Chapter 3 - Basic Crisis Intervention Skills
In this chapter the triage assessment exercises in the accompanying Myer and James workbook and CD should be used extensively to train students in the triage procedure. If you do not have the workbook, the instructor should contrive a role play that has low, medium and high triage assessments. A good example that I use is a battered woman who first appears at a center with only "minor" problems, but these escalate on subsequent visits until it becomes life-threatening.
The exercises for this chapter are extensive in regard to skill-building and take a good deal of time if students are neophytes who have little experience with basic listening and responding skills as they are practiced in therapy. If students do not have these skills, these exercises should be stretched out over the course of the training period and not just dumped on students in one setting. These are critical skills and as such, time should be spent on their cultivation and refinement.
Exercise 1. The Case of Rita
The case of Rita, based on a real situation in my counseling practice, is presented here for you to consider because it clearly demonstrates and emphasizes the six steps in crisis intervention. We suggest that you make notes as you read and reread it. Suppose you were the crisis worker to whom Rita had come for help (in person, not on the telephone).
As an exercise to discover how well you have learned the six-step crisis intervention model, write a personal narrative description of how you might use the six-step model to help Rita during the initial session you have scheduled with her. (We have also written our description. Please write your description before reading ours, found at the end of this case, then compare your crisis intervention strategies with the narrative we have prepared. Remember that in crisis intervention, there is no one best way. Yours may be as effective as ours or more so. We hope this exercise will prove instructive for you.)
Rita is a 35-year-old businesswoman. She is a graduate of high school and a post-high school vocational-technical institute. She holds a certificate in auto mechanics. She has never been to a counselor before. She has come to the crisis worker at the suggestion of a close friend who is a school counselor. Rita owns and operates an automobile tune-up and service shop. She employs and supervises a crew of mechanics, tune-up specialists, and helpers. She works very hard and keeps long hours but maintains some flexibility by employing a manager. Rita's husband Jake is a college-educated accountant. They have two children: a daughter who is 13, and a son who is 8. The family rarely attends church, and they don't consider themselves religious, but they are church members. Their close friends are neither from their church nor from their work. Rita's problem is complex. She constantly feels depressed and unfulfilled.
She craves attention but has difficulty getting it in appropriate ways. For diversion, she participates in a dance group that practices three nights a week and performs on many Friday and Saturday evenings. Rita, Jake, and their children spend most of Sundays at their lake cottage, which is an hour-long drive from their home. Their circle of friends is mainly their neighbors at the lake.
Rita's marriage has been going downhill for several years. She has become sexually involved with Sam, a wealthy wholesaler of used automobiles. She met him through a business deal whereby she contracted to do the tune-up and service work on a large number of cars for Sam's company. Sam's contracts enable Rita's business to be very successful. Rita states that the "chemistry" between her and Sam is unique and electrifying. She says she and Sam are "head over heels in love with each other." While she still lives with Jake, she no longer feels any love for him.
According to Rita, Sam is unhappily married too, and Sam and his current wife have two small children. Rita states that she and Sam want to get married, but she doesn't want to subject her two children to a divorce right now. She is very fearful of her own mother's wrath if she files for a divorce. Sam fears his wife will "take him to the cleaners" if he leaves her for Rita right now. Lately, Sam has been providing Rita with expensive automobiles, clothing, jewelry, and trips out of town. Also, Sam has been greatly overpaying Rita's service contracts, making her business flourish. Jake doesn't know the details of Rita's business dealings with Sam, but he is puzzled, jealous, frustrated, impulsive, and violent. Jake used to slap Rita occasionally. Recently however, he has become more frustrated, impulsive, and violent. Jake has beaten Rita several times in recent months. Last night he beat her worse than he ever has. Rita has no broken bones, but she has several bruises on her body, legs, and arms. The bruises do not show as long as she wears pantsuits.
Rita has told her problems only to her school counselor friend. She fears that her boyfriend would kill her husband if he found out about the beatings. Rita is frustrated because she cannot participate with the dance group until her bruises go away. Rita is feeling very guilty and depressed. She is not particularly suicidal, however. She is feeling a great deal of anger and hatred toward Jake, and she suffers from very low self-esteem.
She is feeling stress and pressure from her children, from her mother, from Jake, and even from Sam, who wants to spend more and more time with Rita. Recently, Rita and Sam have been taking more and more risks in their meetings. Rita's depression is getting to the point where she doesn't care. She has come to the crisis worker in a state of lethargy-almost in a state of emotional immobility. Rita has decided to share her entire story with the worker because she feels she is at her "wit's end," and she wouldn't dare talk with her minister, her physician, or other acquaintances. Rita has never met the crisis worker, and she feels this is the best approach, even though she is uncomfortable sharing all of this with a stranger.
I. A Crisis Worker's Narrative Narrative of Rita's Case II. Assessing a Crisis III. Crisis Intervention Role Play IV. Restatement and Reflection Restatement and Reflection V. Open-Ended Questions VI. Owning Feelings Total Listening Practice
Write your own narrative describing how you would use the six-step model of crisis intervention with Rita. If you are participating in a class, workshop, or other study group, get together with others (preferably in small groups of five to seven people) to share descriptions of your particular method of crisis intervention. Don't sneak a peek below until you are done. NO cheating!!
Following is an example of one narrative description of how to intervene in the case of Rita. Read this narrative only after you have written your own and met in small groups to discuss your narrative with others' narratives.
First, I would explore and define Rita's problem from her point of view. I would use active listening techniques. I would avoid closed questions. Apparently Rita is feeling trapped because of several situational conditions: her marriage, her relationship with Sam, her own web of unfulfilling activity, and the beatings by her husband Jake. I would try to identify the one area that precipitated the crisis and immediately focus on that. After Rita's whole story had been fully examined, I might say, "Rita, what one thing caused you to come to see me today?" I would start with that one event or stressor. Active listening would bring us to that point.
Second, I would take whatever steps I deemed necessary to ensure Rita's safety. From the case data, I assume that Jake does not physically abuse the children, but he might do so. If my assessment indicated that Rita was in imminent danger, I would refer her to Domestic Abuse Services and inform her of their shelter options. Other safe places could be explored with Rita to ensure the safety of both herself and her children.
Third, I would offer myself as an immediate-support person. During the session I would attempt to develop other viable support people to whom Rita could turn, especially in an emergency. I would assume that Rita's school counselor friend is a positive-support person, and I would encourage Rita to maintain that relationship as well as explore others.
Fourth, I would encourage Rita to examine the various alternatives available to her. I would give special attention to the options that Rita could own, and do for herself in a way that would contribute directly to restoring her precrisis level of equilibrium.
Fifth, I would try to help Rita develop a plan of action that she could own and that would represent a positive action step toward her precrisis level of equilibrium. The plan would be concrete, positive, realistic, and clearly oriented toward alleviating her crisis. If her stress level were high, I might immediately use relaxation techniques to help her through the current stressful and anxious state. This could be one method by which Rita might begin to learn to deal with future stresses as she encountered them.
Sixth, before the end of the session with Rita, I would try to get a commitment from her to carry out some action that would be positive and that would help her either restore her equilibrium or make a step toward it. I would ask her to summarize the commitment as a means of helping to solidify it in her mind as an immediate objective and to motivate her toward attainment of the stated goal. I would assure Rita of my support and encouragement and make arrangements for the two of us to check back with each other to follow up on her progress.
In terms of problem solving, I would covertly brainstorm two important components while I listened and responded to Rita: (1) I would make a mental list of adequate situational supports; and (2) I would make a mental list of adequate coping mechanisms. I would not disclose all these to Rita. The mental options would be available to me to effect referrals or to ask appropriate open-ended questions in helping her to discover the alternatives available to her. I would take care not to impose my own solutions, alternatives, or plans on Rita.
Throughout the crisis intervention session, I would be engaged in assessing Rita's situation using a variety of criteria described earlier in this chapter, including the Triage Assessment Form (TAF). Given the information in the case description, I would judge her scores on the Affective Severity Scale to be in the 7-8 range (she is angry, depressed, and lethargic); her Behavioral Severity Scale scores to be in the 4-5 range (she is behaviorally mobile enough to present herself for intervention and to describe her situation in candid detail); and her Cognitive Severity Scale scores to be in the 2-4 range (her thinking is pretty clear and is in sync with reality). Rita's overall TAF Severity Scale score is therefore estimated to be in the 13-16 range, which places her in the moderate impairment range.
During the listening, safety, and support phases of the session, I would be active with Rita. My degree of action would depend on my assessment of Rita's mobility or immobility. If Rita were assessed as immobile, I would be quite directive; if she were partially mobile, I would be collaborative. If she were totally mobile, I would be nondirective.
From the case data and the TAF estimate, I assume that Rita is mobile enough for me to function in a collaborative mode. Depending on my own ongoing assessment, I would move toward either directive or nondirective, but I believe I would function largely in the collaborative mode most of the time.
I would certainly avoid asking closed questions. By continuing to focus on Rita's situation with open-ended questions, I would try to get her to concentrate on what she wants to do; that is, I would focus on alternatives. I would hope to get her to consider as many realistic alternatives as possible. I would assist her in brainstorming to identify these alternatives. From a repertory of choices, I would hope that her plan, mentioned in Step 5, would be a sound one that would move her toward attainment and success.
The optimum plan would be simple and realistic. I would not be trying to get her to solve all her situational problems. My first goal would be to help her get the present crisis under control and then work toward having the mobility to independently take charge of her life.
In problem-solving Rita's case with her, I would start with a list of support people gleaned from the case data. In crisis intervention, a support person is someone whom the client trusts and who is always available. That person or persons can be an acquaintance, a friend, a relative, a coworker-anyone who could be called on to provide temporary comfort, encouragement, or support. In Rita's case, the most obvious support people would be the crisis worker (myself), her school counselor friend, her own children, other dancers in her dance group, her "lake" friends, her shop manager and shop employees, and her former vocational-technical instructors. Other possible supports include her mother, her physician, other members of her family, and even former classmates from school. These are the kinds of people who would be identified and remembered by the crisis worker as possible appropriate supports for Rita to consider. Normally, we recommend using only one or two support persons at a time, not a whole host of people. I would encourage Rita to choose and contact one or two appropriate support people.
Adequate coping mechanisms stored in the crisis worker's mental repertory for possible assistance to Rita could be: leaving Jake the next time he beats her; breaking off the relationship with Sam; setting priorities on the amount of time she is spending on various activities; devising better or different ways to obtain positive attention when she needs it; calling a support person on the phone; calling the Crisis Center or Domestic Violence Services; calling me (the crisis worker); consulting an attorney for legal advice; consulting her physician for a complete physical examination, diagnosis, and advice; initiating marriage counseling with Jake (if he agrees); initiating couples' counseling with Sam, if he agrees; planning ways to spend time with and engage in activities with her school counselor friend; entering individual counseling on a continuing basis; doing something that is recreational or relaxing for herself, such as working on cars or developing a new dance routine; enrolling in an assertiveness training course to enhance her self-esteem and improve her coping behaviors; wearing tights or colored hose to her dance rehearsals until the bruises heal; and thinking of something innovative and creative that she would enjoy to get away from the turmoil.
In helping Rita (using the six-step crisis intervention model), I would seek to involve Rita in prioritizing any of the alternatives, plans, support persons, or coping mechanisms she might wish to pursue. If chosen action steps could truly represent Rita's own priorities, the chances of success would be greatly increased. Finally, and most important, I would reemphasize getting Rita to commit herself to one or more of the actions that we collaboratively developed as her plan. I would ask her to summarize her plan so that she and I could agree on what she was committing herself to. I would try to respond to her during the commitment phase in a way in which she would feel supported by me but not dependent on me. I would certainly want her to be motivated and predisposed toward success.
Adequate assessment is an absolute necessity in effective crisis intervention. In the rapidly changing scene of an active crisis, assessment is difficult, puzzling, and frustrating for beginners. Making a valid assessment during an ongoing crisis is perhaps more an art than a science and comes with practice, making mistakes, obtaining feedback, and plunging in again. This exercise is designed to allow you to try out your assessment skills in the safety of the classroom. It will further allow you to upgrade your skills as you move through the course. Finally, it will provide you with a way to compare the skills you had at the start of the course to your skills at the end.
Divide into groups of seven. Each person chooses one of the following roles: (1) a suicidal client, (2) a battered client, (3) a violent client, (4) a posttraumatic client, (5) a substance-abusing client, (6) a sexual assault victim, (7) a grieving client. Each person will assume the role of one of the foregoing clients for the next class meeting. It is helpful to quickly read the chapter containing the material on the particular client before the next class meeting so you can adequately depict the typical dynamics of the crisis.
At the next class meeting, each person is to role-play the client assigned for approximately five minutes. One other person in the group acts as the crisis worker. The crisis worker's role is to elicit enough information so that a domain severity assessment can be made. While the crisis worker and the client are working with one another, other group members monitor the dialogues and use the Triage Assessment Form in this chapter to assess the severity of the problem in regard to its affective, behavioral, and cognitive components. Write down your thoughts as you systematically go through the form. After each person has completed the role assignment, discuss your respective ratings.
Pay particular attention to why you gave the ratings you did and what those ratings imply for any subsequent intervention you might use. Don't worry about trying to be perfect or about any lack of knowledge you may have about the problem. Just go ahead and do it! Clearly, there are no wrong answers at this point in your education.
After you have finished, save your notes and ratings. As you move through subsequent chapters, reassemble your group and replay the crisis appropriate to that chapter. The "client" should attempt to replay the role as closely as possible to the initial rendition.
Group members will repeat their triage assessment of the client. You will then pull out your initial ratings and compare them with your current ratings. Group discussion should identify changes that occurred and why members may have rated the person differently from the first time. By reassessing these role plays, you should start to feel more comfortable about making educated guesses in crisis situations.
Class members should form pairs. You will practice two roles: (1) being a crisis worker and (2) reliving a real crisis from your past experience. All sessions must be tape-recorded; to begin each tape, the person serving as crisis worker obtains the client's spoken permission to record the session. The crisis worker practices accurate listening skills: attending, observing, understanding, and responding with empathy, genuineness, respect, acceptance, nonjudgmental-ness, and caring. The client relates the past crisis to his or her partner as if the crisis event were being re-experienced in the present moment. When each partner has had an opportunity to play the roles of both crisis worker and client, the class regroups for discussion. Some of the possible discussion questions are:
Communication is often not a simple matter. Words come so fast and easily at times that we have our responses formulated in our heads before we hear the full message of the client who is speaking. Most of us would like to improve the odds that we really do accurately interpret clients' messages when they talk to us. There are many hints to aid us in listening to clients. We will deal with two methods in these exercises.
Client: I don't think I can go back home tonight-just too many heavy problems for me to handle.
Worker: You don't think you can face what's at home.
Client: My boss really chewed me out in front of my friends last night.
Worker: Sounds like it really embarrassed you.
To help you learn to make appropriate responses that contain both restatement and reflection, do the following practice sheet. Do the exercise as directed on the sheet without consulting anyone else. Then obtain feedback from others as the directions indicate.
DIRECTIONS: In your own words, write a restatement and a reflection of the client's statement. In small groups, give one another feedback on whether you are on target.
Asking open-ended questions does not guarantee that every client will respond with full statements. The purpose of this exercise is to help you become aware of how you state your questions so that you can get fuller, deeper levels of response. Decide whether the following counselor questions are closed- or open-ended. Fill in the responses below.
Change the following closed-ended questions to open-ended questions.
Owned Message Practice
The following exercise is designed to let you try out owning your own feelings and expressing them in responses that indicate that you are owning them. We call such messages "I" messages. When we disown a feeling, we usually give someone else the responsibility for it and begin statements with words that refer outside ourselves, such as they, you, people, the experts, the police chief, the principal, your mother, and God. Fill in the worksheet below.
DIRECTIONS: Read the client situation in the first statement. Examine the disowned message in the second statement. Then write an "I" message that indicates you take responsibility for your feelings. The purpose is not to resolve the problem but rather to communicate that you are aware of your feelings and are being honest about them at this moment. In small groups, give each other feedback, making checkmarks under Yes or No to indicate whether the message indicates owning one's own feelings. If, after you have shared your responses, others feel that most of your responses are not "I" messages, please elicit help in restating your message.
Situation Client has been sulking and acting sad all session.
Disowned Message Come on, now. Stop moping around. Life isn't that bad.
Situation Macho man brags about beating wife. He has just responded, "Women need to be kept in control."
Disowned Message Well, I wonder if you'd do that to the Raider linebackers.
Situation People complain about client's body odor. Client's underarm deodorant has failed miserably. (It's bothering you, too.)
Disowned Message James, have you ever, ah, considered that it might be something more than what you believe is your dull personality that's keeping people away from you.
Situation Cynthia has a reputation for being promiscuous and has talked at some length about it.
Disowned Message We crisis workers feel that kind of sexual bragging only leads to acting out behavior. You could get a social disease or even AIDS you know.
Situation John is extremely overweight. Wants to lose weight but doesn't seem to be able to stick to a plan.
Disowned Message Face it, John. You're fat. I'm sorry, but that's it. No wonder you can't get dates. Why not try jogging?
DIRECTIONS: Read the client's statement. Then write a restatement of the message, a reflection of the message, an "I" message that owns your feelings but communicates acceptance, and an open-ended question that elicits more information. Break into dyads (pairs) and role-play the client and the worker in dialogue to one of the statements. Worksheet 2.3 is designed to help you practice (1) attentive listening and (2) formulating responses that communicate acceptance of the feeling behind the message as well as awareness of the message's content. An accepting response combines (1) restatement, (2) reflection, (3) owning one's feelings, and (4) an open-ended question designed to get to the fuller meaning. Thus Worksheet 2.3 is a culmination of the communications skills you've been practicing.
Narrative of Rita's Case II. Assessing a Crisis III. Crisis Intervention Role Play IV. Restatement and Reflection Restatement and Reflection V. Open-Ended Questions VI. Owning Feelings Total Listening Practice
II. Assessing a Crisis III. Crisis Intervention Role Play IV. Restatement and Reflection Restatement and Reflection V. Open-Ended Questions VI. Owning Feelings Total Listening Practice