Those in crisis require different kinds of counseling than those in short and long term care counseling. Those in crisis have emotional and mental wounds that are intensely bleeding from within leading to sometimes lethal and dangerous decision making. Individuals feel lost and without purpose with no light at the end of the tunnel. Hence those in crisis lose cognitive and mental capabilities to make safe and logical decisions. This requires on site mental first aid and de-escalation. Those in EMT, police, FEMA, as well as chaplains and social workers who work with law enforcement approach those in crisis as mental first responders. One does not know what to expect and the job can definitely be dangerous due to the unexpected behavior of those in crisis. Individuals trained in crisis hence provide emotional and mental first aid and look to stabilize individuals from a mental and emotional way. This blog will look at the basic steps of Crisis Intervention and the role of assessing individuals in crisis.
Please also review AIHCP’s Crisis Intervention Specialist Certification and see if it meets your academic and professional goals
Hybrid Model of Crisis Intervention and Steps
Various models of Crisis Intervention look to examine the best psychological way to understand the state of crisis and how to help an individual reach pre-crisis state. Crisis professionals all agree that those in crisis experience disequilibrium as opposed to equilibrium and immobility as opposed to mobility (James, 2017, p. 48). Disequilibrium refers to lack of emotional stability, balance or poise within an individual (James, 2017, p.48) and immobility refers to the state of a being that is unable to autonomously change or cope or respond to different moods, feelings needs, conditions that require adaptation (James, 2017. p. 48). Hence it is the duty and vocation of the crisis professional to help individuals again find balance and ability to cope with the crisis inducing situation. The crisis professional is not again present to help resolve the issues causing the crisis itself but only present to help the person again find ability to cope with the situation in the heat of the moment. The crisis professional can then guide the person to appropriate resources and support to face the problems that created the conditions for crisis to occur. This involves various steps and procedures to help a person in crisis stabilize and find balance again. However, James warns that those in crisis are ones to follow steps but in reality are far more chaotic. With this in mind, these steps serve as a checklist or guidebook that can be adapted, or repeated, or reused as necessary within the process until the person again finds state of mind.
The Hybrid Model serves as a way for crisis professionals to help de-escalate the situation and help a person find pre-crisis state through seven steps. The first step is predispositioning/engaging and initiating contact (James, 2017, p. 50). This essential task sets the table and emotional response between anyone in crisis, whether one is facing little impairment or facing extreme emotional impairment. This step involves the crisis professional introducing him/herself and attempting to form some type of bond or understanding. When a person is in intense crisis, approach is key. An aggressive approach can turn the person to self harm or harm of others or also increase agitation within the mind. Trained police officers who approach someone in a mental breakdown who approach with more calmness and articulation are far better able to de-escalate as opposed to officers who approach as angry, aggressive or authoritarian. Many times, police escalate the situation of a person in crisis by challenging, commanding, or threatening. A person in crisis will not respond logically or calmly to these types of approaches. The best way is to introduce oneself calmly without threatening (James, 2017, p. 50). Within this initiation of contact, police or crisis professionals should attempt to learn the name of the person and also clarify one’s intentions in what the person in crisis should expect to happen next. Calm, clear and precise articulation can help break the ice and begin the process of de-escalation as opposed to making the situation worst.
The second task involves exploring the problem. This involves understanding the problem from the current context of the individual in crisis (James, 2017, p. 51). Key to helping and understanding requires core listening skills that encompass empathy and genuineness (James, 2017, p. 51). In this way, the crisis specialist examines the situation as a detective. H/she not only assesses the person (which we will review in the second part of the blog), but he/she also looks for clues about the current problem and addresses the person’s issue as how he/she is experiencing it. If a person is experiencing a breakdown, the crisis professional will discuss why the person is upset and reinforce understanding of why the situation is bad but also why it can be fixed. In addition to the person, the crisis professional will also see all the other issues surrounding the current issue, such as interpersonal issues, or other environmental issues and understanding how they fuel the current crisis.
The third task involves providing support. The crisis specialist, police or chaplain on the scene can provide support via continued empathetic dialogue. This includes letting the person know he/she is not alone and that the crisis specialist is a person who cares about he or she and that the crisis professional is present to help the person receive the support necessary (James, 2017, p. 52). This type of reassurance can help a person find some stability. Many individuals facing natural disasters will need those simply initial words of support to help them find some peace and calm after being completely overwhelmed. The crisis professional can supply psychological support, logistical support which leads the person to basic survival needs, such as food or water or shelter, social support which includes activating and discovering family, friends, coworkers or church, and information support which can include resources the person can access to find help (James, 2017, p. 53). Sometimes a person in crisis will need to be reassured that there is support before he/she will accept help from someone or leave a potentially dangerous situation. A crisis professional can help alleviate the hopelessness by asking and promising the help one needs. Of course, safety is a huge concern during these discussions. When weapons or erratic behavior exist, crisis specialists are at risk. Whether its a violent person in the street, a person threatening to shoot oneself with a gun in hand, the crisis specialist needs to assess, utilize the proper safety guidelines and also the backup present when hoping to diffuse and talk to individuals in a state of crisis.
The fourth task involves helping the person find alternatives to the current mode of thinking (James, 2017, p. 54). Sometimes rational ideas or different ways of viewing a crisis can help a person find some logic or some hope in finding pre-crisis state. This involves asking about situational supports the client has had in the past involving family or friends who can help, as well as offering coping mechanisms that include actions, behaviors or resources that can help the client in the temporary crisis. In addition, offering positive reframing of the current and temporary situation can help the client or person in crisis think more clearly. A crisis professional can offer a variety of solutions or alternative to the one in crisis to view the situation differently (James, 2017, p. 54). This ultimately involves a serious examination of the person’s realistic options within the current crisis situation.
The fifth task is to create a plan. Usually these plans are short goal but they offer order in the chaos for the person in crisis. The crisis professional offers certain ways of proceeding forward and meeting immediate and short term needs of the person. This type of grounding helps the person find some anchor in the chaos and that there are plans available to escape the crisis. This is important for individuals who may have lost a home to hurricane or a person who lost his or her job, or a person who is going through a divorce and lost his or her children. The crisis professional helps the person find order and some control (James, 2017. p. 55). The person should feel part of the plan and have autonomy within it.
The sixth and seventh tasks involve obtaining commitment on part of the person to follow through on the plan and then following up with the client within a few hours, or even days to ensure the person is still on the right path (James, 2017, p. 55-57). Commitment shows the person understands and comprehends the plan and also gives the person a sense of empowerment. Follow up is key to ensure the person still understands the plan and is meeting with the necessary agencies or persons to permit the plan to blossom. This also shows that the crisis professional cares and wants the person to be able to find permanent success following a crisis. This is important for anyone who lost a job or home and needs to contact certain groups, as well as those who were suicidal are committing to the plan of getting the help they need.
A similar model is referred to as the Robert Model. This involves assessment of the situation and person regarding lethality. Following assessment, involves rapport with the individual as found in the Hybrid model. Following rapport, identifying the problem and crisis and then exploring the emotions is addressed. Alternative options and plans are then addressed with follow up. As one can see, most models share a similar 7 step procedure that involves assessments, making contact, understanding the situation and giving options to de-escalate and help the person return to precrisis state with followup.
Interaction with Those in Crisis
Within the first task of initiating contact, it is crucial to establish trust and a bond with those experiencing crisis. Whether a person is brought to a mental health facility in a state of crisis, or arriving upon a scene, basic interaction with communication and listening skills are important. As they are in any counseling, particular ways crisis counselors speak and listen can play a big role in de-escalating a situation. Open ended questions are important that request descriptions of the situation such as “Please tell me” or “Show me” can help a person open up and communicate the crisis. In addition open ended questions that focus on plans of the person such as “What will you do?” can help make the person in crisis think. Expansion questions can help broaden the story by simply stating, “Tell me more” or questions that look to assess the situation. For most cases, “why” questions should be avoided since they provide opening for illogical defense. While it may attempt to allow one to understand, it also allows the person to intellectualize and defend why one is doing something that one should not do (James, 2017, p. 74). Close ended questions are used for more focus and quicker responses. They can obtain specifics, obtain commitments, and help focus on the issue at hand. Crisis counselors can also apply basic counseling skills that involve restatements of what the person feels as well as summaries of how the person is acting. Sometimes, restating and summarizing can allow a person in crisis to see the insanity of his/her state of mind.
In crisis, crisis professionals many time utilize owning or owning of feelings (James, 2017, p. 75). Utilizing “It” statements in what is to be done, or how one feels can help the conversation become more intimate and less confrontational as “we”. The person in crisis has only the professional to discuss, when “I” is utilized. Such as examples of ” I understand” . It is important not to falsely understand when one does not. In these cases, one should ask for clarification. Assertion statements are also useful when telling the individual what you expect and how you want someone to do something for one’s own safety. In these statements, specific actions are asked in the particular moment with “I” statements. In addition, it is important to offer positive reinforcement when applicable while working a person through crisis. Compliment the person who is able to breathe smoothly or who is starting to show control of emotions (James, 2017, p. 77).
In addition to various statements that can help create bonds and trust, as well as de-escalation, counselors need to listen with empathy and genuineness (James, 2017, p. 78). This involves empathetic listening for clues and acknowledging what the person is saying, but also understanding it while helping to guide the person to better options. It is not patronizing but serious listening and response to what is being related by the person in crisis. If the person in crisis understands that the counselor is acknowledging fears and taking what the person feels as serious, then respect can exist and the person in crisis will be more listening to reason and statements from the counselor. Through this, sometimes, a counselor can help create awareness of the situation during reflection of what the person in crisis is stating. Sometimes, restating the problem via good listening and offering a clear awareness of the difficult situation can be a great aid for the person. Sometimes, it is also important to allow the person in crisis to talk. One needs to allow sometimes for the person to talk, express, swear, curse, rant or mourn before reason can be restored (James, 2017, p. 80). In crisis intervention counseling this is referred to as catharsis. Ultimately, listening and communicating involves empathy with the client in crisis. It involves proper attending, verbal communication, reflecting feelings, and utilizing nonverbal cues and silence as a way to show empathy (James, 2017, p. 82).
Throughout the tasks, especially when discussing emotions, alternatives and plans, the crisis specialist needs to also promote expansion of the client’s tunnel vision of the temporary moment and open possibilities. This helps the client see the overall picture (James, 2017, p. 81). Sometimes during these phases and tasks, crisis counselors can also help individuals focus on the immediate issue. Many times individuals in crisis will spiral out of control and discuss multiple stressors that are not present. The crisis counselor can help partition, decompartmentalize and downsize client’s fears and stressors (James, 2017, p. 81). In addition, counselors during interaction need to know how to supply guidance and help implement order. Those in crisis and chaos depending on their level of impairment need direction and guidance. Finally, crisis counselors need to assure those they are working with that they are safe. “I” statements that assure safety and meeting of physical needs can help a person in crisis become more secure and open to de-escalation (James, 2017, p. 81).
Assessment in Crisis Intervention
The tasks in helping a person find balance and mobility again are essential in crisis intervention. One of the initial observations during the first contact with a person in crisis is assessment of the person. Crisis Intervention offers a variety of assessment tools and charts to help EMT, police, chaplains and social workers to better able assess a person’s threat to oneself and others. Most assessment covers affective and emotional states, behavioral states and cognitive states. It is also important to assess whether a client has been in crisis before or if this is merely an isolated acute situation or if the person is chronic crisis with common re-entry (James, 2017, p. 69). Chronic, long term and transcrisis can all play roles in the persons limitations on resources and resiliency.
Affective states refer to one’s current mood. Hence any abnormal or impaired mood can show signs of crisis upon the scene. A person may seem over emotional or severely withdrawn. The behavioral functioning can also be important in assessing. The crisis professional observes the doing, acting and behavior of the person on scene (James, 2017, p. 58). Finally the cognitive state of the person in crisis in important in crisis. The crisis professional reviews the thinking patterns and thoughts of the person in crisis.
These three observations detail the ABC model of affective, behavioral and cognitive states (James, 2017, p.58). The Triage Assessment system and chart lists a series of questions that look at affective, behavioral and cognitive issues as well as supplying a chart to access severity of crisis (James, 2017. p. 59-64). A person’s affective state will include observing if the person is on medication or not, under a substance, experiencing psychosis or paranoid or any other mood related or physical appearances. A person’s behavioral state is ranked based on if the person is defiant, aggressive, reckless, suicidal, or violent. From a cognitive state, observations include if a person is uncooperative, impulsive, hysterical, confused or unresponsive (James, 2017, p. 60 & 68).
The Affective, Behavioral, and Cognitive scales help assessment with the worst score totaling 30. Important labels include no impairment and minimal to low, moderate, marked and severe. Stable moods are contrasted moods devoid of feeling, behaviors are rated from socially appropriate to behaviors that intensify crisis, and decisions are ranked from considerate of others to decisions that are clear and present danger to self and others (James, 2017, p. 61-62). Ratings are based off of a 1 to 10 model of each facet of affective, behavioral and cognitive. Within affective, one rates anger, fear and sadness. Within behavioral, one rates approach, avoidance and immobility. Within cognitive, one ranks current transgression, perceived future threat and past reflection on loss. In addition, there exists observation questions regarding the person that looks at if the person is on or off medication. Individuals who rate within 3 to 10 total points within assessment are considered minimal impairment and need little direction and can self direct. Those with ratings of 11-15 require some guidance and direction. Those with a score of 16 to 19 are indicative of a person losing more and more control of the situation. Those with scores at 20 are potentially entering into harms way and need intense direction to avoid a lethal range, while those in the upper 20 scores have entered into a lethal range and lethality is present (James, 2017. p. 66).
Conclusion
Crisis Intervention is a structured response to pure and utter chaos. It is mental first aid. While structured it is adaptable and adjustable. Those who are experienced and talented utilize the core concepts and adjust and adapt in the moment. The seven tasks to help a person find balance and mobility are key as well as assessing low impairment and high impairment cases within one’s affective, behavioral and cognitive abilities. Those in crisis intervention whether in police, EMT, social work, mental health, and chaplaincy require empathy, patience and skill to safely deal with those who are harmful to self and others.
Please also review AIHCP’s Crisis Intervention Specialist Program. Qualified professionals can earn a four year certification to help them within this field. Whether working at a crisis center or trained professionals on the scene, the certification can help give academic and core information that can aid others attempting to work in this high stress but high rewarding field. The program is online and independent study with mentorship as needed
Resources
Bengelsdorf, H., Levy, L. E., Emerson, R. L., & Barile, F. A. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal of Nervous and Mental Disease, 172(7), 424–430. Access here
James, R & Gilliand, B. (2017). “Crisis Intervention and Strategies” (8th). Cengage.
Marschall, A. (2023). “How a Crisis Intervention Provides Mental Health Support”. Very Well Mind. Access here
Myer, R. A., Lewis, J. S., & James, R. K. (2013). The introduction of a task model for crisis intervention. Journal of Mental Health Counseling, 35(2), 95–107. Access here
Roberts, A. & Ottens, A. (2005). “The Seven-Stage Crisis Intervention Model: A Road Map to Goal Attainment, Problem Solving, and Crisis Resolution”. Brief Treatment and Crisis Intervention. Access here