLAYS

• Each role play scenario has two parts. First, the
  social worker and client are meeting for the
  first time. Second, the social worker and client
  have met twice already and are now engaging in
  their final conversation (the client may be
  terminating or referred to another provider for
  ongoing assistance)
• A 52-year-old working mother with a spouse and
  two children (aged 25 and 20) learns that she has
  pancreatic cancer and will probably not live
  through another year.
• A family of four (father, 46 mother, 45, and two
  daughters, 16 and 11) has lost its home due to
  hurricane damage. They must break up temporarily
  to occupy other living quarters (the homes of a
  friend and a relative, and a shelter).
• An adolescent learns that his single father is
  going to prison. He will be living with an aunt
  in another city whom he knows but is not close
  to.
• After each role-play discuss the actions of the
  social worker, their rationales, and their
  apparent effectiveness.