Understanding People in Crisis Copyright © 2011 by Mainstream, Inc.

The first step to recognizing people in crisis is recognizing what is a crisis for me may not be a crisis for a client.  

A crisis is a short period of psychological disequilibrium in a person who confronts a problem situation that he or she can’t escape or solve with their usual problem-solving resources. Introduction

A crisis occurs when an individual interprets an event as stressful without hope of relief.

Crisis can often be addressed by encouraging alternative thinking patterns for the person precipitating the crisis.

A crisis occurs when an event is perceived as traumatic without psychological or other supports and the person in crisis believes the end result will be the loss of essential and/or important needs.

A. Traumatic event beyond one’s control   B. Sudden loss of psychological and other supports   C. A threat of loss of anything considered essential and important. Conditions for a Crisis

The Social Readjustment Rating Scale is an inventory of common stressors and an assigned value to reflect relative amount of stress.

Life Event Value Death of Spouse 100 Divorce 73 Marital Separation 65 Jail Term 63 Death of a close family member 63

Phases of a Crisis

  Phase I. Period of impact includes both a hazardous event and a precipitating fact.    In the first phase of a crisis, there is an event and a catalyst. The event is experienced as hazardous represents a change in a person’s life. The change can be either positive, a promotion at work, or negative, divorce. The precipitating fact or factor can be anything that contributes to the problem. The first response is to react to the crisis with familiar problem solving skills.   Phases of a Crisis

The PERI Life Events Scale lists events that are the most traumatic or hazardous as: 1) severe losses, 2) blow to self-esteem, 3) changes in health, and 4) changes in economic status.

Phase II. Period of recoil In the second phase of the crisis, the person’s typical response pattern or customary problem solving skills does not resolve the problem or reduce anxiety. Phases of a Crisis  

Phase III. Post-traumatic period In the third phase of the crisis, after the typical response has failed, the person tries every available resource and coping skill. The goal is to reduce the increasing anxiety. Person’s with limited internal and external resources will have fewer options to try.   Phases of a crisis

  Phase IV. Active crisis state: 1. Internal strength and social support are lacking 2. The person’s problem remains unresolved 3. Tension and anxiety rise to an unbearable degree Phases of a Crisis

Duration and outcomes of a crisis   1. Return to pre-crisis state by internal strengths and social supports   2. Grow from experience and discover new resources and ways of problem solving   3. Reduce tension by lapsing into neurotic or psychotic patterns of behavior

There are a number of factors that influence whether or not a person is at risk or not at risk for a crisis. No two individuals will view or respond to a crisis in exactly the same way.

For example, a person living paycheck to paycheck is more vulnerable to a crisis after losing a job than a person one year away from a planned retirement.

People at risk   1. Probability that a disturbing or hazardous event will occur   2. Probability that an individual will be exposed to crisis   3. Vulnerability of the individual to the event  

 People not at risk   1. People with practice at resolving difficult situations   2. People who believe that they can resolve the problems   3. People with strong social supports

Stress can manifest itself in various forms of emotion (anger, fear, frustration, anxiety, rejection, disappointment) and in various forms of behavior (non-verbal, verbal, non-physical, physical). Symptoms of Stress

The symptoms of stress are varied: internalized emotions, hopelessness, distrust, restricted perception, disassociation, and acting out.

Six Phases of the Stress Cycle

The stress cycle has six phases and each phase has a suggested response.

Phase – Response Stimulation – Support Escalation – Set Limits Crisis – Least Amount of Physical Management De-Escalation – Talk Softly and Move Slowly Stabilization – Supportive Post-Crisis Drain - Supportive

The person is not out of control and has not blown up or acted out. Something has happened to cause the person to become excited and to cause the person emotional and/or physical distress. Stimulation - Support

The person is now showing signs of distress: muscle tension, behavioral changes, such as talking louder or faster, doing something with hands, posturing, rocking, pacing, moving faster or slower. Escalation – Set Limits

The person is now either verbally or physically out of control. The person has blown up or acted out. The person may be dangerous through destructive and assaultive behavior. Crisis – Least Amount of Physical Management Necessary

The person is starting to calm down. A gradual decrease in the out of control behavior begins but there are still signs of distress. De-Escalation – Talk Softly and Move Slowly

The person has returned to normal behavior and emotional and/or physical distress is under control. Stabilization - Supportive

The person may drop down below the normal level of emotional and/or physical intensity before returning to asymptomatic normal behavior. The person may sleep, or look and act tired and/or withdrawn. Post-Crisis Drain - Supportive

Crisis is a short period of psychological disequilibrium in a person who confronts a hazardous circumstance that for him constitutes an important problem which he cannot escape or solve with the usual problem solving resources. Crisis Intervention

Disruptive behavior signals that the person displaying it is in trouble in some way, that the person in a problem situation that he or she does not yet have the skills to solve readily and effectively, and so is experiencing a degree of psychological or emotional pain.

Defusing Tools

1. Listen 2. Acknowledge the emotions 3. Apologize 4. Agree with the situation, principle, or opinion 5. Invite the person in crisis’ criticism Defusing Tools

1. Don’t debate the facts 2. Don’t ask why questions 3. Don’t jump to conclusions 4. Don’t rush the defusing process 5. Don’t be sarcastic with the angry person Defusing Don’ts

6. Don’t criticize or blame 7. Don’t impose your own value judgment 8. Don’t preach to the angry person 9. Don’t counterpunch, i.e. respond with anger 10. Don’t take statements at face value Defusing Don’ts

The verbal, non-verbal and emotional responses of the therapist or individual attempting to avert the crisis matter.

Non-Verbal Calming Techniques: Eye Contact – show undivided attention and focus with eye contact. Body Posture – appear confident, relaxed, and in control. Do not intimidate.

Verbal Calming Techniques: Active Listening – allow the person to feel his or her feelings and frustrations are heard. Modeling – demonstrate appropriate voice level. Reassurance – demonstrate willingness to help.

Self-Calming Techniques: Breathe Deeply – count the biological response of confrontation. Hand Position – palms open and facing down or hands folded in front. Stance – stand slightly sideways and put weight on back foot. Eye contact – make eye contact with another adult.

GOAL: To assist a client in coping with and resolving a personal crisis

Realize that the crisis is time-limited. The central purpose of crisis intervention is to prevent the development of more serious and longstanding problems and help the client resolve the crisis in a positive way.

Try to diffuse the situation by listening, acknowledging the client’s anger and offering emotional support.

Allow the client to express emotion. Be aware of the intense anxiety felt by an individual during the stages of a crisis.

Communicate hope and optimism. A hopeful attitude is an essential element in responding to a person in crisis.

Be actively involved. By listening and participating in a positive discussion, you may help identify possible ways of helping the client resolve their problem.

Use partialization. Try to break the problem situation down into its component parts or into several smaller problems to be addressed one at a time.

Involve others in the helping process. People in crisis are often receptive to assistance that can be provided by those whom they know and trust. Encourage the client to reach out to others.

Anticipate future events. Many people in crisis do not understand the consequences of their behavior. It is important to help the client anticipate what could happen if he/she does not take needed action (without threatening).

Reinforce adaptive behavior. Help the individual determine what kinds of coping and problem-solving behaviors have worked in the past. Reinforce those behaviors; encourage the client to take reasonable actions like those that have worked well in the past.

Work out a contract. You may need to contract with the client concerning concrete actions to be taken and tasks to be accomplished within a given time period. This will help the client see more clearly what needs to be done.

Helping People Form Attachments: Some Suggestions

For the purposes of this workshop an attachment may be defined as an affectionate bond between people that endures through time and joins people together emotionally.

To help people form attachments, one must understand the essential needs people receive from them:

The need to take in supplies. Certain “supplies” are considered essential to maintaining function (food and water); in addition, we need to take in information.

The need to maintain an intimate relationship. A continuing relationship, someone to share secrets, a sense of closeness to someone, a chance to deepen feelings, sex.

The need to be part of a peer group. Referent groups and social networks, such as social clubs, work groups, school groups, which can provide daily give and take.

The need for a sense of identity. A clarity of self-definition, a sense of who one is, cherishing one’s self-definition.

The need for a sense of competency and esteem. A feeling of well-being, knowing that one can handle problems.

The need to be linked to a cash economy. To have a job, be married to a person who supports his or her mate, be a member of a family, be independently wealthy, receive social security benefits, be on public aid.

The need for a comprehensive system of meaning. Provides a system for making decisions, setting life priorities, knowing how one fits in.

People who assist others form attachments possess the following characteristics:

Empathy - the ability to perceive accurately what another person is experiencing and to communicate that perception to them.

Respect – the appreciation of the dignity and worth of another human being, and of that person’s right to make his or her own choices in his or her own time.

Genuineness – the ability of an individual to be themselves.

Concrete – the ability of a person to express themselves specifically concerning the other person’s feelings and experiences.

Confrontation – the capacity to challenge the other person on discrepancies in her or his statements, feelings, and action.

Self-disclosure – the revealing of personal feelings, attitudes, opinions, and experiences on the part of the person for the benefit of others.

Preventing Crises

A Definition of Crisis: A short period of psychological disequilibrium in a person who confronts a problem situation that s/he can’t escape or solve with their usual problem solving resources. Disruptive behavior usually indicates that the person is in trouble in some way, that the person is in a situation that s/he does not yet have the skills to solve effectively.

Crisis can often be prevented or aborted by creating positive relationships between two people.

Some tips on preventing crises:

1. Comment to the person on things that s/he does that are appropriate, helpful or adaptive. 2. Initiate positive, personalized interactions with people as “basic trust builders”. 3. Follow through on any commitments made to another person. 4. Deal with the problem rather than for instance, saying the person is “bad” or wrong.

Recognize that when a person doesn’t comply with a request, it may mean: a. They don’t understand the request b. They may be dealing with something else emotionally at the time. Don’t automatically attribute the behavior to being willful or personally defiant.

6. Keep the person informed of your feelings that relate to their behavior. 7. Resist the inclination to indulge the other person in their negative behaviors. 8. Eliminate the threat of punishment from your options of intervention techniques.

Common Problems in Crisis Prevention

1. Telling people they are “so and so” because they do “so and so”. 2. The use of sarcasm or superior intellectual tactics to belittle a person. 3. The use of unrealistic threats. 4. Promising something and not following through. Common Problems

5. Scare tactics – or using frightening stimuli to force a person into a submissive posture. 6. Not viewing anger as an expression of fear or frustration. 7. Not understanding how you feel at the moment. 8. Not asking what the other person wants. Common Problems

9. Not asking yourself: “Is it bad (crazy, unusual, unhealthy, etc.) for the other person to want this in order to feel safe, important, loved, etc.”

Preventing Crisis Teaching Tools

Preventing Crisis: Teaching Tools Identifying triggers. Break conditional responses. Develop alternative coping strategies. Establish a support network.

Identifying triggers Traumatic life events and stressful conditions can include: severe losses, blows to self-esteem, changes in health, and changes in economic status. When identifying triggers, events can have a cumulative effect.

Break conditional responses The persons current responses to the crisis are not working.

Develop alternative coping strategies Suffolk Cognitive Behavioral, PLLC has a Coping Strategies Checklist which includes 51 items in four content areas: Behavioral (Action Oriented Coping) Cognitive (Perspective Shifting) Inter-personal (Social Coping) General Stress Management & Psychological Hygiene

Establish a Support Network Therapists aren’t available 24/7. What supports are available in the client’s environment? Where can additional supports be found? What skills does the client need to build to have better support, “I feel” and “I would like” statements.

Planning with a person or family in crisis

Questions to ask:

To what extent has the crisis disrupted the person’s normal life pattern? Is she or he able to go to school or hold a job? Can the person handle the responsibilities involved in the activities of daily living --- for example, eating, personal hygiene?

4. Has the crisis situation disrupted the lives of others? 5. Is the person suicidal, homicidal or both? 6. Does the person seem to be on the brink of despair?

7. Has the high level of tension distorted the person’s perception of reality? 8. It the person’s usual support system present, absent, or exhausted? 9. What are the resources of the individual helper and/or agency in relation to the person’s assessed needs?

A good plan has these features:

1. problem oriented. 2. appropriate to the person’s (families’) functional level and dependency needs. 3. consistent with person’s culture and life style. A good plan is:

4. inclusive of significant other and social system. 5. realistic, time limited, and concrete. 6. dynamic and renegotiable. 7. inclusive of follow-up. A good plan is:

What do you want? What have you been doing to get it? How is that working? Do you want to figure out a different way? Let’s work on a plan together. Be specific who will do what by when Be simple Be creative Plan for evaluating the results Negotiating a Plan

Techniques in coping with a crisis

1. Listen with concern. 2. Encourage the open expression of feelings. 3. Help the person gain an understanding of the crisis. 4. Help the individual accept reality. Coping Techniques

5. Help the individual explore new ways of coping with problems. 6. Link the person to a social system. 7. Improve decision-making abilities. 8. Reinforce newly learned coping devices with follow-up crisis resolution. Coping Techniques

People cling to their denial in order to buy time until they figure out what else to do. If they are in denial, it’s because it’s the best alternative they can come up with at the moment. Kearney Denial Model

The Kearney Denial Model describes four levels of denial, each level’s key issue, and intervention guidelines. Kearney Denial Model

Denial of facts (Lying to protect self) For example, “It’s not true.”, “It’s a lie.”, “You have no right to accuse me.” First gather facts, observations and reports from as many sources as possible. Present them without drawing conclusions. Be firm and patient, but do not accuse. Fourth Degree Level of Denial

Denial of implication (Minimization of Facts to Protect Self) For example, “Sure I touched her, but that’s not abuse.”, “Sure I collected pictures of kids, but that doesn’t make me a pedophile.” Provide person with expert to inform and educate about the problem. Provide support group led by a professional. Offer hope Third Degree Level of Denial

Denial of Responsibility (Avoidance of the need to change oneself – blame to avoid pain) For example, “It’s not my fault.”, “She started it.”, “We can handle it ourselves.” Require the person to perform a particular task to demonstrate handling it. Process resistance by exploring alternatives. Affirm how hard it is for the client to meet the demands of change. Second Degree Level of Denial

Denial of Feelings (Classic definition of denial) For example, “It doesn’t bother me what people say.”, “I don’t care”, “I never get angry – it doesn’t do any good anyway.” Support person through the use of empathic feeling oriented responses. First Degree Level of Denial

It is unrealistic to expect someone to surrender their denial to you if you don’t offer them something credible and useful to replace it (e.g. a relationship which is nonjudgmental, affirming and respectful, hopeful, and healing).

The Kearney Trauma Model describes different kinds of traumatic events, symptoms both acute and chronic, and interventions. Kearney Trauma Model

Kinds of Trauma discussed in the model: Violation of trust or basic safety Fundamental blow to self-esteem Loss of a dream that expresses a core value Kearney Trauma Model

“Nothing, no place, and no one is dependable or safe.” “I’m alone – forever.” Violation of trust or basic safety

Acute Symptoms Shock Confusion Panic Withdrawal & Fear Ambivalence toward offending person Regression, etc. Violation of trust or basic safety

Chronic Symptoms General distrust Ambivalence toward caretakers & adults Depression, Despair, and/or Extreme sadness Dissociation Emotionally unavailable Violation of trust or basic safety

Interventions Recognize person’s fear and offer reasonable reassurances (No False Promises). Clarify the person’s experience – what it means to the person. Affirm the person’s experience of violation Violation of trust or basic safety

“I’m essentially bad, wrong, unlovable, and it’s permanent.” “It’s all my fault.” Fundamental Blow to Self-Esteem

Acute Symptoms Protest Confusion Disorganization Affective Upset Regression Self-Doubt Self- Punishment Fundamental Blow to Self-Esteem

Chronic Symptoms Autonomy Disorders Impulse Control Problems Extremes of Timidity or Aggressiveness Shame and Rage Boundary Problems Dissociation Fundamental Blow to Self-Esteem

Intervention Assist the person in clarifying what the trauma means to him or her. Affirm the person’s experience. Encourage the person to discover or create successful experiences in the areas of autonomy, initiative or industry depending on the developmental stage. Fundamental Blow to Self-Esteem

“I’ll never be loved.” “I’ll never be normal.” “I’ll never have a normal family.” “There is no hope.” “It will never get better, why bother?” “I give up.” Loss of a Dream/Core Value

Acute Symptoms Affective upset Disorganization Protest or Withdrawal Regression Loss of a Dream/Core Value

Chronic Symptoms Arrested Grief Response Lack of Future Orientation Inability to Dream or Hope Difficulty in Planning and Following Through Depression and Listlessness Immaturity and Denial Loss of a Dream/Core Value

Interventions Identify the lost dream Grieve it Reframe it (especially guilt and shame) Generate new, realistic dream Invest in the new dream Act on it and make it happen Loss of a Dream/Core Value

Understanding people in crisis can be facilitated by understanding the nature of a crisis, understanding successful components of resolving a crisis, and developing resources to produce a new outcome. Conclusions

While considering each crisis as an opportunity to learn new skills, change perspectives, and heal old wounds, a crisis state is a severe disequilibrium without hope of relief from the perspective of the person in crisis.

Regardless of the cause or the outcome, a crisis is an opportunity to support individuals through life’s most difficult times.

Many aspects of a successful crisis resolution become protective factors against future crises.

The practice of resolving difficult situations becomes a protective factor. Experience resolving difficult situations becomes a belief in one’s abilities to solve problems, also a protective factor. A third protective factor comes from supports explored and built during the crisis.

Increasing coping skills, increasing confidence in one’s abilities and building stronger relationships offer resilience against the constant challenges of life.