CUESES AND REACTIONS TO CRISES
Abdullah Baniyameen
baniyameen@aol.com
September 17, 2009
A. DEFINITION:
- A CRISIS IS A STATE OF MENTAL AND EMOTIONAL CONFUSION THAT IS CAUSED BY THE PERCEPTION OF THREAT,
- IT INVOLVES A SENSE OF URGENCY,
- IT MAY LAST A FEW HOURS TO A FEW WEEKS.
B. TRAUMAS THAT SET OFF CRISES:
- A trauma is an objective event that damages a person’s sense of well – being and creates anxiety,
- For a trauma to set off a crisis, the person has to perceive the trauma event as very threatening,
- There are four types of traumas that set off crises:
1) Situational, 2) Development, 3) Intra Psychic, 4) Existential,
1) SITUATIONAL – the circumstances causes the upset:
e. g. THE DEATH OF A LOVED ONE, THE BREAK UP OF AN IMPORTANT RELATIONSHIP, SERIOUS ILLNESS, SERIOUS FINANCIAL PROBLEMS, FAMILY VIOLENCE ET CETERA.
2) DEVELOPMENT – the process of growing through life stages can cause upset:
e. g. PEER PRESSURE, MARRIAGE, CHILDREN, RETIREMENT,
3) INTRA PSYCHIC – thoughts and feelings can create upset:
e. g. IDENTITY CONFUSION, THOUGHTS AND FEELINGS CREATED DURING INTERPERSONAL FRICTION, SUICIDAL THOUGHTS.
4) EXISTENTIAL – a sense of emptiness and lack of purpose in life causes upset:
e. g. RECOGNITION THAT DAILY ACTIVITIES DON’T PROVIDE MEANING AND SATISFACTION IN LIFE AND AVOID OF FEELING EMPTINESS RESULTS.
REACTION TO CRISIS:
People in crisis perform some form of reactive behavior or to reduce emotions,
Common reactions;
a) SHOCK:
- Trauma may stun some people into a dazed and numb state,
- This numbness prevents other feelings from being felt,
- A person in shock may appear zombie – like have difficulty concentrating, feel helpless, and demonstrate increased suggestibility,
b) AXIETY:
- The trauma may overwhelm, some people they feel like they are falling apart,
- Trauma causes some people to act agitated or perform useless activity such as pacing, hand wringing, smoking, or drinking,
- Some people have symptoms of increased nervous system arousal; rapid heart beat, chest pains, difficulty breathing, dizziness, and sweating.
c) DEPRESSION:
- The traumas may flatten some people creating a sense of hopelessness,
- Some people are immobilized – they are preoccupied with the event, don’t attend to daily needs, have low energy level, or cry frequently.
d) ANGER:
- The trauma may outrage some people,
- They direct the anger outward onto others:
*The cause of the trauma,
*An easy target.
*They direct the anger inward leading to self destructive actions
e) INTELLECTUALIZATION:
- The trauma may cut off thoughts and feelings in some people,
- They use rational thinking to get through crisis,
- They are cut off from painful feelings,
- This will leave the trauma unresolved after the crisis has passed.
CRISIS INTERVENTION:
GOALS OF CRISIS INTERVENTION:
- To stabilize the individual so no further deterioration in functioning occurs,
- To relieve the individual of as much pressure as possible,
- To convert the emergency to a solvable problem and resolve it,
- To return the person to his / her pre crisis level of functioning.
PROCESS OF CRISIS INTERVENTION:
ESTABLISHING RAPPORT – this must be done rapidly at the beginning of the interview – the client must feel he / she has a knowledgeable ally who will see him / her through the crisis,
GATHER RELEVANT DATA:
a) To assess risk of danger to self and others,
b) To become informed about current problem,
c) MEDICAL:
*Current symptoms,
*Precipitating event,
*History of this medical problem (brief).
d) IF ALCOHOL AND DRUGS ARE INVOLVED:
*Include what drug, dose?
*Provide information immediately to medical personnel,
*Allow enough time to observe the client and then interview him / her after the substance level has decreased in order to collect history and plan treatment.
e) IF THE CLIENT PRESENTS WITH PSYCHOTIC SYMPTOMS, A MEDICAL
EVALUATION IS NEEDED:
Anti – psychotic medication may be given to control the psychotic symptoms,
Can assess that the client is out of crisis when he / she shows a marked decrease in thought disorder.
f) PSYCHOLOGICAL:
Current symptoms,
Precipitating event,
History of psychological problem (brief).
g) THE FOLLOWING COMMENTS MAY BE HELPFUL IN DECIDING IF THERE IS A PSYCHOLOGICAL CRISIS:
*Describe your present mood,
*Tell me about the changes in your life,
*Have you ever thought of harming yourself,
*Describe your eating and sleeping habits.
TO ASSESS CLIENT’S ABILITY TO COPE WITH THE CRISIS:
STRENGTHS:
a) Personal,
b) Support network; family, friends and employer,
c) Physical; finances, housing, and transportation (when relevant),
d) The fewer the resources the greater the danger.
WEAKNESS – SAME CATEGORIES AS STRENGTHS:
To form a realistic treatment plan.
REFRAME THE CRISIS INTO A SOLVABLE PROBLEM AND POTENTIAL GROWTH SITUATION:
a) Decrease the pressure on the client when a solution is possible – helps to increase level of functioning,
b) Enables the counselor to pint out:
*What the client is doing that worsens the problem and makes it less solvable,
*What the client is doing that lessens the problem and makes the problem more solvable.
c) Clarifies the focus problem that caused the crisis.
HELP THE CLIENT EXAMINE REALISTIC OPTIONS FOR SOLVING THE PROBLEM:
a) Weigh the advantages and disadvantages of each options,
b) Choose the most workable option,
c) Make a plan of action.
CONTACT NECESSARY SUPPORT INDIVIDUALS WHO CAN HELP CARRY OUT THE PLAN OF ACTION – POSSIBLE CONTACTS INCLUDE:
a) Family,
b) Friends,
c) Employer,
d) Physician or Psychiatrist,
e) Service Agencies.
COUNSELOR DANGER ZONE:
TAKING RESPONSIBILITY FOR THE CLIENT:
a) Once the intensity of emotions has decrease, most people are capable of making choices – the counselor assists in decision making but does not make the decision,
b) Family and friends need to be called upon to make choices for a person who is not capable of decision making – the counselor would make the decision if there is no one else to turn to for help.
GIVING FALSE ASSURANCE:
a) It is not appropriate to paint a brighter picture than really exists:
*The client will feel the counselor does not understand which leads to lack of rapport and trust,
*It sets up false expectations that may not come true leaving the client potentially more devastated.
b) A realistic assessment, phrased in a tactful manner, is more useful.
BECOMING ANXIOUS:
a) It is sometimes difficult to remain calm when dealing with an anxious, panicky individual – it is especially difficult when dealing with potential injury to self or others,
b) Knowing one’s limits and asking for help from others colleagues is a way to ensure appropriate help for the client and a clear head for the counselor.
FOCUSING ON PROBLEM, NOT SOLUTION TO RESOLVE THE CRISIS. IT MUST BE REFORMED AS A PROBLEM WITH SOLUTIONS:
a) Data is needed on the current crisis and sometimes past events,
b) Excessive focus on the crisis will fuel the client’s upset and produce no solution.
PROJECTING ONE’S OWN INTERPRETATION OF THE TRAUMA:
a) The intense feelings the client is experiencing are based on his / her thoughts and belief system. The counselor need to investigate these thoughts to understand the feelings,
b) It is not appropriate to interpret the thoughts based on the counselor’s personal experience – one feeling can be caused by many different and conflicting thoughts.
FACTORS AFFECTING CRISIS OUTCOME:
DURATION:
a) The sooner the person requests help after reaching the breaking point, the better the prognosis – because there has been little time for maladaptive behaviors to set in,
b) Ten to Fourteen days is the average length of time people struggle with a crisis before seeking help.
NATURE OF THE TRAUMA:
a) Generally the less severe the trauma is, as viewed by an uninvolved observer, the better the prognosis,
b) The counselor must remember that individuals have different abilities to cope – what appears to the uninvolved observer to be a mini trauma may have a profound impact on an individual with few coping skills.
CLIENT PERSONALITY:
A person who is normal and healthy prior trauma has a better prognosis that someone who has had previous emotional difficulties, adjustment problem, crises.
SUPPORT NETWORK:
The person who has good relationships with people who can be called upon during difficult times has a better prognosis than the individual who is alone.
QUALITIES OF AN EFFECTIVE CRISIS COUNSELOR:
EMPATHY:
a) Help to rapidly develop rapport,
b) Help client to relax.
GOOD QUESTIONING SKILLS:
a) Ability to gather information quickly for an individual who is in the midst of intense emotions,
b) Able to direct yet tactful.
RAPID ASSESSMENT:
a) Quickly and accurately pinpoints the big issues,
b) Determines risk factors,
c) Discovers option to solve the problem.
REALISTIC VIEWPOINT:
a) Does not make false promises to the client,
b) Knows own limits in being able to help so does not feel responsible for the client beyond professional duties,
c) Ask for help when needed to assure client will receive the best help available.
USERS RESOURCES AVAILABLE:
a) Client’s network,
b) Professional network,
c) Agency network.
SUICIDE:
RISK FACTORS:
Many people think about suicide but would never actually attempt it – others are potential suicide victims,
Certain circumstances increase the potential for suicide:
a) SUICIDE IS ASSOCIATED WITH DEPRESSION:
The signs of depression are not always obvious:
*Sadness, Guilt,
*Inadequacy, Hopelessness,
*Weight Loss,
*Loss of Appetite,
*Loss of Sexual Desire,
*Sleeplessness,
*Fatigue.
b) MEN COMMIT SUICIDE MORE FREQUENTLY THAN WOMEN THOUGH WOMEN ATTEMPT IT MORE OFTEN:
At greater risk are:
*Teenage boys,
*Men older than fifty years old,
*Older people rather than younger people,
*One who suffered a recent permanent loss,
*Someone who is seriously ill,
*Someone who does not have a network of caring people,
*People who have unstable relationships,
*Alcohol and drug dependent people,
*Impulsive people,
*Emotional “burned out” individuals.
CUES TO SUICIDE POTENTIAL:
IN TALKING WITH AN INDIVIDUAL, THE COUNSELOR NEEDS TO BE ALERT TO THE ABOVE LISTED RISK FACTORS,
THE COUNSELOR MUST ALSO NOTE THE FOLLOWING CUES OF IMMEDIATE DANGER:
a) The client has decided on a method, time and place – lethality increases with such methods as shooting jumping, and fast acting drugs,
b) Suddenness of the desire to kill oneself,
c) Depression:
*Especially if Sudden,
*If Combined with:
*Psychotic Thinking,
*Confused Thinking,
*Anger and Aggression,
*Sudden Improvement in Depression.
d) Confused thinking and feeling, indicating inability to cope,
e) Use of phrase like:
“Tired of living – won’t be long now”…
“Want out”…
“Family is better off without me”…
f) Previous suicide attempts – as a person gets older, the chances of succeeding increase,
g) Talking about suicide:
*It is not true that those who talk suicide never do it,
*Threats must be taken seriously.
DEALING WITH SUICIDE CRISIS:
a) THE COUNSELOR SHOULD FORM A RELATIONSHIP WITH THE CLIENT SO THE INDIVIDUAL WILL TALK ABOUT SUICIDE:
*Prepare him / herself for the flood of emotional confusion that will pour out,
*Don’t interrupt client to relieve his / her own feeling of discomfort about suicide – take care of own needs later with colleague,
*Act calm – keep any inner upset hidden because it will only agitate the client.
b) DO NOT ATTEMPT:
*To cheer up the client by minimizing his / her loss of pointing out what good things are left – *he / she will feel the counselor does not understand the possibly terminate the conversation,
To talk the client out of committing suicide:
*Request he / she postpone the deed for a day or so,
*Ask to discuss the situation again to be sure suicide is what the client really wants to do.
c) IDENTIFY THE KEY ISSUES:
Clarify what the precipitating event was?
Address the current problem in concrete terms – don’t shift focus to past problems which will minimize the importance of the current suicide issue.
d) ASSESS LETHALITY BASED ON:
*Concreteness of Plan,
*Sex,
*Age,
*Depression,
*Resources,
*Important Relationship,
*Losses,
*Evaluate the client’s strength and resources which can be called upon to decrease the threat of suicide.
e) DESIGN A TREATMENT PLAN AND PUT IT INTO ACTION:
Ask the client to postpone suicide and set a time to talk again – make yourself or agency available for contact before the date if the client finds it necessary,
Help the client begin to reduce stress by action, if appropriate.
Contact Resources:
Psychiatrist for Evaluation,
Inpatient Hospitalization,
Client’s Network.
Plan for Follow Up Treatment:
Provide hope at hat someone cares,
Provide hope that something can be done to make life bearable.
f) IF A CLIENT INFORMS THE COUNSELOR THAT HE / SHE HAS FREQUENT THOUGHTS OF SUICIDE AND A DEFINITE PLAN WHICH HE / SHE WILL CARRY OUT IF THE COUNSELOR TELL ANYONE, THE COUNSELOR SHOULD:
*IMMEDIATELY NOTIFY HIS / HER CLINICAL SUPERVISOR,
*FORMULATE A PROTECTIVE TREATMENT PLAN.
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