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Chapter 11 Working with People in Crisis

Chapter Outline



Chapter 11 Working with People in Crisis
I. Crisis

A. Crisis

1. Affords both danger and opportunity

2. Shock or grief commonly accompanies

3. A common occurrence

4. Illuminates coping resources and vulnerabilities

B. Trauma


  1. Catastrophic crisis or series of insidious or unsettling events

  2. Shatters or alters assumptions about people life, and familiar institutions and ways of being

  3. Overwhelms cognition, feeling, biology, coping, and relating

  4. Alters beliefs about self and safety

  5. Often brings outsiders in to help

  6. Microaggressions

  7. Insidious trauma

Exercise 11.1 Oppression Based Traumas

8. Secondary trauma


a. the overwhelmed response of witnesses or others who learn of the trauma and are deeply distressed by it

9. Hate crimes are intended to harm or intimidate

a. often due to membership in a vulnerable group

b. all members can be shaken by hate violence perpetrated on individuals


II. Common Features of a Crisis

A. A Precipitating or Triggering Event

1. Situational crises

a. predisposing factors like poverty and racism create risk

b. poor neighborhoods have more hazards

2. Developmental crises

a. life transitions: birth, death, divorce

b. different cultures have different transitions and interpretations of these

3. Environmental crises


  1. natural disasters (tornadoes, floods)

  2. human-made disasters (oil spills, fires)

c. biological disasters (epidemics)

d. politically-based disasters (war, refugee migrations, ethnic “cleansing”)

e. economically-based disasters (severe economic depressions; widespread

plant closings, layoffs)

4. Compound crisis or transcrisis states

a. current crisis rekindles unfinished business

b. delayed grief reactions activated

B. Perception of Danger, Loss, or Threat

1. The meanings people make of events are crucial

2. Different people may interpret same event differently

3. Cultural, familial, and spiritual influences on meaning making

C. Customary Coping Mechanisms Do Not Work

1. Coping methods used to overcome, reduce, or accommodate to the demands of stress

2. Methods can be healthy or maladaptive, effective or ineffectual

3. Method can work and still be maladaptive

D. The Person Feels Overwhelmed and Anxious,

1. Physiological changes and symptoms of stress

2. Emotional numbing or intrusion of feelings

3. Feelings of estrangement, of not being like others

4. Relational withdrawal or the need to be with reassuring and protective others constantly

E. Opportunity to Re-stabilize at a Higher or Lower Level of Functioning

1. Positive effects of coping with stress

2. Material and social supports are crucial

3. Resilience builds on experience with adversity and the leveraging of internal assets and social supports

4. Person can decompensate

5. Vulnerability can leave people open to new ideas, connections, and growth

6. May rework past issues and feelings

F. Crisis Window of Opportunity

1. Suggested eight-week limit

2. Strategically focused help can be more effective than more extensive help when less emotionally accessible

III. Crisis Intervention

A. Characteristics of Crisis Intervention

1. Immediate

2. Brief, with rapid assessment and intervention

3. Specifically focused

a. clear, organized description of precipitant

b. discussion of related reactions and interpretations

c. action to meet urgent concrete or safety needs

d. less exploration or linking with history unless an urgent need to do so

4. May require more frequent meetings and meetings of varying durations

a. shorter intervals to organize, calm, and relieve pressure

b. increasing intervals as problems abate

5. May require more clinician activity than usual

a. may inform, guide, structure, and advise more

b. may accompany client for support or take action on client behalf

B. What Clinicians Do in Crisis Intervention

1. Help the client tell the story

a. biological processes may distort memory or put it out of reach

b. clinicians help clients find a medium of expression right for them

c. a coherent story helps people begin to feel more capable and in control


Exercise 11.2 Helping to Structure the Story


2. Validate events and distress reactions

a. normalize universal human feelings, and ideas

b. if feelings culturally taboo, explore thoughts, actions, and bodily complaints

c. explain reasons for exploring crisis reactions



CLIP 11.1 ELICITING AND VALIDATING THE STORY

3. Focus on safety and concrete needs

a. assist immediately with concrete needs

b. establish safety plans

CLIP 11.2 ESTABLISHING A SENSE OF SAFETY

4. Help clients contain feelings and reduce stress

a. importance of expression and self-restraint

b. demonstrate and practice stress reduction techniques

c. minimize contact with stress-inducing people and situations

d. may volunteer to help others in crisis

Exercise 11.3 Eliciting and Containing Feelings

CLIP 11.3 STRESS REDUCTION


5. Quickly establish a baseline of previous functional capacity

a. compare customary functioning with current resources and behaviors during crisis

6. Focus on effects on relationships and feelings of relatedness

a. help restore positive ties

7. Involve family and friends in the intervention

a. rich sources of information and support

b. faith communities may offer non-stigmatized help and association

c. at times, family or friends may be contributing to the crisis

d. others may experience “emotional contagion”

e. extend support to those who need it

8. Focus on strengths and hope

a. people in crisis can forget their strengths

b. competence increased by exercising it in own and others’ behalf, restoring locus of control

c. avoid directives, excessive control and actions undermining that of clients

9. Help the client make meaning of the events

a. bring gradual coherence to the narrative

b. enlarge perspective and deepen understanding

c. work supportively with “why me?” questions

d. challenge self-blame and harsh self-judgments

e. discuss alternative explanations, interpretations

f. share stories of other survivors

g. see the crisis as one part of a whole life


CLIP 11.4 MAKING MEANING OF EVENTS

10. Maintain a here-and-now focus

11. Check regularly for suicidal or other self-harming behaviors

a. signs of despair, hopelessness, and wishes to escape or rejoin lost ones

b. means and opportunity for self-harm

c. suddenly giving away possessions or money

d. suddenly presenting as strangely relieved and happy

e. contract for safety

12. Use rituals and other marker events

a. restore agency, dignity, and connections

b. anniversary reunions, permanent memorials, websites, quilts or other installations

EXERCISE 11.4 Rituals for Healing


13. Refer to mutual aid groups

a. importance of kinship and reference group ties

b. mutual aid strengthens all through support, coping tips, and shared caring

c. advocacy groups can form to change laws, institutions, and community norms

14. Prepare the client for ending

a. crisis bonding can be quite strong

b. agreed-upon time limits ease the process

c. work ends when functioning approximates pre-crisis levels or better

15. Provide follow-up and support

a. periodic check-ins to assess coping and well-being

b. clients may reach out at important anniversaries

C. When Ongoing Clients Experience Crises

1. Compare with previously managed events

2. Encourage use of knowledge and skills learned in the ongoing work

D. Critical Incident Stress Debriefing (CISD)

1. Immediate intervention

a. provide information about normal stress reactions

b. discuss what they witness

c. how they felt and how interpreted events

d. validation and support

e. what they can learn from the experience

f. resources

2. People may feel trauma is “re-triggered”

3. Not appropriate in all cultures

IV. Community Crises

A. Characteristics of Community Crises and Interventions

1. Infrastructure can be lost or destabilized

a. loss of customary supports

b. leadership and community resources unable to provide immediate protective and reorganizing responses

c. clinicians may also be traumatized by losses and unable to respond as helpers of others

d. sense that all is lost or changed forever, a despairing and helpless worldview

e. some members may flee and not return

2. People from outside the community may come to help

a. state and federal emergency teams, Red Cross, counseling and social work response teams


  1. focus first on concrete survival and safety needs

  2. suspicion of strangers, danger of outside “experts” sidelining residents in the rush to help

  3. indigenous leaders must introduce and welcome in order to legitimize

e. importance of utilizing the community’s own power

f. many helpers, many complications

1. centralized coordination crucial

2. communications center and accurate dissemination of information

minimizes rumor and distortion

3. utilizes all local languages

4. clear, specific, and focused
V. The Clinician in Crisis

A. Can experience symptoms similar to clients’

1. Re-experiencing their traumatic events in dreams or intrusive thoughts

2. Experiencing hyperarousal through sleep disturbances, hypervigilance, inability to concentrate, irritability

3. Avoiding reminders through detachment, efforts to avoid thought or feelings, numbing, or withdrawal from social contact

4. Shaken faith in relationships, cynicism

5. Clinician reactions referred to as

a. emotional contagion

b. secondary traumatic stress

c. traumatic countertransference

d. compassion fatigue

e. vicarious trauma reactions

6. Greater capacity for empathy may put clinicians at greater risk for compassion stress

B. Direct Stress of Working Long Hours in Difficult Situations

C. Unresolved Personal Crises Can Be Stirred Up by Client Stories

D. Current Personal Crises

E. Can Lose Belief in Power to Help

F. Self-care Counters Stress

1. Loving relationships and mutual aid

2. Good health practices

3. Time-outs from crisis work

4. Meditation, exercise, recreation, and personal time



5. Spirituality


CLIP 11.5 COMMUNITY CRISES
VI. Conclusion


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