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SIXTH EDITION
A GUIDE TO
KRISTI KAN EL
California State University, Fu Ilerton
~-•#
·- CENGAGE
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A Guide to Crisis Intervention, © 2018, 2015 Cengage Learning, Inc.
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This book is dedicated to the many human service
students who have given me their feedback over
the years and to all the brave individuals who have
survived and grown through their crises.
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it
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Preface xv
•
About the Author XIX
CHAPTER I
An Overview of Crisis Intervention I
CHAPTER 2
Ethical and Professional Issues 24
CHAPTER 3
The ABC Model of Crisis Intervention 37
CHAPTER 4
Intervening with Crises Related to Danger to Self,
Others, or Being Gravely Disabled 68
CHAPTER 5
Developmental and Cultural Crises 92
CHAPTER 6
Crises of Loss: Death, Relationship Breakups, and Economic Loss I 13
CHAPTER 7
Community Disaster,Trauma, and Posttraumatic Stress Disorder 133
CHAPTER 8
Crises Related to Military Service 152
CHAPTER 9
Crises Related to Personal Trauma 173
CHAPTER IO
Crises Related to Sexuality 206
CHAPTER I I
Substance Use Related Disorders and Crises 227
CHAPTER 12
Crises Related to Aging, Serious Physical Illness, and Disabilities 251
Name Index 271
Subject Index 275
Editorial revie\V has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Preface xv
•
About the Author XIX
CHAPTER I
An Overview of Crisis Intervention I
Crisis Defined 2
Crisis as Both Danger and Opportunity 3
Crisis as Opportunity 4
Crisis as Danger: Becoming a Crisis-Prone Person 5
Other Factors Determining Danger or Opportunity 7
Precipitating Events 8
Developmental Crises 9
Situational Crises 9
Emotional Distress 9
Failure of Coping Methods and Impairment in Functioning 11
The Wellesley Project: The Development of Crisis Intervention 11
Crisis Intervention and Suicide Prevention Strengthen Nationwide 13
Community Mental Health Act of 1963 14
The Rise of Managed Care 14
Contributions from Other Theoretical Modalities 16
Psychoanalytic Theory 16
Existential Theory 17
Humanistic Approacl1 17
Cognitive-Behavioral Theories 18
Brief Therapy 18
Critical Incident Stress Debriefing 19
Trauma-Informed Care 19
The ABC Model of Crisis Intervention 2 0
Chapter Review Questions 20
Key Terms fo r Study 21
References 23
CHAPTER 2
Ethical and Professional Issues 24
Introduction 2 5
The Need for Ethics 25
What Are Ethics? 25
••
VI I
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•••
VI 11 Contents
Defining Law 25
Controversies 26
Use of Paraprofessionals 27
Ethical Issues 28
Self-Awareness and Self-Monitoring 28
Dual Relationships 29
Confidentiality 2 9
Elder Abuse Reporting Act 30
Child Abuse Reporting Act 31
Competence 32
Client's Rights 32
Virtual or e-Therapy 33
Multicultural Competence 33
Key Terms for Study 34
References 3 S
CHAPTER 3
The ABC Model of Crisis Intervention 37
Introduction 38
A: Developing and Maintaining Rapport: Follow the Client 38
Attending Behavior 40
Questioning 41
Clarifying 44
Paraphrasing 44
Reflection of Feelings 45
Summarization 46
B: Identifying the Problem: Follow the Model 47
Identifying the Precipitating Event 51
Recognizing the Meaning or Perception of the Precipitating Event 51
Identifying Emotional Distress and Functioning Level 52
Making Ethical Checks 52
Substance Misuse/Abuse Issues 53
Therapeutic Interaction 54
C: Coping 57
Exploring the Client's Own Attempts at Coping 57
Encouraging the Development of New Coping Behaviors 57
Presenting Alternative Coping Behaviors 58
Commitment and Follow-Up 61
Case Example: Using the ABC Model of Crisis Intervention with
a Survivor of Military Sexual Trauma 61
References 67
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•
Contents IX
CHAPTER 4
Intervening with Crises Related to Danger to Self,
Others, or Being Gravely Disabled 68
Introduction 69
A Brief History of Suicide 69
Introduction to Suicide 70
Current Suicide Statistics 70
Symptoms and Clues 71
Suicide Assessment 72
Interventions 7 5
Discussion of Risk Level and Intervention Strategies 76
Low-Risk Suicidal Clients 76
Middle-Risk Suicidal Clients 76
High-Risk Suicidal Clients 78
A Phenomenological Look at Suicide 78
Non-Suicidal Self-Injury (NSSI) and Self-Mutilative Behavior (SMB) 79
Assessment ofNSSI 81
Interventions for NSSI 81
Managing a Client Who Is a Danger to Others 82
Risk Factors for Violence Against Others 82
Psychotic Breakdowns and Gravely Disabled Mentally Ill Persons 84
The Mental Status Exam 85
Key Terms for Study 8 8
References 89
CHAPTER 5
Developmental and Cultural Crises 92
Introduction 93
A Brief Review of the Life Cycle Crises 93
Cognitions Association with FOMO 95
Consequences of FOMO 95
Emotional Distress and Impairments in Functioning 9 5
The Quarter-Life Crisis 96
Family Systems Theory 97
Structural Family Therapy 97
Evolutional Crises 100
First Stage of a Family: Creating a Marital Subsystem 100
Creating a Parental Subsystem 102
Creating Sibling Subsystems 102
Creating Grandparent Subsystems 102
Crisis Related to Culture 103
Development of Cultural Humility 103
Etic Versus Ernie Issues 103
Ernie Patterns Related to Latinos 104
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x Contents
Issues Related to Different Rates of Acculturation 105

Ataque de N ervios 105
Ernie Issues Related to African American Families 106
Religion 106
Racism 106
Black Lives Matter 106
Ernie Issues Related to Asian American F arnilies 107
Asian American Family Structure 107
Shame and Obligation in Asian American Culture 108
Communication Process in Asian American Culture 108
References 112
CHAPTER 6
Crises of Loss: Death, Relationship Breakups,
and Economic Loss I 13
Death and Dying 114
Kiibler-Ross's Five Stages of Death and Dying 114
Tasks of Mourning 115
Manifestations of Normal Grief 117
Determinants of Grief 11 7
Intervention 118
Suggestions for Those Suffering Loss 119
Losing a Child 120
Divorce and Separation 122
Intervention 124
Children and Divorce 12 4
Crises Related to Blended Families 125
Job Loss 126
The Role of Perceptions 126
Interventions 127
References 132
CHAPTER 7
Community Disaster, Trauma, and Posttraumatic
Stress Disorder 133
Posttraurnatic Stress Disorder (PTSD) 134
Traumas That Often Lead to PTSD or Acute Stress Disorder 135
Effects on Young Children 136
Military Service 136
Personal and Family Victimization 136
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•
Contents XI
Natural Disasters 13 7
Four Phases of Community Disasters 138
Intervention Guidelines 139
Man-Made Disasters 139
Terrorism 140
Gun Violence and Shootings 142
Interventions 144
Critical Incident and Debriefing 145
Debriefing Process 146
Other Therapeutic Approaches Commonly Used to Treat PTSD 146
Secondary Posttraumatic Stress Disorder 147
References 150
CHAPTER 8
Crises Related to Military Service 152
Serving in the Military: An Historical View 153
Introduction to the Population of OIF and OEFVeterans 153
Statistics 154
Military Culture 154
Issues Particular to These Veterans 15 5
Invisible Wounds 155
PTSD 155
Depression and Suicide 15 5
Anger Issues 15 6
Alcohol Misuse 15 6
Treatment of PTSD and Depression, Anger, and Alcohol Misuse resulting
from PTSD 157
Traumatic Brain Injury 158
Other Treatment Approaches to Help Veterans with PTSD, Depression,
TBI, Alcohol Misuse, Anger, and Combat Stress 159
Issues Facing the Families of Veterans 160
Issues Facing College Enrolled Veterans 161
A 2008-2009 Research Study of OIF and OEFVeterans and PTSD 161
General Interventions 163
Military Sexual Assault 164
Military Sexual Trauma 166
References 170
CHAPTER 9
Crises Related to Personal Trauma 173
Sexual Assault and Rape 17 5
What Is Rape? 17 5
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••
XI I Contents
What Is Sexual Assault? 175

Interventions with a Rape Victim 176
The Empowerment Model with Sexual Assault Survivors 177
Date and Acquaintance Rape 178
Intimate Partner Violence 179
A Historical Perspective 179
Cultural Factors and Universal Factors Related to Intimate Partner Abuse 181
Prevalence of Intimate Partner Abuse 182
Why Do People Stay? 183
The Battering Cycle 183
Battered Woman Syndrome 184
Intervening with Battered Women 185
The Batterer 187
A Phenomenological View of the Batterer 188
Interventions with the Batterer 189
Child Abuse Issues 190
Types of Child Abuse 191
How to Detect Child Abuse and Neglect 191
Presumptive Indicators of Child Sexual Abuse 192
Infant Whiplash Syndrome 193
Association of Child Abuse with Posttraumatic Stress Disorder 193
Reporting Child Abuse 194
Interventions with an Abused Child 195
The Battering Parent 197
Interventions for Adults Who Were Sexually Abused as Children 199
Intervention for Perpetrators of Sexual Abuse 199
Bullying 199
Definition 2 00
Statistics 200
Intervention Strategies 200
Working with Families and Victims 201
Working with Families and the Bully 201
References 204
CHAPTER 10
Crises Related to Sexuality 206
Teen Pregnancy 207
Issues Related to Abortions 208
Why Do Women Have Abortions? 208
How Does Abortion Affect the American Man? 210
Issues Related to Sexually Transmitted Infections (STis) 211
Hepatitis C 212
Crisis Intervention for Individuals and Couples Dealing with STis 212
AIDS and HIV 213
Trends Among Particular Groups 213
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•••
Contents x 111
WhatisAIDS? 215
Modes ofTransmission 216
AIDS Testing 216
Treatment 216
Social Aspects 21 7
Type of Clients Who May Seek Crisis Intervention Related to HIV/AIDS 217
Interventions 219
Issues Facing Individuals Who Identify as Gay, Lesbian, Bisexual, Transgender,
Gender Variant, Gender Fluid, or Queer 220
Issues Facing Individuals Who Identify as Transgender/Gender
Variant/Gender Fluid 222
Chapter Review Questions 22 5
References 22 5
CHAPTER 11
Substance Use Related Disorders and Crises 227
An Historical Perspective of Substance Abuse and Misuse in the United States 22 8
Drug Use Statistics in the Twenty-First Century for the United States 228
What Is Substance Abuse 228
What Might Trigger a Substance Abuse Crisis? 228
Family Crises 2 2 9
Medical Crises 2 2 9
Legal Crises 230
Psychological Crises 2 31
Alcohol: The Most Common Drug of Abuse 2 31
The Alcoholic 232
Intervention with Alcohol and Substance Abusers 2 32
Medical Approaches 2 3 5
The Addiction Vaccine 2 36
Other Approaches Focusing on Treating Substance and Alcohol Abuse 236
Brief Intervention for Alcohol Problems 2 37
Understanding Enabling Behavior 238
Adult Children of Alcoholics 238
Treatment for the Codependent 239
Other Substance Abuse Issues 2 39
Speed: Cocaine, Crack, and Crystal Meth 2 39
Effects of Cocaine and Speed on the Family 242
Marijuana 2 4 2
Lysergic Acid Diethylamide (LSD) 24 3
Heroin 244
Prescription Drug Misuse and Abuse 244
Chapter Review Questions 24 5
References 249
•
x Iv Contents
CHAPTER 12
Crises Related to Aging, Serious Physical Illness,
and Disabilities 25 I
Palliarive Care 2 52
The Biopsychosocial Model 252
Serious Illnesses 2 53
Chronic Pain 253
Eating Disorders 254
Alzheimer's Disease 2 56
What Is Alzheimer's Disease? 2 57
Effects on the Caretaker 257
Issues Related to Disabilities 2 59
A Brief History of Disabilities 2 59
The Disabled Population and the Americans with Disabilities Act (ADA) 260
Vulnerable Subgroups Within the Disabled Population 261
Disabled Elderly People 261
Elder Abuse 262
Interventions with Abused Elderly People 264
Mentally Disabled People 264
Developmentally Disabled People 265
Crisis Intervention Strategies for Persons with Disabilities 266
Chapter Review Questions 2 6 8
References 2 69
Name Index 271
Subject Index 275
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When I first wrote this book, my intent was to create a student-friendly text that
would guide both new and more experienced counselors through specific procedures
when conducting brief crisis intervention sessions with a variety of client populations.
Although I have included much research and theory throughout the book, the focus
has stayed the course how to conduct interviews in a structured fashion.
In general, this book is written for college students and beginning mental health
professionals who might benefit from a step-by-step practical guide on how to work
effectively with clients in a variety of settings. There are many case examples and
practice opportunities woven throughout the text. This text works great in courses
in which students are given opportunities to practice what they are reading through
role-plays with one another, or with actual clients, under the supervision of the
instructor or other mental health counselors. It has been useful for professionals such
as police, firefighters, military personnel, as well as mental health counselors.
Organizing Features
I have included many real-world examples and sample scripts for students throughout
the text. Over the years, I have found that students benefit from seeing what others
actually say during counseling sessions. They can then practice similar types of com-
ments when they conduct role-play sessions.
I have also presented the major theory behind crises, and then how the theory is
utilized when conducting crisis intervention. Connecting theory with practice helps
students better understand both and systematically learn how theoretical constructs
are put into practice. Once theory is presented, students are provided with a detailed
description of the ABC Model of Crisis Intervention. In order to practice that model,
students are then provided with various chapters that deal with specific client popu-
lations, their needs, and how to implement the ABC model with that type of client.
Pedagogical Aids
Boxes have been inserted through the book to highlight interesting new case exam-
ples and scripts. Tables, diagrams, boxes, and figures have also been inserted to keep
students focused on essential theoretical and clinical material.
In chapters dealing with client populations, case vignettes to practice are placed
at the end of the chapter. Included with these are specific ideas such as precipitat-
ing events, cognitions, emotional distress, impairments in functioning, suicidality, and
therapeutic interaction statements so that the student can more easily practice the
ABC model with other students. Chapter review questions are located at the end of all
chapters along with key terms for study.
xv
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•
XVI Preface
New to This Edition

As I have revised the text over the years, I have included new information as the
world has changed, and as various traumas have been experienced by many of us.
For example, my second edition included the issues surrounding the effects of
9/11, and the third edition included information about the Katrina disaster. In the
fourth edition, I had included data based on my own research study related to
the types of crisis experiences described by the returning military personnel who
were stationed in Iraq and Afghanistan. In the fifth edition, an entire chapter was
devoted to just veteran issues. In this sixth edition, I have included material related
to gun violence, ISIS terrorism, Fear of Missing Out (FOMO) and the Quarter
life crisis, transgender issues, Black Lives Matter, and have updated all statistics on
• •
various issues.
I have changed the names of some chapters, and have included a chapter on crises
of sexuality, which includes issues surrounding abortion for both men and women. I
have added a true case about a man transitioning to a woman.
Ancillaries to Accompany the Text

There is an instructor's manual that includes a section on how to teach the course I
have taught for 31 years, test items for instructors to use (both multiple choice and es-
say style) and a description of the lectures for each chapter. Also available is a Power-
Point slide presentation and quiz items for students. These materials can be accessed
through the instructor's companion site at login.cengage.com. For access, please con-
tact your Cengage Learning sales representative.
New to the sixth edition is MindTap®, a digital teaching and learning solution,
that helps students be more successful and confident in the course and in their
work with clients. MindTap guides students through the course by combining the
complete textbook with interactive multimedia, activities, assessments, and learn-
ing tools. Readings and activities engage students in learning core concepts, prac-
ticing needed skills, reflecting on their attitudes and opinions, and applying what
they learn. Videos of client sessions illustrate skills and concepts in action, while case
studies ask students to make decisions and think critically about the types of situa-
tions they will encounter on the job. Helper Studio activities put students in the role
of the helper, allowing them to build and practice skills in a nonthreatening environ-
ment by responding via video to a virtual client. Instructors can rearrange and add
content to personalize their MindTap course, and easily track students' progress with
real-time analytics. And, MindTap integrates seamlessly with any learning manage-
ment system.
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••
Preface XVI I
Acknowledgments
I so appreciate the energy and efforts of the many reviewers of this text over the
years. For this edition I would like to thank Ann H. Barnes, Stephan Berry, Angela-
Cammarata, Lisa Corbin, Valerie L. Dripchak, Amanda Faulk, Amy Frieary, Nichelle
Gause, Mary S.Jackson,JalontaJackson, Steven Kashdan, Naynette Kennett, Cinda
Konken, Jim Levicki, Ashley Luedke, Lisa Nelligan, Bob Parr, James Ruby, Lauren
Shure, Cathy Sigmund, Bonnie Smith, Matt Smith, Rodney Valandra, Jennifer Waite,
Jennifer Walston, Michelle Williams.
Lastly, I give much appreciation to my students who have provided me with
invaluable feedback over the years about what aspects of the text help and hinder them.
I have tried to eliminate any hindering aspects and strengthen the helping aspect.
Editorial review has deemed that any suppressed content does not materially affect the overdll leaming experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Copyright 2019 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed c-ontent does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent right~ restrictions require it.
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Dr. Kristi Kanel has been a teacher, practitioner, and scholar of human
services for over 3 8 years. She has been a college professor for the past
34 years. She helped create the first crisis intervention course at California
State University, Fullerton, in 1986 and has been teaching the course since
then. She also teaches basic counseling theories, case analysis, human
service delivery to Latinos, Group Leadership, and Serving Veterans
and their families. She will be serving as the Chair of the Department of
Human Services for the next three years.
Throughout her career as a human services practitioner, Dr. Kanel has
worked at a free clinic as a counselor, interned with the Orange County
Board of Supervisors as an executive assistant, worked as a mental health
worker and specialist for the County Mental Health agency, worked as a
clinical supervisor at a battered women's shelter, and provided psychother-
apy for individuals, families, and groups in private practice and at a large
health maintenance organization. She has worked extensively with victims
of child abuse, partner violence, and sexual assault. Additionally, she has
worked with Spanish-speaking Latinos and has conducted research related
to the needs of this population. She specializes in crisis intervention and
has conducted research on the most effective approach to working with
people in crisis.
Dr. Kanel earned her Ph.D. in Counseling Psychology from the Uni-
versity of Southern California, her Master of Counseling degree from
California State University, Fullerton, and her Bachelor of Science degree
in Human Services from California State University, Fullerton.
Her hobbies include teaching Zumba, indoor cycling, karaoke, beach-
ing, and hiking.
•
XIX
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An Overview of Crisis
Intervention
Learning Objectives
After studying this chapter, readers should be able to:
Understand how a crisis state is formed and the factors that make up
a crisis state.
L02 Increase functioning in a person going through a crisis .
'
Understand the beginning of the history of crisis intervention.
Identify how a crisis can be both a danger and an opportunity.
Recognize the crisis-prone person.
Be aware of trauma-informed care.
Decipher the difference between stress and crisis.
Discern characteristics of effective coping people.
Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicate(j, in whole or in pan. Due to electronic rights, some third pany content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the over.all leaaiing exper}.e~~l£aming reserves the right tC>.cremove additional content at any time if subsequent rights restrictions require it.
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2 Chapter 1 I Tn Overview of Crisis Intervention
Crisis Defined
The term crisis can be defined in a variety of ways. Gerald Caplan, often referred to
as the father of modern crisis intervention, described crisis as ''an obstacle that is, for
a time, insurmountable by the use of customary methods of problem solving. A period
of disorganization ensues, a period of upset, during which many abortive attempts at
a solution are made'' (1961, p. 18). In its simplest form, according to Caplan, ''it is an
upset in the steady state of the individual'' (p. 18). James and Gilliland (2013) offer
nine definitions for an individual crisis. Most of these focus on a situation that an
individual cannot respond to in an effective way, leaving the person in a state of emo-
tional and psychological imbalance. The definition of a crisis referred to throughout
this book contains four components based on Caplan's defmition and on more mod-
ern cognitive-behavioral approaches such as Ellis's Rational Emotive Behavior Ther-
apy (Ellis, 1994) and Beck's Cognitive Therapy (Beck, 197 6). These aspects will be
essential when conducting the ABC Model of Crisis Intervention to be described in
detail in Chapter 3 and mentioned briefly in this chapter. The four parts of a crisis as
used in this text are: (1) a precipitating event occurs, (2) a person has a perception of
the event as threatening or damaging, (3) this perception leads to emotional distress,
and (4) the emotional distress leads to impairment in functioning due to failure of
an individual's usual coping methods that previously have prevented a crisis from
•
occurnng.
These components of a crisis must be recognized and understood because they are
the elements the crisis counselor will be identifying and helping the client to over-
come. The perception of the event is by far the most crucial part to identify, for it is
the part that can be most easily and quickly altered by the counselor. It is the focus in
this definition that differentiates crisis intervention from other forms of counseling.
By keeping this particular definition in mind, the crisis worker can perform the
necessary services in a brief time. Whereas other forms of counseling may focus on
building self-esteem, modifying personality, or even extinguishing maladaptive behav-
iors, in crisis intervention the focus is on increasing the client's functioning. Everly
(2003) describes the goals of crisis intervention as including four aspects: stabilization
of psychological functioning, mitigation of psychological dysfunction and distress,
return of adaptive psychological functioning, and facilitation of access to more care
if needed. A more thorough history of the development of crisis intervention as a
proven approach to helping emotional crises will be addressed later in this chapter.
For now, two useful formulas for the crisis interventionist are provided:
Figure 1.1 provides the essential definition of how a crisis state occurs, and Figure 1.2
presents the process for leading a client out of a crisis. It will be shown later in this
Figure 1.1 Formula for Understanding the Process of Crisis Formation
Precipitating Perception - ---,>• Emotional ------'>• Lowered functioning

event distress when coping fails
Figure 1.2 Formula for Increasing Functioning
Change in perception of the precipitating Decrease in Increase in

event and acquiring new coping skills emotional distress functioning
(Both figures developed by the author.)
chapter how Caplan's characteristics of effective coping people corresponds with the
formula in Figure 1.2.
Notice that this method involves changing the perception of the precipitating
event. Since it is not possible to change the precipitating event, the best one can do is
work at changing or altering the client's cognitions and perceptions of the event, offer
referrals to supportive agencies, and suggest other coping strategies. These ideas are
explored further in subsequent chapters.
One additional thought about crises in general: The word crisis often conjures
images of panic, emergency, and feeling out of control. Sometimes this is true as in
the case of natural disasters, bombing, shootings, and personal attacks. When the pre-
cipitating events are experienced by entire communities or directed at specific groups,
the terms critical incident stress management and disaster mental health are often used
(Everly & Mitchell, 2000). Critical incident stress management will be discussed in
more detail later in this chapter.
Crisis states may also be viewed as a normal part of life. Crises frequently occur
in the lives of normal, average individuals who are just having difficulty coping with
stress; therefore, they represent a state to which most of us can relate.
Crisis as Both Danger and Opportunity

Some crisis states are seen by many as somewhat normal developments that occur
episodically during ''the norn1al life span of individuals" Ganosik, 1986, p. 3). Whether
the individual comes out of any crisis state productively or unproductively depends on
how he or she deals with it. In Chinese, crisis means both danger and opportunity (see
Figure 1.3). This dichotomous meaning highlights the potentially beneficial as well as
the potentially hazardous aspects of a crisis state. A person might face the challenge
Figure 1.3 Danger or Opportunity
DANGER OPPORTUNITY
or
(Obusnsha's Handy English-Japanese Dictionary, 1983)
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Figure 1.4 Crisis as Both Opportunity and Danger
OPPORTUNITY
Help - -1!11i•Higher level of functioning
Normal functioning interrupted by Growth, insight, coping skills

1. Precipitating event
2. Perceived as threatening
3. Emotional distress
4. Impairment in functioning
due to failure of coping
DANGER
Drop in level of functioning
1. No help !Iii Lower level of functioning
or
2. No help !Iii Nonfunctioning level
Greater vulnerability,
disequilibrium
Suicide, homicide, psychosis
of the precipitating event adaptively, or might respond with a neurotic disturbance,

psychotic illness, or even death.
According to Caplan (1961, p. 19), "Growth is preceded by a state of imbalance or
crisis that serves as the basis for future development. Without crisis, development is
not possible. As a person strives to achieve stability during a crisis, the coping process
itself can help him or her reach a qualitatively different level of stability. This state of
stability may be either a higher or lower functioning level than the person had before
the crisis occurred" (see Figure 1.4).
Box 1.1 provides an example of how a rape victim's crisis might create a lowered
level of functioning if she does not receive help. This lowered level of functioning is
an example of the potential for danger addressed above.
Crisis as Opportunity
Even if a person receives no outside intervention or help, the crisis state will eventu-
ally cease, usually within four to six weeks. A crisis is by nature a time-limited event
because a person cannot tolerate extreme tension and psychological disequilibrium
for more than a few weeks (Caplan, 1964; Janosik, 1986, p. 9; Roberts, 1990; Slaikeu,
1990, p. 21 ). Although a person's character influences how he or she emerges from a
crisis, that is, either stronger or weaker, seeking and receiving focused help during the
crisis state have a big impact on the person. In the midst of a crisis, a person is more
receptive to suggestions and help than he or she is in a steady state. A crisis worker can
gain significant leverage at this time because of greater client vulnerability. Instead of
Editorial review has deemed that any suppressed content does not materially affect the overdll leaming experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
BOX 1.1
Example of Crisis as Danger
fter having been raped, a woman might function normally. In reality, however, she is func-
not seek help or even tell anyone about the tioning at a lower level than she did before the rape
trauma. About a month after the violation, and will be somewhat impaired until she gets inter-
she may slip into a state of denial, with reduced vention. The longer she waits to get help, the more
contact with the world, lowered trust levels, in- resistant she will be to it because of the amount of
creased substance abuse, poor interpersonal re- energy she will have invested in the denial process.
lations, and a state of dissociation. However, she She may exist in a chronic state of depression, low-
may continue to be able to work, go to school, put ered trust toward people, and anxiety, which would
on a front with family and friends, and appear to affect interpersonal functioning.
stabilizing at a lowered level of functioning, an individual who receives help is likely

to stabilize at a higher, more adaptive level of functioning, learning coping skills that
might prepare him or her for future stresses.
An example of how receiving help soon after a trauma would be more benefi-
cial than waiting years or getting no help at all might be in the case of sexual abuse
of a child. It seems fairly obvious that a 3-year-old girl brought in for counseling
after being molested one time will respond better than a 30-year-old woman who was
molested at age 3 and never talked about it, and then seeks help after 2 7 years.
Once a client has returned to a previous, or higher, level of functioning, he or
she may opt to continue with therapy. Brief therapy is a reasonably cost-effective
approach for dealing with aspects of life that have plagued a person regularly but
have not necessarily caused a crisis state. A counselor may work with an individ-
ual for 6 to 20 sessions and obtain excellent results in behavioral and emotional
changes. Once a person has benefited from crisis intervention, he or she is often
more open to continuing work on additional in-depth personal issues because of
increased trust in the therapeutic process and the therapist. The choice to con-
tinue in postcrisis counseling will of course depend on financial resources and time
availability.
Crisis as Danger: Becoming a Crisis-Prone Person

Not everyone who experiences a stressor in life will succumb to a crisis state. No one
is certain why some people cope with stress easily, whereas others deteriorate into
disequilibrium. Several explanations seem plausible. Figure 1.5 expands on Figure 1.4
to include the crisis-prone person. If a person does not receive adequate crisis inter-
vention during a crisis state but instead comes out of the crisis by using ego defense
mechanisms such as repression, denial, or dissociation, the person is likely to function
at a lower level than he or she did before the stressful event. The ego, which has
been hypothesized to be the part of the mind that masters reality in order to function
(Gabbard, 2014), must then use its strength to maintain the denial of the anxiety or
pain associated with the precipitating event. Such effort takes away the individual's
strength to deal with future stressors, so that another crisis state may develop the next
Figure 1.5 Crisis as Danger:The Development of the Crisis-Prone Person
Higher functioning level:

growth, coping skills learned for use with future stressors
t
Receives help
State of disequilibrium
Receives no help
Lower functioning:
defense mechanisms
New stressor hits; lack of ego strength

to cope with it leads to new crisis state
NO HELP
Lower functioning than before, fewer coping
skills for future stressors
New stressor hits
Another state of disequilibrium
Lower level of functioning, death or psychosis,

severe personality disorder
time a stressor hits. This next crisis state may be resolved by more ego defense mech-
anisms after several weeks, leading to an even lower level of functioning if the person
does not receive adequate crisis intervention.
This pattern may go on for many years until the person's ego is completely drained
of its capacity to deal with reality. Such people often commit suicide, harm others, or
have psychotic breakdowns. When people were exposed to trauma or toxic parent-
ing in their early years when the neurological structures of the brain were forming,
they usually do not seek crisis intervention due to their age. These developmental
and situation crises sometimes lead to personality disorders. People with personality
disorders are usually seen as suffering from emotional instability, an inability to mas-
ter reality, poor interpersonal and occupational functioning, and chronic depression
(Gabbard, 2014).
When trauma and other stressors occur after basic personality structures are in
place, a person may not develop a personality disorder, but instead may use defense
mechanisms and may misuse substances to cope with the traumas instead of seeking
professional help.
Traditional psychotherapy has usually been the course of counseling implemented
with people suffering from personality disorders. In today's economy and with health
maintenance organizations (HMOs) dictating mental health treatment, clinicians
often cannot take the traditional road with crisis-prone people. Because short-term
treatment is the only service offered in most settings, it is essential to begin working
with people as soon as possible after the crisis state sets in to prevent a chronic cycle
of poor functioning from developing.
Other Factors Determining Danger or Opportunity

Other factors may also determine whether a crisis presents a danger or an oppor-
tunity. These factors are generally found in the client's own environment. In addi-
tion to receiving outside help, having access to (1) material resources, (2) personal
resources, and (3) social resources seems to determine the level an individual reaches
after a crisis. Material resources include things such as money, shelter, food, trans-
portation, and clothing. Money may not buy love, but it does make life easier during a
crisis. For example, a battered woman with minimal material resources (money, food,
housing, and transportation) may suffer more in a crisis than a woman with her own
income and transportation. A woman with material resources has the choice of staying
at a hotel or moving into her own apartment. She can drive to work, to counseling
sessions, and to court. The woman with no material resources will struggle to travel
to sessions and will have to be dependent on others. Her freedom to choose wher-
ever and whenever she goes will be largely decided by those on whom she depends.
According to Maslow's (1970) hierarchy of needs, material needs must be met before
other needs of personal integration and social contact can receive attention. Not until
she is housed, fed, and safe can the battered woman begin to resolve the psychological
aspect of the crisis.
It is important to remember that despite financial and other material resources,
people with material resources are not immune to suffering. They may at times
suffer more than those with fewer resources because of various psychological and
social factors, the duration and severity of the victimization, or other precipitating
events. After her material needs are met, the woman can begin to work through the
crisis. Her personal resources, such as ego strength, previous history of coping
with stressful situations, absence of personality problems, and physical well-being,
will help determine how well she copes on her own and how she accepts and imple-
• •
ments 1ntervent1on.
If the ego is the part of our mind that carries the ability to understand the world
realistically and act on that understanding to get one's needs and wishes met, then
ego strength refers to how well one can do this on a regular basis and in times of
stress. At times a crisis worker will serve as a client's ego strength (as when a person
is psychotic or severely depressed) until the client can take over for himself or her-
self. Some clients can neither see reality clearly nor put into action realistic coping
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behaviors. They need someone to structure their behavior until the crisis is managed
successfully, often with medication, family intervention, and individual counseling.
When someone has coped successfully in the past with various stressors, then usually
his or her ego strength is high. However, when someone does not cope successfully
with stressors, the person's ego strength is lowered (see Figure 1.5). A crisis worker
must ''tune into'' a client's level of mastering reality in order to set up realistic goals
and problem-solving strategies.
Certain personality traits may interfere with coping and also with accepting inter-
vention. Some people have problems accepting help or being strong. Others are par-
anoid or avoid conflict. These people present challenges to counselors, in contrast to
clients who are open and trusting.
A client's physical well-being also affects how well he or she deals with crises.
Physically healthy people have more energy and greater ability to use personal and
social resources. The ability to move about and exercise is essential in coping with
stress. Clients with disabilities and suffering from illnesses must constantly cope with
their conditions, and so when stress occurs, they simply do not have as much psycho-
logical energy to deal with it as physically healthy individuals do.
A person's level of intelligence and education also affect the outcome of a crisis
state. Well-educated people are better able to use cognitive reframes and logical argu-
ments to help them integrate traumas psychologically. People with lower IQs have
more difficulty understanding events and their reactions to events, and may be less
flexible when solving problems.
A person's social resources also affect the outcome of a crisis. A person with strong
support from family, friends, church, work, and school has natural help available, pro-
vided these support systems are healthy. A lone individual struggles more during a
crisis and tends to depend on outside support systems such as professional counselors,
hotlines, emergency rooms, and physicians. Part of the crisis worker's responsibility is
to link clients with their natural support systems so their dependency on mental health
workers is reduced. Knowledge of support groups such as 12-step self-help groups is
vital to a counselor's effective intervention. Clients without much natural support can
participate in these groups indefinitely, and the 12-step group may become a natural
support resource. The use of 12-step groups will be explored in Chapter 3.
Precipitating Events
Personal crises have identifiable beginnings or precipitating events. These can be
new adjustments in the family, loss of a loved one, loss of one's health, contradictions
and stresses involved in acculturation, normal psychosocial stages of development,
or unexpected situational stressors. Previously, it has been proposed that the most
important aspect of any crisis is how the person perceives the situation. The meaning
given to the event or adjusunent determines whether the person will experience emo-
tional distress. This meaning has been termed the cognitive key (Slaikeu, 1990, p. 18).
It is the key with which the counselor unlocks the door to understand the nature of
the client's crisis. Once the helper identifies the cognitive meanings the client ascribes
to the precipitating events, the helper can work actively to alter these cognitions.
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Emotional Distress 9
This new way of perceiving the event aids the client in reducing emotional distress
and increasing coping abilities, and ultimately increase functioning.
The way the precipitating event interacts with the person's life view is what
makes a situation critical. If people cannot cope with new situations by using their
usual mechanisms, a state of disequilibrium will occur. However, if their cognitive
perspective of a potential hazard or precipitating event allows people to relieve the
stress effectively and resolve the problem, the crisis will not occur in the first place.
Stress is different from crisis, though the two terms are often confused. When a
person experiences a negative precipitating event, suffers from negative emotions, but
does not experience impairment in functioning due to being able to cope with it, he
or she is probably suffering from daily or normal stress. Stress is part of modem life;
in fact, it is part of daily life. This does not mean that crises are part of daily life, how-
ever, because people typically cope with stress without falling apart emotionally. Even
if people undergoing stress experience some emotional distress, if they have the cop-
ing skills to master the stress, their functioning level will not be impaired, and hence,
a crisis state will not ensue.
For conceptual purposes, we can describe two types of crises: developmental and
situational.
Developmental Crises
Developmental crises are normal, transitional phases that are expected as people
move from one stage of life to another. They take years to develop and require adjust-
ments from the family as members take on new roles.James and Gilliland (2013) sug-
gest that developmental crises are part of the normal flow of human growth in which
change occurs and people respond abnormally. Developmental crises will be explored
in Chapter 5 along with crises related to cultural issues. Clients often seek counseling
because of their inability to cope with the evolving needs of one or more family mem-
bers. Effective crisis workers are sensitive to the special issues surrounding this type of
• • •
prec1p1tat1ng event.
Situational Crises
Situational crises ''emerge when uncommon and extraordinary events occur that an
individual has no way of forecasting or controlling'' Games & Gilliland, 2013, p. 16).
Some examples of situational crises are crime, rape, death, divorce, illness, and com-
munity disaster. The chief characteristics that differentiate these from developmen-
tal crises are their (1) sudden onset, (2) unexpectedness, (3) emergency quality, and
(4) potential impact on the community (Slaikeu, 1990, pp. 64-65).
Emotional Distress
A rise in anxiety is a typical reaction to the initial impact of a hazardous event. A
person may experience shock, disbelief, distress, and panic (e.g., stage 1 of Kiibler-
Ross's stages of death and dying). If this initial anxiety is not resolved, the person may
Figure 1.6 Curvilinear Model of Anxiety as Motivator for Change
Moderate anxiety
(highest level of performance)
(optimal motivation)
Low/very little anxiety High anxiety
(inertia/low motivation) (overwhelmed paralysis)
experience a period of disorganization. During this period of disorganization, a per-

son often experiences feelings of guilt, anger, helplessness, hopelessness, dissociation,
confusion, and fatigue, and often is unable to function at their previous level at work,
school, or home. Ironically, in certain circumstances anxiety has the power to generate
energy and increase coping abilities, as when a child is in danger and a parent has a
surge of adrenaline that helps him or her rescue the child, or when a natural disaster
hits and people have the increased physical strength and endurance to carry bodies
and sandbags.
Anxiety, however, seems to fit the curvilinear model (see Figure 1.6) in that too
much or too little leaves a person in a state of inertia or with undirected and disinte-
grative energy CTanosik, 1986, p. 30).
When the anxiety level is moderate and manageable, the crisis worker can use
it to help motivate the client to make changes. In sum, anxiety is not always a bad
thing; it is considered necessary, at moderate levels, to spur people to make changes
in their lives.
Anxiety is an internal experience; therefore, interventions might first be aimed
at alleviating the internal component of stress. This action makes sense because the
external component of a crisis (the precipitating stressor) usually cannot be undone.
The only remedy for emotional distress is to change the internal experience.
Changing the internal experience as a remedy for distress can be done in several
ways. One way would be to medicate the person (e.g., inject a tranquilizer) to relieve
the anxiety or grief. The benefit of this intervention is immediate reduction in emo-
tional distress. Sometimes clients cannot benefit from cognitive crisis intervention
because their anxiety or grief is too great; in these cases, medication can provide tem-
porary relief until their cognitions can be altered. Crisis workers often work jointly
with psychiatrists when medication is necessary. The crisis worker might call a psychi-
atrist or physician whom he or she has worked with in the past to create a bridge for
the client with the psychiatrist. At other times, the crisis worker might consult over
the phone with a physician and set up a relationship in which the psychiatrist and crisis
worker feel comfortable having ongoing communication while both are working with
the client. Some agencies employ both counselors and psychiatrists. In these cases,
it is rather simple for the crisis worker to work jointly with the psychiatrist because
both workers generally get together during regularly scheduled staff meetings. It is
not uncommon for colleagues at agencies to ''pop'' into each other's offices from time
to time to engage in ''informal'' communication about the progress of mutual clients.
No matter which way crisis workers choose to engage with a psychiatrist or a client's
primary care physician, it is wise to be knowledgeable about the medications being
prescribed and to let the physician take the lead in medication management.
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The Wellesley Project: The Development of Crisis Intervention 11
The crisis worker, however, would not want to rid clients of all emotional distress
too soon without helping them change their perception of the precipitating event or
without encouraging coping behaviors. Without discomfort, clients are not as moti-
vated to change. The crisis counselor depends on clients to be in a state of disequilib-
rium and vulnerability if cognitive change and behavioral change are to occur. Clients
with good ego strength and no history of mental illness can often work through a
crisis without any medication. Some people, though, absolutely need medication, and
knowing when the situation calls for more than just talk therapy is a helpful skill for
crisis workers.
For clients who do not seem to need medication to relieve emotional distress, the
internal experience is best changed through cognitive restructuring, discussed in sub-
sequent chapters. Some clients may also be able to implement recommended behavio-
ral changes, which can be done in a number of ways.
The essential idea to remember is to keep the focus not on changing precip-
itating events but rather the way in which clients experience them. Changing
perceptions will lower clients' emotional distress and increase their functioning
levels. Offering coping strategies also aids in lowering emotional distress and
increases functioning.
Failure of Coping Methods and Impairment

in Functioning
The final component of a crisis state refers to a person's inability to cope with the
emotional distress leading to a decrease in functioning. When people in crisis are
experiencing feelings of bewilderment, confusion, and conflict, they are in a vulner-
able position. They lack skills to improve their situation. The ability to perform at
work, at school, and in social situations may be impaired. Likewise, there may be a
change in one's eating, sleeping, and everyday tasks, which are often referred to as
''tasks of daily living.'' People sometimes try to fix these impairments on their own,
but when they cannot, they may seek help, adapt through the use of ego defenses, dive
into a deep depression, or, unfortunately, attempt or succeed at killing themselves.
Thus, the urgency to get them intervention as soon as possible when they enter a
crisis state is clear.
The Wellesley Project:The Development

of Crisis Intervention
Eric Lindemann (1944) introduced the first major community mental health pro-
gram that focused on crisis intervention. He studied the grief reactions experienced
by relatives of victims injured or killed in the Cocoanut Grove fire in Boston, on
November 28, 1942. On that night, 493 people perished as the Cocoanut Grove
nightclub burned. It was the single largest building fire in U.S. history. As Lindemann
joined others from Massachusetts General Hospital to help survivors who had lost
loved ones, he came to believe that clergy and other community caretakers could help
people with grief work. Before this time, only psychiatrists and psychologists had
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provided services for those with anxiety and depression, symptoms that were thought
to stem from personality disorders or biochemical illnesses.
After his study, Lindemann worked with Gerald Caplan to establish a commu-
nitywide mental health program in Cambridge, Massachusetts, that became known
as the Wellesley Project. They worked at first with individuals who had suffered
traumatic events such as surviving the fire, losing a loved one in the fire, sudden
bereavement in other situations, or the birth of a premature child. This focus on
working with women dealing with the grief of either the death of an infant or the
birth of an infant with abnormalities was most likely influenced by the baby boom,
which began during the late 1940s, after World War II had ended. Millions of
women were pregnant, and some had complications with their pregnancies. Phy-
sicians were experimenting with a new drug, thalidomide, that prevented morning
sickness. Unfortunately, the drug also led to birth defects and other complications.
Women whose babies had birth defects because of the drug needed a way to deal
with their trauma.
Caplan's focus on preventive psychiatry, in which early intervention was provided
to promote positive growth and minimize the chance of psychological impairment,
led to an emphasis on mental health consultation (Slaikeu, 1990, p. 7). It may seem
hard to believe that the term crisis intervention had not even been thought of at that
time in history. Caplan's approach began a trend toward short-term, directive, and
focused crisis intervention. Interestingly, much of current-day crisis intervention the-
ory has come from the Wellesley Project.
In his research at the Wellesley Project, Caplan (1964, p. 18) discovered certain
people were able to cope with the situation better than others. He describes seven
characteristics of effective coping behavior that were displayed by those who were
able to climb out of their crisis state and of those who did not enter into a crisis (see
Table 1.1).
Once a client's emotional distress has been lowered to a manageable level, the
crisis worker may offer coping strategies. These range from referrals to agencies,
groups, doctors, and lawyers to reading, journaling, and exercising. Caplan's seven
characteristics of effective coping behavior can guide the counselor in creatively con-
structing a treatment plan that changes cognitions, lowers emotional distress, and
increases functioning. Although the name of crisis intervention has gone through
TABLE I • I Caplan's Seven Characteristics of Effective Coping Behavior
1. Actively exploring reality issues and searching for information

2. Freely expressing both positive and negative feelings and tolerating frustration
3. Actively invoking help from others
4. Breaking problems into manageable bits and working through them one at a time
5. Being aware of fatigue and pacing coping efforts while maintaining control in as
many areas of functioning as possible
6. Mastering feelings where possible; being flexible and willing to change
7. Trusting in oneself and others and having a basic optimism about the outcome
Source: Caplan (1964). Principks ofpreventive psychiatry. New York, NY: Basic Books.
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Crisis Intervention and Suicide Prevention Strengthen Nationwide 13
changes (e.g., trauma response, critical incident and debriefing, and critical incident
stress management), the ideas that Caplan proposed between late 1940s and the
1960s are still relevant and effective.
As Rapoport noted in 1965, ''A little help, rationally directed and purposely
focused at a strategic time is more effective than extensive help given at a period of
less emotional accessibility, p. 30'' (cited in Everly, 2003).
And by 1989, the American Psychiatric Association Task Force Report on the
Treatment of Psychiatric Disorders stated that ''Crisis Intervention is a proven
approach to helping in the pain of an emotional crisis, p. 2 52 O'' (Swanson & Carbon
cited in Everly, 2003).
This acceptance of crisis intervention over time is particularly important in under-
standing how mental health today is practiced in the community. It essentially moved
from a focus on medication and long-term psychoanalytically focused approaches to
short-term crisis management, ultimately leading to trauma response and critical inci-
dent stress management.
Crisis Intervention and Suicide Prevention

Strengthen Nationwide
In the early 1960s, the crisis intervention trend gave rise to the suicide prevention
movement. This movement grew rapidly, and many community centers offered
24-hour hotlines. These centers developed out of the social activist mentality of the
1960s and Caplan's theory. They relied on nonprofessional volunteers for their tele-
phone counseling programs. Caplan's focus on critical life crises attracted nontradi-
tionalists, who were dissatisfied with medical-model and psychoanalytic treatments.
Many current nonprofit organizations specializing in the treatment of certain per-
sonal crises evolved from these nontraditional grassroots programs such as free clin-
ics for abortion of unwanted pregnancies, battered women's shelters, rape centers, and
AIDS centers. Nonprofit agencies still exist today dealing with these same issues and
many more.
Parallel to the suicide prevention movement was the community mental health
movement in the United States. In 1955, there were over 500,000 patients in mental
hospitals, which was the highest in U.S. history. With the introduction and wide-
spread use of psychiatric medications such as Thorazine and lithium in the 1950s,
patients who suffered from chronic mental illness could be managed in the commu-
nity, which fostered the deinstitutionalization of the mentally ill over the ensuing
two decades. Consequently, this population of the mentally ill was reduced to about
200,000 in the decades that followed (Cutler, Bevilacqua, & McFarland, 2003). In
19 55, Congress established the Joint Commission on Mental Illness and Health and
found that three out of every four individuals treated for mental illness were in public
mental hospitals, and by 1960, the joint commission recommended that the mentally
ill be cared for in the community and that federal financial assistance would be pro-
vided to the states to accomplish this (Library of Congress, 1989-1990). President
Kennedy was very interested in community mental health as there was someone in
his own family with a mental disability, and in 1963, he proposed a new national men-
tal health program.
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Community Mental Health Act of 1963

The goal of Community Mental Health Act of 1963 was that by 1980 there would
be one community mental health center per 100,000 individuals, or 2,000 such
centers nationwide. In 1967, Congress reaffirmed the goal of having 2,000 commu-
nity mental health centers built, but by 1980, there were only 768 centers, which
may have been the cause of the high homeless population among the mentally ill
(Cutler et al., 2003). Subsequent to the federal legislation, many states have devel-
oped their own laws and ethical standards to implement community mental health
programs, but not without controversy in some areas. Some of the specific natures
of these controversies (including involuntary confinement and the definition of
''dangerous'') will be explored in Chapter 2, which deals with ethics, laws, and the
mentally ill.
One aspect of the community mental health programs was the development of
the 24-hour emergency service, which became known as psychiatric emergency
treatment (PET) services. Most community mental health services are still based
on this 1963 act. The original intent of these services was to deal with psychotic,
suicidal, and homicidal crises, which had previously been dealt with in the mental
hospitals. Many changes have come about in these agencies but the overall goal of
evaluating and treating crises of this nature is still relevant today. Current interven-
tion approaches related to these populations are addressed in Chapter 4.
In the late 1960s and early 1970s, journals such as Crisis Intervention and Journal
of Life-Threatening Behavior, which dealt specifically with crisis topics, were pub-
lished. Crisis intervention became more valued in the 1970s as economic condi-
tions led to greater use of community resources (Slaiku, 1990, p. 8). In the 1970s,
there was a growing anti-medical attitude in mental health centers. There was an
increase in the number of psychologists, nurses, and master-level workers serving
in mental health. Psychiatrists were leaving these centers and being replaced by
other types of mental health workers (Cutler et al., 2003) who could be paid lower
rates than psychiatrists and could efficiently provide crisis management and case
•
management services.
During this time, the country also saw an increase in university and col-
lege programs in which curricula focused on psychology and counseling. Many
paraprofessionals who had previously staffed community mental health centers
went to college to become professional therapists. Soon, the profession of licensed
therapy was big business. Insurance companies paid for counseling services offered
by individuals with master's degrees; this led to a rise in the number of people seek-
ing mental health counseling as well as to complaints by insurance companies about
the financial burden.
The Rise of Managed Care

The complaints resulted in managed care by indemnity insurance companies. Insur-
ance companies no longer paid for patients to stay in therapy as long as clinicians felt
necessary.
The short-tem1 crisis intervention model is cost-effective and, thus, the approach
sought by most HMOs, preferred provider organizations, and other insurance carriers
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Community Mental Health Act of 1963 15
in today's mental health treatment community. This type of payment for services
became confusing as state-operated Medicaid programs began to emerge. Public
funding and private funding became integrated and although many poor people were
eligible for public welfare, an estimated 40 million people had no coverage at all, leav-
ing them without any third-party payer for health services. By the 1990s, community
mental health programs came under government scrutiny. Once the Clinton initiative
for a single-payer system failed, finding fraud seemed to be the main purpose of the
federal government in dealing with mental health services. In 1969, Gerald Caplan
stated, ''In a democratic capitalist country, individual psychiatrists have the freedom
to decide how they will use their skills and make a living, but as corporate profes-
sionals, they must either be responsive to organized communal demands to deal with
formally recognized population needs or they will incur sanctions and eventually be
pushed aside in favor of some other profession, the development of which will be fos-
tered in order to deal with the neglected problem'' (Caplan & Caplan, 1969, p. 320).
Currently, most managed care facilities, insurance companies, nonprofit agencies,
and public mental health agencies (which have been relabeled as behavioral health
agencies) focus on providing short-term, crisis, and emergency services. Under-
standing how to conduct crisis intervention is vital for modern-day counselors at all
educational levels.
The Need for Nonprofessionals A

continuing controversy in the field of crisis inter-
vention centers on the use of paraprofessionals to provide services to clients. Some
licensed professionals believe that these workers, who have traditionally provided cri-
sis intervention, do not have enough training to do intervention. Some professionals
have proposed that only those with at least a master's degree should be allowed to
provide services to those in crisis. Beigel (1984) suggested we should re-medicalize
community mental health centers, which has indeed happened in recent years because
it is more cost-effective to medicate than offer ongoing psychotherapy. One can often
hear terms like ''treat 'em and street 'em,'' or ''evaluate, medicate, evacuate'' on televi-
sion shows. It often sounds cold, uncaring, and negative.
If nonprofessionals are forbidden to provide crisis management, this might have a
negative impact on poorer communities that cannot afford the costs of services pro-
vided by counselors of master level and above. Also, not everyone in crisis needs med-
ication to heal. The use of paraprofessionals would be cost-effective, and with proper
training and supervision, this level of worker can offer effective crisis management as
has been shown for the past 60 years. Understandably, politics and perhaps profes-
sional jealousy and fear play a part in the opposition to paraprofessional counseling.
But, it is without doubt that many clients in need would go untreated if these workers
were prohibited from practicing crisis intervention.
Many professional therapists are not aware of the historical foundations of cri-
sis intervention, which was based on paraprofessional services during the Wellesley
Project period. Although crisis intervention is used in most mental health offices,
not all mental health workers have received specific training in the field. It is often
included in other courses in graduate schools and other counseling preparatory col-
leges. Hence, students must provide crisis intervention based on their interpretation
of how to shorten the traditional therapy process. Because crisis intervention is not
often emphasized in traditional counseling and psychology graduate schools, many
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TABLE 1.2 Time Line in the Development of Crisis Intervention
Time Frame Development

1942 Cocoanut Grove fire; use of nonprofessionals to provide counseling
1946-1964 Baby boom; increase in stillbirths, birth defects, and miscarriages caused by
thalidomide; WWII Shell Shock Syndrome
1950s Psychotropic medications introduced; deinstitutionalization of the mentally ill
1963 Community Mental Health Act
1960s Publication of professional journals related to suicide prevention and crisis
intervention; increase in professional studies in psychology and counseling
1960s-1970s Civil rights movement; grassroots movements; rise in nonprofit agencies; use of
paraprofessionals
1970s-1980s Increase in college programs offering psychology and counseling courses;
professionalization of mental health; proliferation of licensed counselors;
movement away from crisis intervention and toward traditional longer-term
mental health counseling
1980s-1990s Managed-care takeover of medical field, including mental health; return to crisis
intervention in private industry and in community mental health
nonprofit agencies provide specific training in crisis intervention to ensure that non-
professional volunteers can work effectively with clients.
One cannot say that traditional models have had no influence on crisis work. In
fact, each traditional counseling approach has contributed to the field of crisis inter-
vention. This seems reasonable considering that the founders of crisis intervention
were themselves trained in these models. Table 1.2 provides an historical outline of
events leading up to modern day crisis intervention.
Contributions from OtherTheoretical Modalities

No single discipline or school of thought can claim crisis theory as its own, for this
theory has been derived from a variety of sources. The result, therefore, is an eclectic
mixture drawn from psychoanalytic, existential, humanistic, and cognitive-behavioral
theories.
Psychoanalytic Theory
Psychoanalytic theory has contributed to the treatment of people in crisis. Sigmund
Freud postulated an idea that is applicable to crisis intervention and crisis theory in
his assumption that psychic energy is finite and that only a limited amount exists for
each person. This assumption helps explain the disequilibrium that develops when
customary coping skills fail and a person's psychological energy is depleted. It also
helps explain why people with personality disorders, neuroses, and psychoses react
poorly in a crisis: Much of their psychic energy is being used to maintain their disor-
der; they do not have the ''spare'' energy to combat unforeseen emergencies (Brenner,
1974, pp. 31-80).
Contributions from Other Theoretical Modalities 17
In crisis theory the counselor is advised to assess the client's ego strength and at
times take over the function of the ego. The concept of ego strength is directly related
to psychic energy. People with personality disorders or psychotic disorders usually
cannot cope effectively with precipitating events because their psychic energy is being
used to deal with previous stressors, losses, and traumas.
Existential Theory
Existential theory has contributed to crisis treaunent. Although true existential psy-
chotherapy is a long-term therapy with the goal of basic revision of life perspective
(Bugental, 1978, p. 13), some ideas are also useful in a short-term adjusunent model.
Certainly, the existential proposition that anxiety is a normal part of existence which
often serves as a catalyst for self-development and growth may be a useful concept
when working with people in crisis. This idea coincides with the Chinese idea of
danger and opportunity. Without anxieties caused by new life situations, people
would never grow. Therefore, anxiety as a motivator for risk taking and growth is a key
concept from existential theory that has contributed to crisis theory. The belief that
all people will suffer in life at one time or another and that suffering can strengthen
people can be used to reframe a crisis for the person experiencing it.
Another useful concept from existential theory relates to the acceptance of per-
sonal responsibility and realization that many problems are self-caused. Choice then
becomes a major focus for the person in crisis. Empowering clients with choices
and encouraging them to accept responsibility are useful strategies in many crisis
situations. For example, a person who has recently been confronted about his or
her cocaine abuse can be helped to accept responsibility for his or her addiction.
The worker can offer alternative choices and be supportive while the client struggles
with the anxiety of withdrawing from the cocaine habit.
Humanistic Approach
The humanistic approach and person-centered therapies have much to offer crisis
intervention. This style of helping stresses the importance of trusting clients to realize
their potential in the context of a therapeutic relationship. Having optimism and hope
that clients will recognize and overcome blocks to growth are the foundations for try-
ing to help someone work through a difficult situation (Bugental, 1978, pp. 35-36). If
the crisis interventionist does not truly believe that his clients can work through their
problems, why would he waste his efforts on them? True, clients may not resolve their
difficulties his way, or in his time frame exactly, but he needs to respect clients at their
level and work from there.
Carl Rogers, the founder of person-centered counseling (considered a humanistic
therapy), has contributed to the field of crisis intervention by his focus on reflective
and empathetic techniques. These techniques, shown to be effective in treatment
outcome, help clients acknowledge and freely express their emotions (Corsini &
Wedding, 1989, pp. 17 5-179). In addition to these outcomes, humanistic techniques
create an environment that is special.
Practitioners of person-centered counseling believe that people can grow in a ben-
eficial direction if they can experience a relationship of true acceptance, genuineness,
and empathetic understanding. Crises are seen as blocks to growth and the poten-
tial for growth. By their presence, counselors help clients begin to accept themselves,
trust in themselves, and make new choices based on this self-acceptance and trust.
Cognitive-Behavioral Theories
Most crisis models are based on a behavioral problem-solving model, which involves
the following steps:
1. Define the problem.
2. Review ways that you have already tried to correct the problem.
3. Decide what you want when the problem is solved.
4. Brainstorm alternatives.
5. Select alternatives and commit to following through with them.
6. Follow up.
The cognitive approaches that blossomed in the 1970s and 1980s are also impor-
tant in crisis work. As has previously been stated, a person's cognitions, meanings,
and perspectives about the precipitating event are important in the counselor's deter-
mining the key to the crisis state. Cognitive approaches are largely based on Albert
Ellis's Rational Emotive Behavior Therapy (Ellis, 1994), Beck's Cognitive Therapy
(Beck, 197 6), and Meichenbaum's Self-Instructional Training and Stress Inoculation
Training (Meichenbaum, 1985). These approaches are concerned with understand-
ing the person's cognitive view of the problem and then restructuring and reframing
any maladaptive cognitions (Peake, Borduin, & Archer, 1988, pp. 69-71 ). Cognitive
approaches stress homework assignments and follow-up.
Table 1. 3 offers a summary of the contributions from other models to crisis
• •
mterventton.
BriefTherapy
Brief therapy may be confused with crisis intervention. It may be short term, but the
focus is not only on increasing functioning. In this approach, clients explore past pat-
terns of behavior and how the patterns have prevented them from succeeding in life in
TABLE 1.3 Contributions from Counseling Models to the ABC Model of Crisis
Intervention
Theoretical Model Contribution
Psychoanalytic Finite psychic energy and ego strength
Existentia I Responsibility; empowerment; choices; crisis as danger and
opportunity for growth; anxiety as motivation
Humanistic Rapport; safe climate; hope and optimism; basic attending skills
Cognitive-behavioral Focus on perceptions; reframing; goal setting; problem solving;
follow-up
the way they have wanted to succeed. They may explore interpersonal relationships,
self-concept, and family patterns. The focus is on creative change and incorporating
new styles of relating to the world. Sometimes the precipitating event is the best thing
that could happen to a person because it leads him or her to a counselor's office, where
some chronic debilitating patterns can be identified. If past ineffective patterns can be
recognized, they can be eliminated and the client can learn more effective behaviors
for dealing with current as well as future stressors.
Brief therapy seems to be as effective as long-term therapy. According to
Garfield (1980, p. 282), ''The evidence to date suggests that time-limited marital
family therapy is not inferior to open-ended treatment.'' The average length reported
in his research was seven sessions, a number that certainly fits with crisis intervention
philosophy.
Critical Incident Stress Debriefing

Since posttraumatic stress disorder was officially recognized by the American Psychi-
atric Association as a psychiatric disorder in 1980, people suffering from traumatic
events have been the focus of several interventions (Everly, 1999) including crisis
intervention, critical incident stress debriefing, eye movement desensitization and
reprocessing, trauma response, and disaster mental health. Throughout the 1980s
and 1990s, there were a variety of traumatic events that instigated the Red Cross and
other agencies to seek the services of clinicians trained in these models.
In 1994, a new category was added to the Diagnostic and Statistical Manual ofMen-
tal Disorders that highlighted exposure to trauma: acute stress disorder (Everly, 1999).
Workers were called in to assist people who were traumatized by the Oklahoma City
bombing, the workplace violence that occurred at a post office, and a variety of other
situations. Of course, after the terrorist attacks on 9/11/2001, the Katrina floodings,
the gun shootings, and ISIS threats that have occurred in the twenty-first century,
critical incident stress debriefing and other forms of crisis work have become essential
for many individuals throughout the world.
Critical incident stress management refers to an integrated, multicomponent cri-
sis intervention system that includes a seven-phase structured group discussion, usu-
ally provided 1-14 days post crisis, designed to mitigate acute symptoms, assess the
need for follow-up, and provide a sense of postcrisis psychological closure (Everly &
Mitchell, 2000). This approach will be revisited in Chapter 7 when we address com-
munity disasters.
Trauma-Informed Care
One of the most recent developments being researched and utilized in many federal-
and state-level agencies is referred to as trauma-informed care. This model focuses
on three key elements:
1. Realizing the prevalence of trauma
2. Recognizing how trauma affects individuals
3. Responding by putting this knowledge into practice.
This model becomes valuable for the crisis worker who may be working with cli-
ents currently dealing with a trauma, who have a history of having already experienced
trauma. This approach engages clients with histories of trauma and how trauma has
played a role in their lives. According to Wisconsin Department of Health Services
(2017), trauma refers to extreme stress that overwhelms a person's ability to cope. It
can be a single event, a series of events, or a chronic condition. This new model com-
plements our definition of a crisis state and the ABC Model of Crisis Intervention.
This will be explored more in Chapter 7.
The ABC Model of Crisis Intervention

The ABC Model of Crisis Intervention is useful in most nonprofit agencies, county
agencies, hospitals, and HMOs and with most insurance plans. It is a convenient
crisis interviewing technique that can be used either face-to-face or over the phone.
It can be completed in a 10-minute phone conversation, in one session, or over six
•
sessions.
The ABC model, developed by Kanel beginning in 1995 and revised repeatedly,
is loosely based on Jones's (1968) ABC method of crisis management as well as on
lecture notes from, and discussions with, Mary Moline at California State University,
Fullerton, in the 1980s (prior to crisis intervention being a regular part of graduate
level training). Chapter 3 explores in detail the different aspects of the model. In
general, crisis intervention is an action-oriented effort between a helper and a person
immobilized by an emergency situation; the purpose is to provide temporary, but
immediate, relief. This treatment differs from psychotherapy, which is usually a more
intensive, introspective analysis between a professional therapist and a client; psycho-
therapy's goal is to provide self-understanding and reconstruction of long-standing
personality traits and behavior (Cormier, Cormier, & Weisser, 1986, p. 19).
The focus of the ABC model is to identify the precipitating event and the client's
cognitions about the precipitating event, emotional distress, failed coping mechanisms,
and impaired function. Remember that these are the aspects of a crisis. The goal is to
help the client integrate the precipitating event into his or her daily functioning and
return to precrisis levels of emotional, occupational, and interpersonal functioning.
Chapter Review Questions

1. What are the components that make up a crisis state?
2. What role does a person's perception play in creating and overcoming a crisis?
3. What is the goal of crisis intervention?
4. How can crisis be both an opportunity and a danger?
5. What are the characteristics of effective coping behaviors?
6. Who began the Wellesley Project and what types of crisis were they dealing with
in the 1940s?
7. What was the focus of the Community Mental Health Act of 1963?
8. What contributions have been made by traditional approaches to counseling to
the field of crisis intervention?
9. What is critical incident and debriefing?
10. How does stress differ from a crisis state?
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Key Terms for Study

ABC Model of Crisis processes and how these lead to danger and opportunity:
• •
Intervention: One way to cr1sis states. Dichotomy associated with
• • • •
structure cris1s Intervention cognitive key: The perception a a crisis. A crisis can be an
that includes (A) developing person has of the precipitating opportunity when the person
and maintaining contact, events that lead to emotional grows by developing new
(B) identifying the problem, distress. The crisis worker coping skills and altering
and (C) coping. must identify the perception if perceptions. It can be a danger
behavioral problem-solving he or she is to help the client when the person does not seek
model: Approach focusing on change it and thereby increase help and instead copes with
goal setting, problem solving, functioning. the crisis state by using defense
and brainstorming alternatives. mechanisms, resulting in a
Community Mental Health
lowered functioning level and
brief therapy: May be confused Act of 1963: Legislation
possibly psychosis or even death.
with crisis intervention, but enacted during the Kennedy
focuses on changing longer- administration directing all developmental crises: Normal
standing behavior patterns states to provide mental transitional stages that often
rather than on only the current health treatment for people trigger crisis states, which all
• • •
prec1p1tat1ng event. • • •
In cr1sis. people pass through while
Caplan, Gerald: Known as growing through the life span.
coping methods: The behaviors,
the father of modern crisis thinking, and emotional ego strength: The degree to
intervention. Worked with Eric processes that a person uses to which people can see reality
Lindemann on the Wellesley handle stress and continue to clearly and meet their needs
Project after the Cocoanut function. realistically. People with strong
Grove fire. egos usually cope with stress
crisis: A state of disequilibrium
Caplan's seven characteristics better than people with weaker
that occurs after a stressor
of effective coping behavior: egos.
(precipitating event). The
Behaviors proposed by Gerald person is then unable to emotional distress: Painful
Caplan (1964) as essential for function in one or more areas and uncomfortable feelings
getting through a crisis state. of his or her life because experienced by a person in crisis.
They can be learned through customary coping mechanisms existential theory: Theory from
formal crisis intervention, have failed. which crisis intervention took
through experience, or the ideas of choice and anxiety.
curvilinear model of anxiety:
while growing up. In any The crisis worker believes that
Model showing that anxiety
case, the crisis worker anxiety can be a motivator
has the potential to be either a
needs to acknowledge these for change and encourages
positive or a negative influence
characteristics and to transmit the client to master anxiety
for someone in crisis. Too
them to clients when possible. realistically by making choices
much anxiety may overwhelm
Cocoanut Grove fire: Nightclub the person and lead to lowered and accepting responsibility for
fire in 1942 in which over 400 functioning. However, the choices.
people died, leaving many moderate anxiety may offer an functioning level: The way
survivors in crisis; considered opportunity for growth and a person behaves socially,
one of the major events leading transition from one stage of occupationally, academically,
to the development of crisis life to another or may motivate and emotionally. The
intervention as a form of the person to grow from the functioning level is impaired
mental health treatment. experience of trauma. People when a person is in a crisis.
cognitive approaches: Approaches who have no anxiety tend not The goal of crisis intervention
focusing on a person's to be motivated to make any is to increase functioning to
perceptions and thinking changes at all. precrisis levels or higher.
t"-n.n , ..i,...h+ 'ln10 l"-,e.,n,...,,.,...,,,. I ,,,.,,. .. n;.,.,... All Di,...h+.,, Q,,,..,,,,,. .. ,,,,....i ~JI,,.,, nn.+ hie,, "n.ni,e.,.-1 "'""'nn,e.,.-1 n. .. .-1,,nll""'*"".-I in •••hn.l,e., n. .. in"""'" \lllf"-1\1 n'l 'lnn_'ln'l
grassroots programs: Upward food. They constitute one but with certain ideas useful for
movement from local groups determinant of how well a the crisis worker. The notion
that led to the creation in person is able to deal with a that we have only a certain
• •
the 1960s and 1970s of many cr1s1s. amount of psychic energy to
agencies to meet the needs paraprofessionals: Originally deal with life stressors leads us
of various populations not community volunteers. Because to keep our clients proceeding
being helped by traditional of the tremendous number at a slow pace so they do not
governmental agencies. of clients needing help at the deplete this energy. Also, ego
grief work: Crisis intervention same time after the Cocoanut strength is a useful concept.
largely based on working Grove fire, it was necessary to Rogers, Carl: Founder of person-
with survivors and family employ community volunteers, centered therapy and well-
members of victims of the who were not professionally lmown contributor to the
Cocoanut Grove fire. It was trained, to conduct crisis humanistic approaches to
with this population that intervention sessions. These counseling.
Caplan and Lindemann learned paraprofessionals became situational crises: Unexpected
how to conduct short-term part of many agencies in later traumas having a sudden onset
• •
1ntervent1ons. decades. that impair one's functioning
health maintenance personal resources: Determinants level.
organizations (HMOs): of how well a person will deal social resources: A person's
The current trend in health with a crisis. They include friends, family, and coworkers.
insurance. These organizations intelligence, ego strength, and The more resources one has,
focus on maintaining health physical health. the better will one weather a
rather than curing illness. precipitating event: An actual
• •
cr1s1s.
The orientation of mental event in a person's life that stress: A natural, though trying,
health care under this style of triggers a crisis state that part of life. A reaction to
management is defmitely crisis can be either situational or difficult events usually
• •
1ntervent1on. developmental. involving feelings of anxiety.
humanistic approach: Model preventive psychiatry: The Stressful events do not become
using a person-centered term Caplan originally used crises if a person can cope with
approach in developing to describe his work with the them and functioning is not
rapport with clients; counselor survivors of the Cocoanut impaired.
uses basic attending skills to Grove fire and others going trauma-Informed Care: An
focus on the inherent growth through crises. approach to engaging people
potential in the client. psychiatric emergency team with histories of trauma
Lindemann, Eric: Worked (PET): The professionals that recognizes the presence
with Gerald Caplan on the designated by a county/hospital of trauma symptoms and
Wellesley Project and helped to assess whether someone acknowledges the role that
• • • • •
create cr1s1s 1ntervent1on as 1t should be involuntarily trauma has played in their lives.
is known today; recognized for hospitalized due to a mental Wellesley Project: Developed by
his contributions to grief work. disorder. Caplan and Lindemann, it was
material resources: Tangible psychoanalytic theory: An the first organized attempt at
things such as money, approach considered the introducing crisis intervention
• •
transportation, clothes, and opposite of crisis intervention mto a community.
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Issues Related to Different Rates of Acculturation 105

What Is Sexual Assault? 175

New to This Edition

Ancillaries to Accompany the Text

Understand the beginning of the history of crisis intervention.

Identify how a crisis can be both a danger and an opportunity.

Recognize the crisis-prone person.

Be aware of trauma-informed care.

Decipher the difference between stress and crisis.

Discern characteristics of effective coping people.

Figure 1.1 Formula for Understanding the Process of Crisis Formation

Precipitating Perception - ---,>• Emotional ------'>• Lowered functioning

Figure 1.2 Formula for Increasing Functioning

Change in perception of the precipitating Decrease in Increase in

(Both figures developed by the author.)

Crisis as Both Danger and Opportunity

Figure 1.3 Danger or Opportunity

Figure 1.4 Crisis as Both Opportunity and Danger

Help - -1!11i•Higher level of functioning

Normal functioning interrupted by Growth, insight, coping skills

of the precipitating event adaptively, or might respond with a neurotic disturbance,

stabilizing at a lowered level of functioning, an individual who receives help is likely

Crisis as Danger: Becoming a Crisis-Prone Person

Figure 1.5 Crisis as Danger:The Development of the Crisis-Prone Person

Higher functioning level:

New stressor hits; lack of ego strength

New stressor hits

Another state of disequilibrium

Lower level of functioning, death or psychosis,

Other Factors Determining Danger or Opportunity

Figure 1.6 Curvilinear Model of Anxiety as Motivator for Change

experience a period of disorganization. During this period of disorganization, a per-

Failure of Coping Methods and Impairment

The Wellesley Project:The Development

TABLE I • I Caplan's Seven Characteristics of Effective Coping Behavior

1. Actively exploring reality issues and searching for information

Crisis Intervention and Suicide Prevention

Community Mental Health Act of 1963

The Rise of Managed Care

The Need for Nonprofessionals A

TABLE 1.2 Time Line in the Development of Crisis Intervention

Time Frame Development

Contributions from OtherTheoretical Modalities

Critical Incident Stress Debriefing

The ABC Model of Crisis Intervention

Chapter Review Questions

Key Terms for Study

Wood-ticks, iv. 733