CRISIS INTERVENTION

Introduction Dr.L.Ratna

Crisis therapy has many antecedents such as brief therapy (Malan) goal orientated psychotherapy and emergency counselling. It differs in that the sole goal is not simply to return the individual to his previous functional level. The aim is to use the opportunities presented by crisis to enhance coping skills so that the tragedy becomes a learning experience and a point of psychosocial change. There are several attitudes that are required to achieve these goals. Carl Rogers stated that for therapy to be successful three ingredients were vital. First the therapist should be warm. S/He should not be cold or distant. S/He should be perceived as caring and concerned by the client. Secondly s/he must be empathic. S/He must have a capacity to accurately sense the patients experience. Thirdly there must be constant positive regard. If the therapist becomes judgmental or rejecting the work of therapy will be adversely affected.

Morley from his work in the Benjamin Rush crisis centre formulated seven goals

1. It is essential that the therapist see crisis therapy as the treatment of choice not as an adjunct or as something that is second best

2. An accurate assessment of the presenting problem not a diagnostic evaluation for medical categorisation, is essential for successful intervention. i.e. problem solving is more important than diagnosis in the crisis interview

3. Both the therapist and the client should be aware that crisis therapy is sharply time limited and they should strive together to resolve the presenting problem.

4. Only material directly relating to the crisis should be dealt with. i.e. a sharp focus must be maintained

5. The therapist must take an active and directional approach. Passivity and neutrality so fundamental to conventional therapies are inappropriate in the crisis setting.

6. The therapist must be very flexible. Information giving, contacting relevant resources, mobilising other agencies and individuals are all part of crisis intervention.

7. The explicit goal of therapy is to return the individual to his pre crisis level of functioning.

While these views are not written in stone they offer important guidelines to scope and thrust of crisis therapy.

Morley also went on to define 4 stages in crisis intervention

1. Assessment of the individual and his problem.

2. Planning therapeutic intervention.

3. Intervention. In this phase he saw 4 substages

a. Helping the individual get an intellectual understanding of his crisis

b. Helping the person explore and discharge his feeling engendered by the crisis

c. Exploring coping mechanisms

d. Reopening his social world.

4. Resolution of the crisis and anticipatory planning.

Ann Hoff lists the basic features of crisis planning as follows

1. Develop the plan with the patient. The search for a solution to the crisis needs to be collaborative. Doing things to a patient as opposed to with a client can solve a problem in the short term but leads to devaluation and dependency.

2. Problem orientated. The plan focuses on immediate concrete issues.

3. Appropriate to persons functional level and dependency needs. If the person is too anxious the therapist needs to be active. If there is a lot of pent up emotion time needs to be given to discharge it. If there is high dependency ;Interdependency needs to be created.

4. Consistent with the patients life style. Patients life style, value system, cultural, religious and ethnic expectations need to be considered in planning crisis resolution.

5. Inclusion of significant others and social network. The person in crisis needs to be connected up with significant others to enlarge the scope of support and coping.

Morleys approach is very suitable where there is some preselection of the patients and crises are separated from acute psychiatric emergencies. Issues such as rape, bereavement and loss in otherwise healthy individuals are well served by this approach. Where there is no control over the input and the service is more comprehensive in its approach, these principles need to be modified.

Aguillerra and Messick

CASE STUDY: POST NATAL DEPRESSION

STATE OF EQUILIBRIUM

Birth of baby Critical & Unsupportive Husband

STATE OF DISEQUILIBRIUM Anxiety and Depression

Need to reduce Anxiety and Depression

BALANCING FACTORS PRESENT One or more balancing factors Absent

Realistic Perception of the event

Feels she is an inadequate and incompetent mother

PLUS AND

Adequate situational support

Inability to communicate concerns to Husband and carers

PLUS AND

Adequate Coping Mechanisms

Lack of experience in caring for a difficult baby

RESULT IN RESULT IN

Resolution of the problem

Increased Anxiety and Depression

Equilibrium Regained

Increased fears of inability to cope with infant.

NO CRISIS

CRISIS

Aguilera & Messick have developed a paradigm for the evolution of crises. They see crisis as stressful event precipitating disequilibrium. Now if there are what they call balancing factors then there is coping and the crisis is resolved. These balancing factors are first a realistic perception of the event . Second the availability of adequate situational support and lastly the mobilising coping mechanisms which resolve the problem and re-establish equilibrium. On the other hand if one or more balancing factors are absent such as a distorted perception of the event and or the lack of adequate situational support with no coping mechanisms, then the problem is unresolved ,the disequlibrium continues and a crisis ensues. This model explains why when faced with distressing events some people go into crisis and others do not. It also gives us a model for intervention in crisis - the creation of balancing factors

Phases of crisis intervention

1. Assessment. The first interview in crisis intervention is a key interview. Its style and content can skew the out come. The initial encounter has two key goals the first is to discover what the problem is, the context in which it arose and they ways in which it may be resolved. The second is to help the client enhance his coping skills and gain ego strength from the experience. The first part of the interview may be taken up with attempts to reduce the anxiety level, so that an exploration of the problem can be made. In a very disturbed situation the therapist can do this by taking charge despite the drawbacks of such a position. If it is done it needs to be done in a calm collected fashion and it is important that the therapist does not become infected by the anxiety inherent in the crisis situation. Taking charge does reduce tension but it can also produce passivity and dependence so it is a tactic that should be used with caution. The essence of the interaction should be contractual rather than didactic. The team should state how and why they have been called .Opening questions address the issues what help the client/family are seeking , so that a contract of care can be entered into. Professionals sometime fail to recognise the fact that the context of an interview affects its course and content. For example interviewing a distressed person in a hospital by a doctor often produces more medical symptoms than if the same person was interviewed at home by a social worker. Clients also make assumptions about what they want to communicate .

For example J. D Salinger’s celebrated novel "Catcher in the rye” opens with

" if you really want to hear about it, the first thing you will probably want to know is where I was born, and what my lousy childhood was like, how my parents were occupied and all that before they had me, and all that David Copperfield kind of crap, but I don’t feel like going into it, in the first place that stuff bores me in the second place my parents would have about two haemorrhages apiece if I told them anything pretty personal about them. They’re quite touchy about anything like that, especially my father. They’re nice and all ‑ I'm not saying that ‑but they’re also touchy as hell. I'm not going to tell you my whole autobiography or anything. I'll just tell you about the madman stuff that happened to me".

All patients edit their communications not only in terms of what they consider relevant but also in terms of the anticipated responses of their families and the professionals. This is particularly so in psychiatry where there is a cultural myth that psychiatric professionals can infer deeper meanings from trivial remarks. This paves the way for convoluted communications . The aim of assessment is to cover three main areas

1. To delineate the life problem that the client cannot solve

2. To explore the depth and variety of his coping mechanisms and the options available.

3. To diagnose the presenting symptom complex.

The problem with a exclusively medical interview is two fold the first is Reification the second is Dependence. Reification is the process by which the distress experienced is isolated from the life problems connected with them. They are presented as independent entities, having no connection with the persons life and experience. Freud called called this process isolation, where as a defence mechanism emotions and meaning were cut away and isolated from experiences. This process is accelerated by an exclusively medical approach since the primary problem is seen as being genetic - biochemical as opposed to human - interpersonal. In theory there is no real contradiction between these two views and they can be profitably used in conjunction with one another. Unfortunately in practice these can become the ideologies underlying power battles between the patient and the therapist, between the patient and his family or between therapists. By reification the symptoms and the symptom complex, are isolated from their human and social context and presented as the sole problem which becomes the responsibility of the doctor to treat. It confuses and makes concrete the human pain experienced. For example a woman who is unhappy about her husband having an affair simply states she is "depressed" and does not disclose anything about the situation with her husband. The problem is thus transformed from a marital conflict to a biochemical deficit. This way she doesn’t challenge her husband who might then leave her for the other woman whilst at the same time signalling her distress to the family and the doctor. She is not breaking family loyalties by “grassing" to outsiders about the husbands misdemeanour. The husband in turn can appear concerned and demand treatment whilst concealing the causal conflict. The process can backfire in that the woman is then seen as mentally ill suffering from “psychotic” depression and she may pushed further into the role of a person who has no control over her emotional life. She comes to suffer her problem now "depression" like an object, a tumour within her, unconnected with her life as a person. I am depressed becomes analogous to I have cancer ‑ a concrete but invisible entity, a disease. She has lost the emotional continuity of her life and agency of her actions. One of the features of people who have been treated on a strictly medical model is that they are more likely to become disconnected from their relationships pleasures and interpersonal activities. As with institutional neurosis and institutionalisation this is attributed to the disease rather than the process of disconnection inherent in diagnosing distress as disease.

The issue is not whether an experience is distress or disease - a dichotomous “Either / Or” construction. The approach is a “Both - And” where the symptoms are dealt with as an experience in a person living a given social context, so that the Biological, Personal, Social family issues are all addressed. Crisis intervention is fundamentally an eclectic approach and it happily marries drug treatments with attempts to help develop the clients ego strengths and coping mechanisms . It is a question of balancing out and blending the treatment strategies rather taking up dialectically opposed positions. Dependence is the assumption that all that is necessary to solve the problem is to take the tablets as prescribed by the doctor. Medication does help with symptom relief, but in many cases there are also life problems and issues that need to be worked on. By combining work on these issues with medication it is possible in many cases, to optimise the outcome.

Initial inter-action.

Assessment cannot be distinguished from treatment. The very act of accepting an interview with a client or family has already set in motion changes and roused expectations . The family in seeking help are saying in effect that they do not have the means to deal with the problem. There is a breach in the family circle that has necessitated the invocation of an outsider to sort out the matter. Families have differing levels of tolerance and some families will go to great lengths to contain their distress within the family nexus before seeking help. The straw that broke the camels back is an important clue to the aetiology of the problem. Addressing issues such as

"what help are you asking for?"

"why now?"

who made the decision to seek outside help?"

can often open up communication channels. Where the interview is carried out who carries out the interview and the interactions that led to the crisis interview being set up all have an important bearing on the outcome. Palozolli has called attention to the systemic implications of the referral process and these will need to be explored.

The multidisciplinary team

The crisis interview in Barnet is conducted by a multidisciplinary team consisting of a doctor a nurse and a social worker. The interviewing system is multidisciplinary. This is because one cannot predict in advance what the patients treatment package is going to demand, and their prescence at the crisis opens up the availability to the patient, the various resources, that each professional has access to. The prescence of all three professionals enables them to take an active role in the exploration and to have say in what each of them has to offer rather than have their services prescribed to the client in his or her absence. Since the decision is made jointly communication and commitment of the professional is enchanced and saves time in that the professional who becomes the key worker doesn’t have to repeat the process of assessment, as would be the case if s/he wasn’t at the crisis interview. From the patient’s and family’s viewpoint it gives them an opportunity to meet ,interact and contract with the professionals who will be treating them. It increases choice in that they will have three personalities to choose from with three separate skill systems that can be blended if necessary. From a team point of view it allows observation and feed back of fellow professionals, there is a richness of perceptions and most important with difficult cases there is support, when dealing with difficult anxiety provoking situations. It permits a variety of interviewing styles and enables a wider variety of strategies to be used. For example one therapist can be hard and take a confrontational approach and be balanced by a soft therapist who takes a supportive approach.

Problems in multidisciplinary work arise from three main sources Power, Personality and Philosophy. Power is a key issue with psychiatric professionals and their need for it is rarely acknowledged by them. Where there is an intense commitment to one or other ideology the power conflict can surface as a conflict between two or more systems of management. This is best defused by defining and blending the packages in the actual treatment situation, but the underlying conflicts need to be recognised and dealt with separately. Resolving these conflicts, may involve the evolution of hierarchies, but ideally the spirit and practice of crisis intervention should be democratic. As with all democracies the cost is one of constant vigilance.

Personality is a key issue and team work can become an interplay of personality styles. The ability of various professionals to get along with one another professionally and personally is an important determinant of the quality of practice. Petty rivalries and personal conflicts can affect treatment outcome. The capacity to form informal networks outside the work setting appears to reflect good team functioning. The ability to respect one another value each others contributions is a necessary part of multidisciplinary team work. Differences in opinion on the use of coercive strategies such as involuntary admission under the mental health act, is a common cause of conflict between doctors and social workers.

Philosophy is the different models of madness and therapy that various professionals and individuals espouse. Different professionals may have differing views on the nature of the clients problem and its treatment. In reality there are no treatments that are mutually totally exclusive, and different strategies can be blended together provided professionals respect one another. In the hospital hierarchies and boundaries are usually clearly established. In the community this is not the case. Team building therefore is a key part of community work. David winter in his study of the professionals working in crisis services found that those with liberal political views who were flexible and able to function in disorganised situations found crisis therapy more satisfying than authoritarian individuals who had a more structured approach.

The Crisis Interview

1. Introductions

2. Disclosure

3. Openings

4. Communication

5. Exploration‑ symptoms, life, problems, coping mechanisms.

6. Catharsis

7. Formulation

8. Inhibition of negatives

9. Resolution‑symptom control, problem solving

10. Support network

11. Communication network

12. Follow-up and Termination

There are three main stages:- the first stage is setting up the interview and gathering the relevant information ‑sections 1 to 4. The second stage is the work of the crisis interview the discharge of emotion, the arrival at an intellectual understanding of the problem and the inhibition of negative mechanisms. The final stage is the evolution and the enaction of the plan of action.

1. Introductions

Crisis interviews are far more chaotic than standard medical interviews conducted in outpatient clinics or even in settings such as emergencey rooms. The very pressures that generated the crisis situation will affect the interview. The patient may fear that you have come not to help but “to lock him or her up”. The patient may not have been told and he or she may perceive it as an unwarranted intrusion. The arrival of a team as opposed to a single doctor may confuse cultural expectations of privacy and raise fears of coercive strategies. It is important to spend time gaining trust before engaging on the task of information gathering or therapy. State who you are and how you come to be there. Egs "hello I am Dr. Kildare this is social worker Mary Brown and this is community nurse Francis Turnbull. Your family doctor Dr. Frommer has asked us to come and see you". Use the greeting ritual to mirror the communication pattern you want to establish. Ask to be introduced to all those present. Egs. "I take it you are Mr. Adam can we know who all of you are". Spend time explaining the basis and reasons for your visit. Avoid rushing into the interview.

Very often relatives will ask whether they can see you on your own before you see the client. This in effect disempowers the client and creates an atmosphere of conspiracy and engenders passivity. Encourage them either to disclose it where relevant at the family interview or arrange for their concerns to be explored at a separate interview

2. Disclosure

State what you know already egs. "Dr. Frommer your family doctor tells us you have been feeling depressed since you became redundant ". By being open create a culture of openness that will facilitate disclosure. If the client is distressed or anxious spend time calming her down and postpone the gathering of information till the client feels secure enough to discuss matters. If the client is chaotic violent manic or out of control it may be necessary to establish boundaries, but drop it in favour of a supportive stance as soon as possible.

3. Openings

Open the interview with an open ended question egs. "Can you tell us what has been troubling you?" Or "how can we help you?" Ask for a brief statement of the problem from the clients point of view. Directive questioning from the beginning tends to make the client passive. One of the tenets of crisis work is to encourage the client to help himself.

This raises the question of the silent or noncommunicative client. One then needs to distinguish between elective mutism and mutism that is secondary to some problem. Many silent clients are angry or frightened. They may not have asked to see you and the visit may have been imposed on them by an anxious relative. There are four basic type of questions - open, closed, choice and hypothetical.

Open questions - are very general and don’t indicate an answer - egs “ How are you?”

Closed questions - involve an yes or no response - “ Are you feeling depressed?”

Choice questions - ask the client to choose between two possibilities - “ Are you feeling anxious or depressed at the moment?”

Hypothetical questions - involve an assumption imposed by the interviewer egs “ If you weren’t depressed today what would you be doing?”.

4. Facilitate communication

Listen with caring concern. Reinforce the narrative flow by your body language ‑ sitting forward maintaining eye contact. Use verbal reinforcers such as "uhm uhm","aha" and "go on","and tell me more about that". Besides the standard methods of interviewing to gather medical information, there are certain approaches to interviewing , which can be selectively used in certain family situations.

QUESTIONS
The aim of the question in the therapy is not simply to elicit information for the therapist to process and arrive at a diagnosis but to enter into a dialogue. The sharing of ideas and hypotheses as opposed to making learned pronouncements, helps empower the client.

Systemic Thinking

Looking at the problem not as a fixed piece of pathology in one person - the patient, but as the product of an interaction between a group of people. Also look at the consequences of the disturbances on the life and interactions of the family.

The classic example is a bad relationship between the parents leading to an adolescent being "disturbed". By presenting the child as the problem the parents avoid talking about the marriage. Their problems in turn are blamed on the stress caused by the sick son. The conflict may bring the family closer and there may be a sense of pseudomutuality created in the family by the act of coming together to solve the problems presented by the “sick” child. This may be satisfying in itself, despite the pressures engendered ,and the son may fear that if he gets better the parents will part. The mother finds that since the son's illness the father is more involved with family matters. The father may find that because of the son's illness, people at work are nicer towards him and his wife complains less about him and gives him more authority. Such a family may talk of nothing but the son's symptoms and, more importantly, they may oppose explorations that are not solely concerned with a confirmation of the son's “sick” status. The therapeutic consequence is that they may resist change, whilst at the same time seeking it. This resistance to change is called the “negative consequences of change”. This process of inquiry does not seek to deny the problems the patient has, but to explore their context and clarify those elements in the responses to it that may be directly or indirectly reinforcing and perpetuating it.

Techniques of Interviewing

The Eliciting stance:

The therapist is in a “one down” position and asks, inquires, elicits from the family members their theories and ideas about "the problem" or "the situation".

The therapist avoids the invitation to confirm a one true reality and communicates implicitly or explicitly equal respect for different formulations of the problem, modelling a "both and" position. Different constructs offered by the family are explored non judgementally encouraging an attitude of discovering new approaches.

E.G., so what is your theory as to what is making your wife unhappy?

What makes you say that?

This is an useful way of engaging families stuck at the level of reciting the same symptoms. It is an invitation to explore the possibility that there are other ways of conceptualising and responding to the problem. Openness has to be modelled and explorations positively reinforced.

Probing Stance

Therapist keeps offering different views of what the family members are saying. S/he "Reframes" their statements not as an expert interpreting reality, but as part of an evolving dialogue. The different views offered must be plausible and sufficiently different, from that offered by the family members, to be useful. They must be valid enough to be acceptable and not be offensive or rejected out of hand.

The family members may agree, dissent or ignore the construction offered. Use the response to explore further.

E.g., Mother My daughter is anorexic.

Therapist: I get the feeling she may be trying to get your attention

Mother “I don’t agree”.

Therapist: “OK tell me how you would exclude that possibility. When does she get attention?”.

The Contextualizing Stance

Places the symptoms in an interactive field. What effect does the symptoms have on the other members?.

Example. Therapist “when Laura does not eat, who gets upset?”

Husband. “My wife”.

Therapist. “And when she is upset, to whom does she turn?”

Husband. “To me.”

Therapist. “And what do you do?”

The eliciting and probing stances explores the meaning and ideas family members have about the symptom. The contextualizing stance emphasises behavioural interaction. It shifts away from interior experiences to the pattern of connections and responses.

When one says Laura "is" depressed one speaks of an internal field of inner experience. This leads to questions about what is she depressed about. What type of depression it is etc.

When one says Laura "shows" depression we move out into the external interactional field - to whom does she show her depression? If she were to show her depression at work or to someone else what might happen?

The Shift is from "is", to "shows".

This looks at the function of the system and explores behaviours that may be supporting the maintenance of the symptom.

The Matching Stance

This involves mirroring back what the family presents.

Matching the pattern presented by the individual is called empathy. Matching the pattern presented by a family is called mirroring.

There is an old rule in family therapy.

If you want to reinforce or entrench a position, counter it.

If you want to liberate a position, join it.

A common example is of a marital couple who argue all the time. To entrench the position you oppose it by telling them they must stop arguing forthwith. In the joining position, you and a co-therapist argue amongst yourselves, in front of the couple, and then apologise for doing so.

The Amplifying Stance

You express interest or you pay a lot of attention to some aspect of behaviour and thereby encourage its recurrence.

E.g., So you didn’t drink when the boss criticised you. This is very important, tell me all that you can about it. How did you cope with your hurt and anger. How did you succeed in avoiding the bottle?”.

or

You can amplify some aspect of behaviour , for example, in a couple who were bickering and fighting a great deal.

Therapist "Was there anytime you felt angry but did not get into a fight?"

Wife. Yes last night he switched channels without asking, but I bit my tongue and did not say anything".

Therapist. (with surprise) Now that is really interesting, how did such a miraculous thing happen. Tell me all that you can remember about it. This is very important.

This is to encourage the attitude that there are alternative strategies and they are not fixed in some inexorable process.

5. Exploration

There are four key sets of information that need to be gathered.

1. The symptom complex

2. The life problems and stresses. The psychosocial transition

3. The pattern of coping mechanisms and available supports

4. The negative reactions.

In response to your invitation to state their problems some clients respond with symptoms, this is called the Medical presentation. Others respond with their problems, worries and anxieties, the Problem presentation. Explore the duration of symptoms and delineate the symptom complex. Egs "you tell me you have been crying a lot ‑ is this worse in the morning or the evening?". Plot the relationship of symptoms to life events and psychosocial transitions. Remember “post hoc non ergo propter hoc”. The fact that something happened after an event doesn't mean that it is the event tthat caused it to happen. Egs "have any changes occurred in your life recently" "what do you think has caused all this?" "What is it you have been worrying about?" Establish the connection between the symptoms and the life problems. Egs "it seems that your depression ‑ your feeling of unhappiness and anger began from the time you daughter got married and left home". Get the patient to make these inferences . Conclusions arrived at by the patient encourage the development of a sense of mastery over the problem. State your formulation or summary in simple terms in language that is at the level the patient has be using. This humanises the symptoms and creates a formulation of the problem that enables them to play a more active role. All explorations should be done in conjunction with the patient, crisis therapy is something done with a client not to a client. An important part of the interview is an exploration of the patients traditional problem solving techniques. The way the client has coped in the past is a clue to his ability and resources. So explore past crises and look at how he dealt with them egs. "So when your girl friend left you felt upset. How did you deal with that hurt". Look for positive and negative patterns of coping

6. Catharsis.

Catharsis

Relief through the discharge of emotion.

1. Identify feelings ‑ accurate empathy

2. Experience feelings ‑ reflecting, interpreting, acknowledging

3. Expressing feelings ‑ permitting, accepting, containing

4. Giving time.

Too much affect needs to be contained too little needs to be discharged.

Alexithymia, Strangulated affect, Denial

Danger! - do not unpack what you cannot put back.

Catharsis is the purging of the soul by the discharge of emotion. What makes a crisis a crisis is the intensity of emotion it generates. A controlled discharge enables the client not only to unburden him or herself but also to gain mastery over their feelings. Encourage tension reduction by permitting this. Egs‑ "you must have found that very distressing". "How did that make you feel". "Do you still feel that way". To enable this to happen it may be necessary to give permission. “Most people faced with that situation would be very sad indeed" It is also may be necessary to create a framework in which the client feels it is safe to discharge his or her feelings. " We are here to help and we will be here as long as it takes to sort this problem out”

Giving people who are in intense states of mind, time is an important part of crisis intervention. Attempts to hurry things along or to achieve goals prematurely are likely to intensify rather than relieve the pressure.

The converse problem ,Alexithymia or the inability to find words for emotions. Suppression of feelings is as serious a problem and can lead to acting out or physical symptoms. Encouraging and enabling a client to express them is a key task.

7. Formulation

Help the patient gain an intellectual understanding of the problem ‑ to get a handle on it. This loss of a sense of mastery over one's life is often at the core of the clients experience of crisis . Arriving at a definition of the problem is the beginning of its resolution. The conceptualisation of the problem is the beginning of mastery. It should not be confused with or stop at simply arriving at a diagnosis. The word dia (through) gnosis (knowing)- knowing through or seeing through the symptoms. It implies an understanding greater than identifying a constellation of symptoms. The medical diagnosis indicates what kind of medication is most helpful and what the course and prognosis are likely to be. The crisis model is a problem centred model. We need also to look at how the individual patient is affected by this problem. We need to explore the effects it has on his family. Beyond the diagnosis we also need to see what is healthy and reparative. Most doctors are aware of the word Pathogenesis - what makes things go wrong. They are less aware of the term Salutogenesis - what is it that heals people and puts them right. The crisis interview assesses the strengths and resources of the individual and his social network. The formulation of the problem must lead to a solution that utilises these resources. In general if the crisis event is seen as a loss , negative feelings are evoked. On the other hand if it is seen as a challenge more positive experiences are engendered.

The expression of emotion and formulation of the problem are the key active functions of the crisis interview itself..

8.INHIBITION OF NEGATIVE STRATEGIES

Blocking

Inhibition of negatives coping mechanisms

Projection ‑ blaming, scapegoating

Denial‑absolute & relative.

Trivialisation

Dependence

Passivity

Escapism ‑drinking

madness

manic defence

Key goals

Acceptance

Involvement

Option generation

Decision making enacting

Empowerment

Many people are in crisis not because of the immensity of the problems facing them but because of the use of maladaptive solutions, that make the problem worse. Alcohol is the archetypal maladaptive solution engendering problems of its own that serve to intensify and perpetuate the underlying crisis.

Emily Bronte in “Wuthering Heights”gives us a vividly describes negative patterns of coping in her account of Hindley Earnshaw’s behaviour following the death of his wife.

“ He grew desperate. His sorrow was of that kind that will not lament. He neither wept nor prayed. He cursed and defied; execrated God and man and gave himself up to reckless dissipation. The servants could not bear his tyrannical and evil conduct long. Joseph and I were the only two that would stay...the curate dropped calling and nobody decent came near us at last”...

Clearly for Bronte Mourning and prayer were the appropriate responses to this crisis. Hindley not only fails to mourn, but also engages in reckless dissipated behaviour that amplifies his loss and cuts him off and alienates him from those who might support or help him through this crisis. Thus in addition to the primary crisis of bereavement he now has secondary problems in loss of social status, risk of financial ruin and alienation from friends and supportive agencies. Identifying and eliminating the secondary problems engendered by inappropriate responses to crisis is called blocking. It helps free up energies that can be devoted to dealing with the primary crisis.

The blocking of maladptive me mechanisms is a part of crisis problem solving. Inappropriate coping mechanisms can range of a various forms of denial to active self defeating strategies. For example a mother of a teenager who had spent several months in a darkened room using a drawer as a toilet agreed with the client that he was “going through a phase and would soon get over it.” This is called trivialisation. Another student after failing his exams embarked on a series of complaints against his university , thereby undermining the support he needed to get a grant to continue his studies. Clients in crisis tend to blame themselves or others inappropriately. Egs‑ "if only I had not gone out on Tuesday" or "if only my husband had changed his job this would never have happened". Scapegoating and blaming are classical in marital crises and it should be gently pointed out that the event has now occurred and recriminations are not going to help solve the problem. The role of drinking or denying the problem as a means of escaping from it should be explored and the client helped to face it. Flights in to madness can also be an escape and need careful handling.

9. Resolution.

Resolution

Problem solving

1. Options generation - explore possible solutions

2. Option selection - weighing up the pro & cons and deciding

3. Option enactment - Role of the client

Role of the family

Role of the therapist

Logistics - Residence

Work

Finances

Key tasks

Informing

Reframing

Negotiating

Reflecting

Reviewing

Criticising

Mediating

Enabling

Empowering

Once you have reached the stage of formulation and that has been made explicit and agreed you move to the stage of options analysis and strategies for resolution.

There are two key areas ‑ symptom control and management of the underlying problem. Symptom control may involve anxiety management techniques ,cognitive strategies, time tabling, daily living programs, thought stopping ,drugs etc. If drugs are used emphasise the need for action in other areas or it can lead to medicalisation and passivity. Drugs are particularly useful if insomnia, anxiety or other symptoms are so disabling that problem solving is impaired. When used in mild cases they often lead to dependence both physical and emotional and can actually impair work on life problems. The issue is not whether drugs are appropriate or not but the clarification of their role in solving the totality of the problem.

Case Study -

26 year old single female a patient who is in a severe state of panic after her house was burgled. Her father was killed by a mugger when she was five years old

The options generated in her case were

"So the possibilities are

1. For you to go and stay with your mother

2. For you to stay here alone and fight it out.

3. To come into hospital"

Explore the advantages and disadvantages of each

egs "if you went and stayed with your mother you wouldn't have to be alone in your flat and you would get some support from her. But you wont be able to come to see us because its too far. I can of course get in touch and refer you to the services there. At some time of course you have to face coming back to the flat and your job". "If you stayed here and fought it out you will have to face the anxiety and tension on your own . Of course you have friends and neighbours and you can contact us on the phone. Its probably the hardest option but on the other hand its one you are going to have to face at sometime". "Hospital. This will make you feel safe and you will be with other people and there is occupational therapy. On the other hand it may be a disturbing experience and it may have long term consequences about the way employers and others perceive you. You could of course come as a day patient but then your problem is mainly at night"

Let the patient make the decision. If asked for an opinion express it but always give the reasons for your view so the patient can judge them. Avoid prescribing a solution as far as possible otherwise you tend to perpetuate passivity. Once the patient has come to a decision explore how it may be enacted. Go into practical details and be prepared to give information and assistance on practical matters. Egs. "OK so you want to come as a day patient for relaxation training fine the day hospital starts at nine am. The number 39 bus should get you to the top of the road and its a 5 minute walk. The nurse in charge is Florence Keenan and you can ring her on . . . ." In the heat of crisis the nitty gritty of every day existence is lost. Facilitate the return to normality by reminding the client about practical matters. "Have you got enough food or have you got to do the shopping. Do you have a locksmith if not the police have a list of emergency locksmiths and their crime prevention officer can advise you". This involvement in practical day to day matters is a crucial part of work in the community and the greater the local knowledge you have the better.

At the end of the consultation four things must be clear

1. What work the client is going to do

2. What you as the therapists are going to do

3. What the carer is going to do

4. What they are to do in the event of a further emergency.

10. Communication

Set up a communication network. Inform GP social services nursing or any other agencies who might become involved of your management plan. Emphasise the need to contact the keyworker if further information is needed. If further crises are anticipated set up plan B i.e. strategies for dealing with further anticipated emergencies.. Egs. "If she panics at night she may demand admission. Try and talk her down on the phone and if that doesn't work try some medication, failing which I think she should have an emergency home visit. She does calm down if given time". Communication in crisis is crucial. In the community informing all the agencies who may be involved is not easy and systems need to be developed so that information can be passed on. Computer databases, bleeps portable phones all have their part to play, and a culture of linking up needs to be fostered. A system of open referral where a client or relative in crisis can directly contact the crisis team or key worker, without going through the GP is called “Direct Access”. It can be time limited to cover a difficult period.

11. Support network

The support a person receives through a crisis is a key determinant of outcome. Support must enable not undermine the client. 3 Key sources . Personal professional & volunteer

Personal

1. Family

2. Friends & social networks.

3. Fellow victims

4. Neighbours

5. Work & informal contacts

6. Strangers

Professional

1. Medical agencies‑ G.P, C.P.N., District nurse, Health visitor

2. Social work agencies

3. Keyworker & crisis team

Volunteer

Specialised support group ‑ egs Alzheimer’s society Samaritans fellow victims

Religious groups

Strangers

The setting up and backup given to the clients support network is a key strategy not only in the resolution of the current crisis but also in the prevention of future crises. Crisis is point at which locked doors are opened, boundaries of separation are breached and new people enter the social field of the client. Use the emotion and breakdown of traditional positions to create new networks that are more constructive. Often the fact that professionals are called in is an index of the poverty of the clients social field. In other cases the crisis may not be in the client but in a carer. In a study of a 150 elderly emergency referrals we found that the biggest single cause for emergency referral was illness or dysfunction in the carer. The setting up of support networks is a critical preventive strategy in isolated marginalised people. As far as possible encourage the growth of a non professional network. Avoid conceptualising the network purely in terms of managing the problem. Encourage the evolution of social relationships expressed in terms of human contact, empathy, mutuality, friendship and leisure. Connecting people up in crisis can create enduring bonds of mutual self help.

one of the key reasons for going to see the patient at home, as opposed to seeing them in a hospital or community centre, is meet and interact with the family and support network. When patients are asked to come to a hospital or centre to be seen, the patient often tends to come only with one or two carers or alone. By going to the home one enters the socile mileu of the client and interacts directly with a whole range of people who may be able to play a supportive role. more importantly, there is an opportuinity for the family and carers to meet and get to know the proffessionals who will be dealing with the index client.

there is a wealth of evidence attesting to the role that the support network plays in helping a person cope with adverse events and difficult times. Argyle and Henderson (1985) showed that the significance of relattionships in order of importance were spouse, followed by family and friends with workmates and neighbors as a third group. They fund three dimesions of interaction - material tangible help, emotional support and shared interests. Another important dimension was the amount of concern for others shown by the network( Brim 1974, Crandall 1984).

12. Follow-up.

Follow-up

Who ‑ the key worker. Doctor, nurse, social worker, other.

Where ‑ at home ,hospital, SW office, other

What ‑ the contract ‑ What the client is going to do

When ‑ frequency, duration.

The Contract What the client is going to do.

What the family is going to do

What the therapist is going to do

The crisis interview can be quite exciting. Follow-up interviews however are less so. The heart of crisis intervention is the quality of the work done in follow-up. It is here that the contract entered into is enacted. Though the crisis interview is conducted by a multidisciplinary team, follow up is usually through a single key worker, who serves as an interface to the various resources within the services. Continuity of care is very important in crisis work and as far as possible the key worker should be a member of the team that saw the client in crisis. From time to time other professionals may be called in again on various matters such as housing or medication. Arrangements for follow-up should be clearly defined at the end of the first crisis interview. When and where and with whom are easily defined. The provision of a summary statement, giving names phone numbers and the proposed plan of care to the client is an useful adjunct as research suggests that patients in crisis don’t always take in the instructions given. It is also important to involve the family and carers not only to support them but also to use their resources in helping sort out the problem for the client and themselves.

Termination

1. Fixed at crisis visit

2. Determined by course of therapy

3. Open ended

Referral onwards if indicated

The contract with the keyworker can be time limited or open ended. This involves developing the work initiated at the crisis interview and supporting the client in enacting the solutions evolved. New coping strategies should be actively reinforced. Some services offer a strictly time limited service classically six sessions of therapy. This is usually sufficient for most clients with healthy personalities. Patients with a history of mental illness, hospitalisation, personality problems and poor coping skills, however will probably need more. They may merit referral onwards for more intensive work or support.

PROBLEM PRESENTATIONS

The Medical patient Or Somatisation

The aim of the interview is determine not only the symptom complex but also assess the context in which it arose, its consequences and the resources available to resolve it. The medical or somatic presentation ‑ here the client system presents solely as a series of symptoms egs “he’s been withdrawn and refusing to eat or drink. He kept us up all night he doesn’t know what he is doing”. The problem with this is that the underlying issues can be concealed behind this presentation this symptom screen. The problems in the persons life are objectified ,medicalised and to some extent the role of social and personal factors is denied. This is a process called Reification where the emotions and interactions in the persons life are turned into an object ‑ the disease, and that is seen as a concrete entity. The medical presentation patient also tends to deny agency ‑ the person is deemed no longer responsible for his actions and therefore cannot participate actively in the decisions concerning treatment which are now the responsibility of the expert doctor. This can create increased dependency which can reduce the potentials for growth. The problem model ‑ this is a statement of the pressures on the person at the time. Egs “since my divorce I cant sleep I am listless, I cant concentrate and I feel a failure” Neuroses obviously are more likely to present in this way than psychoses, middle class educated clients are more likely to present in this way than say clients from the ethnic minorities and people in acute stress as opposed to people who have had time to recover. The problem with acute crisis work is that the therapist can be confronted by people in extreme states of disorganisation, distress and high emotion.. Knee jerk diagnoses of psychosis can easily be made, and the therapist needs to be cautious in making such a serious diagnosis. Many people in extreme crisis fear that they have gone mad. Confirming that by making a premature diagnosis can precipitate further regression.

Coping with Somatisation

1. Ask for the content and context of the symptoms. egs.” When you cry, what do you think of?”.

2. If this doesn’t work switch to a life history approach. Egs “you have told me about you symptoms tell me about yourself”. Plot the time and duration of symptoms against the life history. Look for recent events and life transitions. Egs “has anything changed in recent times” look for precipitants. Plot the duration of symptoms and explore the symptom complex. Egs “you tell me you have been crying a lot ‑ what sort of memories or situations make you sad?.” Plot its relationship to life events and psychosocial transition. In the problem presentation this is not a problem but in the medical presentation it some times can be difficult and in severe cases the symptom screen can practically impenetrable. It must be remembered this presentation is culturally reinforced and there may be tactical advantages to the client and the family in this presentation particularly if they have decide on admission to mental hospital.

3. Look for gains. A strongly medical presentation is sometimes motivated by primary or secondary gains. Primary gains are an internal process where the illness solves some internal conflict. For example if a person is ill, it means they don’t have to leave home. Secondary gains are some advantage in relation to the life situation. Such as compensation neurosis or relief of demands at work. One way of exploring this is to look at the consequences of the illness. Egs “suppose you weren’t ill what would you be doing?”

4. Look at the consequences for others in the symptom. What is the pattern of communication? How do others respond to the symptoms? Egs “when she is depressed who notices it first? To whom does she talk about her depression? What do you do when she is restless and pacing about? The strategic consequences of the symptom for example in stopping the husband going out, may have a part to play in its maintenance.

5. Give time - One of the issues that consistently surprises me is how often after a period of time clients come up with significant material. For example a very depressed patient who could not think of any reason for feeling sad, told me after 45 minutes that his wife had died last week. Clients understandably have a need to get familiar and safe enough with you before they can disclose painful material.

6. Use of a problem check list. Patients may not be aware of the roles of precipitants or of causation. A problem check list may jog them into thinking in those terms.

Simple check list

PROBLEM CHECKLIST

1. Relationship with partners, spouse

2. Relationship with family ‑ parents and children

3. Job or study problems

4. Social isolation and relationship with friends

5. Bereavement . Impending losses changes

6. Housing

7. Money worries

8. Physical heath.

9. Sexual adjustment.

10. Legal problems

11. Alcohol and other drugs

12. Life stage ‑ leaving home, mid life, old age.

In our experience concrete life problems of the life events kind are reported but psychosocial transitions such as leaving home and positive events such as job promotion are not.

The silent patient: This presentation is most often seen in police stations and after overdoses. It has a complex differential diagnosis. Mutism can be elective or secondary. S/he may be very depressed or too anxious and frightened to participate in an interview. Spend some time reassuring and calming the client down. The usual fear is of being “put away” in mental hospital. Commonly they are angry. They may not have requested the interview. A concerned parent may have contacted the service, and the client may be angry about not having been told or his agreement obtained. It can also be a way of passing the responsibility of solving the problem onto others by not participating in the search for a solution. You may have no choice but to interview the relatives, but do this in the prescence of the client. Wherever possible try and include the client. Egs “ your father tells me you are upset about the breakup with your girl friend. Is that Right?” Use direct questions involving yes or no minimal answers and look for body language as a clue to the response. Try remotivating the client to participate “ it looks like if you are not able to express a view other people are going to end up making decisions for you, is that what you want?” You can try becoming an advocate for the client and speak on his behalf. “Your dad tells me he has been nagging you to go to work. I get the feeling you are not happy there and if I was in your shoes, I would feel your dad wasn’t listening to what you are saying” Given time most clients open up and there is a need for patience and caution.

CONTROLLED TRIALS OF CRISIS INTERVENTION

1.LANGSLEY.D.(1969) - 300 Patients randomised to conventional treatment and Emergency family therapy (EFT). Crisis admission was avoided in all the EFT patients and those admitted subsequently stayed a shorter time in hospital. At 6 and 18 mth follow up EFT was as good or better in symptom control and social adjustment. EFT was 1/6th the cost of conventional care.

2.DECKER AND STUBBLEBINE(1972) - Two groups Conventional and crisis followed up for two years. Crisis therapy group had fewer admissions, shorter hospital stays, fewer readmissions and a lower suicide rate.

3.RATNA. L(1976) - two matched populations of 150,000 each one with a crisis service and one without. The crisis population had 60% fewer first admissions, 45% fewer readmissions, less chronicity and a fall in the parasuicide rate.

4.HOULT.J.(1983)-Randomised patients needing admission. One group admitted the other given intensive community treatment. Community care no worse and in some respects superior to hospital treatment. It was 25% cheaper.

5.BURNS. T.(1993)162 patients randomised between conventional and community based treatment. Both group clinically and socially indistinguishable at 6 weeks , with continuing improvement in both groups over time. Costs were 50% cheaper. There were fewer suicides.

CRISIS INTERVENTION THERAPY

1. SEE THE PATIENT AS SOON AS POSSIBLE.

2. ASSESS

A. SUICIDAL RISK- feelings, impulses, previous attempts

B. SEVERE DEPRESSION, ANXIETY - may need to be alleviated before therapy.

C. SERIOUS MENTAL ILLNESS - Mania, Psychosis

D. CHRONIC PERSONALITY PROBLEMS - Crisis or Furor?

E. ADDICTIONS - Alcohol, Drugs

F. RISK OF VIOLENCE

G. SEXUAL ABUSE - history of increases chances of presentation as a crisis

Some services exclude patients if they have these conditions. The scope and type of crisis therapy will be modified by these factors

3. EVALUATE STRESS SITUATION

A. THE PRECIPITATING EVENT

B. ITS SIGNIFICANCE TO THE CLIENT

C. THE REACTION OF THE FAMILY / CARERS

D. PAST METHODS OF COPING WITH SIMILAR CRISES

4. EVALUATE SUPPORT SYSTEM

A. WHO ARE THE CARERS?

B. WHAT IS THEIR VIEW OF THE SITUATION?.

C. WHAT ARE THEIR STRENGTHS, RESOURCES, FEARS & PROBLEMS

C. WHAT ARE THEY PREPARED TO DO?

5. ESTIMATE PATIENTS STRENGTHS

A. COPING SKILLS

B. PAST PATTERNS OF SUCCESS

C. ABILITY TO WORK ON PROBLEMS

6. WORK TO ACHIEVE A “PROBLEM SOLVING” FORMULATION OF THE PROBLEM.

A. WHAT CAUSED IT

B. WHAT CAN BE DONE ABOUT IT

7. HELP RELIEVE EMOTIONAL DISTRESS

A. EMPATHY

B. SUPPORTIVE REASSURANCE

C. CATHARSIS

D. TIME

8. FOCUS ON HERE AND NOW

A. AVOID PROBING THE PAST

B. “DIAGNOSE” IN TERMS OF PROBLEMS TO BE WORKED ON NOW

9. ENCOURAGE PROBLEM SOLVING

A. SUPPORT CLIENT INITIATIVES

B. GIVE INFORMATION

C. ADDRESS PRACTICAL ISSUES.

10. INVOLVE FAMILY AND FRIENDS

A. CONTACT AND CONNECT UP CARERS

B. SUPPORT THEIR INITIATIVES

C. INVOLVE THEM IN THE TREATMENT PLAN.

11. PLAN TERMINATION.

REFERENCES '

Aldrich C., Mendkoff E., Journal of the American Geriatric Society, 1963, 11, 185.

Alexander F., Psychoanalysis & Psychotherapy, 1956, W. Norton & Co., New York.

Ayd F., Personal Communication, 1975.

Balson P., Journal of Behaviour Therapy and Experimental Psychiatry, 1971, 2, 297.

Bandura A. et al., Journal of Personal and Social Psychology, 1967, 5, 16.

Bellak L. & Small L., Emergency Psychotherapy & Brief Psychotherapy, 1965,Grune & Stratton, New York.

Birley J. & Brown G., British Journal of Psychiatry, 1970, 116, 327.

Bloch H., Archives of General Psychiatry, 1968, 18, 178.

Brown F. et al., Castle Square: Final Report, 1964, United South End setlements, Boston.

Brown G., Bhrolchain M. & Harris T., 1975 Sociology, 9, 225.

Brown G., Journal of Psychosomatic Research, 1974, 16, 311.

Bruggen P., Paper read at the Quarterly Meeting of the Royal College of Psychiatrists, 1972.

Carse J. et al, lancet, 1958, 2, 39

Cleisner J., Hewett, S. , Mann S., in Evaluating a Community

Coleman M. & Rosenbaum M., Israel Annals of Psychiatry, 1963, 1, 99, 106.

Farebrow W. & Shneidman E., The Cry for Help, 1961, McGraw‑Hill, N.Y.

Fried M, The Environment and the Metropolis, 1962, Ed. J. Dahl, Basic Books, N.Y.

Golan N., Social Casework, 1969, 50, 7, 389.

Harris M., Mails B., Freeman E., Mind, 1964, 198, (2), 213.

Hill R., Social Casework, 1958, 39, 139.

Horuwitz J., Kaplan D. & Kaiser E., Social Casework, 1962, 43, 10.

Jacobson G. et al., American Journal of Psychiatry, 1965, 121, (12), 1176.

Jacobson, G., Stickler M. & Morley W., American Journal of Public Health, 1968, 58, 339.

Langsey L. et al, Family Process, 1968, 7, (2), 145.

Lazaras A., Behaviour Research and Therapy, 1966, 4, 209.

Leitenberg H. et al., Journal of Applied Behavioural Analysis, 1968, 1, 131.

Liberman R., American Journal of Orthopsychiatry, 1970, 40, (1), 106.

Lovaas O. et al., Behaviour Research and Therapy, 1967, 5, 171.

MacGregor R. et al., Multiple Impact Therapy with Families, 1964, McGraw Hill, New York.

McGee R., Crisis Intervention in the Community, 1974, University Park Press Baltimore.

Minuchin,S., Families & Family Therapy, 1974, Harvard University Press, Cambridge, Mass.

Morley W. & Brown V., Psychotherapy, Theory Research & Practice, 1969, 6,30.

Nathan H. & Master B. , Jones R., Behaviour Research and Therapy, 1973, 11, 365

Parad H. & Caplan G., Social Casework, 1960, 5, 3

Patterson G. & Reid J., Behaviour Modification and Clinical Psychology, 1971, Ed. C. Neuringer & J. Michel, Appleton‑Century Crofts, N.Y.

Psychiatric Service, Ed. Wing, J. , Haiey A., 1972, Oxford University Press.

Querido A., British Journal of Psychiatry, 1968, 114, 293

Ratna L., Paper read at the Conference of Psychoanalysis, Milan, 1975

Ritchie A., Social Work, 1960, 5, 3

Rubinstein D., American Journal of Psychiatry, 1972, 125 (6), 715

Sadock B., Newman L., Normand W., American Journal of Orthopsychiatry, 1968,38,724.

Scott R. & Ashworth P., British Journal of Medical Psychology, 1967, 40, 109.

Scott R., British Journal of Medical Psychology, 1973, 46, 45

Shaw F., Behavioural Approaches to Counselling and Psychotherapy, University of Alabama, 1961.

Strickler M. & Allgeyer G., Social Work, 1967, 12, (3),

Stuart R., Journal of Consulting and Clinical Psychology, 1969, 33.6, 675

Stuart R.B. , Journal of Behaviour Therapy & Experimental Psychiatry, 1971, 2, 1.

Tonge S., James D. & Hillam S., Families without Hope, 1975, Headley Bros., Kent.

Tyhurst J., Symposium on Preventive and Social Psychiatry, 1958. Walter Reed Army Institute of Research, U.S. Printing Office Washington D.C.

Williams H., Human Organisation, 1957, 16, 15