A Hybrid Model of Crisis Intervention Perhaps the biggest change in the seventh edition of this book is our notion of how a model for crisis intervention operates. There are numerous models for crisis intervention (Aguilera, 1998; Kanel, 1999; Kleespies, 2009; Lester, 2002; Roberts, 2005; Slaikeu, 1990). All of these models depict crisis intervention in some linear, stepwise fashion. Indeed, through 20-plus years of publishing this book we did much the same, with the admonition that changing conditions might well mean that the interventionist would have to recycle and move back to earlier steps. In our earlier model we depicted crisis intervention as starting with problem exploration, examining safety concerns, looking for support, examining alternatives to present behaving, planning how to restore equilibrium, and finally gaining a commitment to take action. We no longer believe that a stage or purely step model captures the way crisis intervention works, and heres why. The problem that we have struggled with as we try to teach students like you about crisis intervention is that at times crisis is anything but linear. A lot of the times crisis intervention absolutely epitomizes chaos theorywith starts, stops, do-overs, and U-turns. At times doing crisis work is a lot like being a smoke jumper, controlling a psychological brush fire on this side of the mountain only to be faced with a new one on the other side of the valley. Fighting those psychological fires according to a neat, progressive, linear plan is easily said but not so easily done. Therefore, we have combined our former linear model with a systems model we helped develop (Myer, James, & Moulton, 2011), resulting in what could more appropriately be called a hybrid model for individual crisis intervention that is generally linear in its progression but can also be seen in terms of tasks that need to be accomplished. While certainly some of these tasks would usually be done in the beginning, middle, or end of a crisis, changing conditions may mean you have to accomplish some task you would normally do later, first. Or indeed, a task you thought was already accomplished comes apart and has to be done over not once, but multiple times. A further problem with a strict linear model is that each step should be discrete, following from step one to step two and so on, with particular techniques to employ in each of those steps. In crisis intervention, issues suddenly erupt that defy discrete, stepwise techniques. Focus on getting a commitment from a person to do something, which would normally come at the end of a crisis session, may need to happen immediately if that person is standing out in the middle of a busy intersection at rush hour! Likewise, gaining that commitment to get out of the street may call for assertion techniques that are anything but what we might normally do when making initial contact with a client. Consider the following analogy. Picture yourself as a linesperson on the cross arm of a power pole, hard hat on, heavy insulated clothing, leather over insulated gloves, dug in with your climbing spikes, attempting to repair a high-voltage (crisis) transmission line in North Dakota in January with the wind blowing sleet in your face at 20 miles an hour. On your utility belt are a variety of tools. You know the steps required to get the transformer hooked back up and the sequential manner in which you will employ the tools on your belt to get the job done. The problem is, Mother Nature is not happy and the wind picks up and a coupling breaks loose or a new fuse you just put in blows and you have to start all over again! If you can picture this analogy in your minds eye, you are well on the way to understanding how crisis intervention works. As we describe the model, we will give you some examples of when you have to change tools to meet the changing conditions up on that pole. The model you are about to examine is the hub around which the crisis intervention strategies in thisbook revolve, and the tasks/steps are designed to operate as an integrated problem-solving process. It is not complex, but rather is designed to be simple to implement, easy to use, and adaptable to just about any crisis we can think of you would likely encounter. Task 1. Predispositioning/Engaging/Initiating Contact Predispostioning may be seen as first and foremost getting ready to do something. It is usually the first step in a crisis model: placing oneself, or something, in a position to be of use in some future occurrence. Typically, systems such as the armed forces and government agencies such as FEMA use predispositioning to get supplies, equipment, and personnel ready to meet some future emergency. Indeed, in Chapter 17, Disaster Response, you will see predispositioning in operation on a very large scale. In the counseling literature, predisposition was originally studied by Prochaska, DiClemente, and Norcross (1992) in regard to what motivated people who were suffering from addiction to decide to change. Since their seminal work, the concept of predisposing clients to get them ready for counseling has become widespread. In crisis intervention, predisposition is somewhat different. It means predisposing individuals to be receptive to our intervention when, in many instances, they may not be at all enthused about our presence or be so out-of-control that they are only vaguely aware of us. Therefore, predisposition has a lot to do with the attitudinal set and predisposition of how the crisis worker enters the situation. A number of clients the crisis worker will meet do not act, talk, look, or even smell nice! The ability to convey empathy and be authentic as to who and what you are doing without pretense is critical (Kleespies & Richmond, 2009). Particularly with a first contact, predispositioning the client as to what to expect is critical. Along with letting the client know what is going to occur, it is important to make contact in such a way that the client can see the interventionist as an immediate ally and support, and not another in a long line of people, representative of bureaucracies and institutional authorities, who have been anything but helpful in resolving their problems. One of the most critical initiating components of crisis intervention is how the worker introduces him- or herself to a client who has never met the crisis interventionistwhich is a fairly common occurrence in this business. It is not just to fill time that our practicum training with aspiring crisis intervention team police officers now devotes an initial session specifically to how the officer introduces him- or herself to a recipient of services (Memphis Police Department, 2010). Our primary objectives in predisposing an individual to accept crisis intervention are twofold: (1) to establish a psychological connection and create a line of communication and (2) to clarify intentions with regard as to what is going to happen. Establishing Psychological Connection. First and foremost, you need to introduce yourself in a way that is nonthreatening, helpful, and assumes a problem-solving as opposed to an adversarial approach. Leron: (standing in the middle of a main city street in five oclock rush hour traffic waving two broken whiskey bottles) The God damned house authority. NO place to live. Kicked me out, the rotten bastards. Everybody needs to know them for the crooks they are. CIT officer: (slowly approaching the subject from a distance with hands visible, empty, and open) Man! You really are angry with them to make this kind of statement out in the middle of Union Avenue during rush hour. My names Scott Lewis, a CIT officer with the Memphis Police Department. I didnt catch your name. Mind telling me? One of the most important elements in making first contact is getting the clients name and introducing yourself in a nonthreatening manner. Note that Scott approaches the subject slowly, not only because he is armed with two whiskey bottles (which has to do with another task that is pretty important here, providing for the clients safety and your own), and responds to his current affective and behavioral state of being. Before he ever asks a question about why this has happened, he immediately states his name and asks for the clients. Also note that his full name, not his rank or the police department, comes first. Another advantage with the approach used by Scott is that he allows Leron to maintain some control over the situation. The housing authority has already taken his home and barred him from his belongings. Imagine if Scott rolled onto the scene and immediately began demanding Leron get out of the street and put down the whiskey bottles. Scott would likely get the response screw you, cop. Scott would be seen as just another authority figure who doesnt listen. By establishing a problem-solving, helpful connection, Scott allows Leron to maintain momentary control of the situation. By reflecting Lerons anger, the crisis worker immediately attempts to convey empathic understanding of theextreme measures the client has taken in attempting to problem-solve. Clarifying Intentions. Clarifying intentions means informing the client about what the crisis intervention process is and what the client can expect to happen. For many clients who are in crisis, this will be their first contact with a crisis interventionist, and they will have little if any idea of what is going to happen or how it is going to happen. Leron most likely has had experiences with the police that will lead him to believe that nothing positive is going to happen with Officer Lewis. Thus, the CIT officer needs to quickly apprise him of what will happen. CIT officer: Okay I can see right off you clearly have some issues with the housing authority. Right now I am going to listen very closely to what got you out here. I may ask you some questions so I get a clearer notion of the problem. Weve got some time and I am going to take the time to hear you out. Ill also probably kinda sum up what youre saying so Im sure I heard you right. So I wonder if we could move this over underneath that shade tree cause its hot and not very safe out here. Leron: (weaving unsteadily and sweating profusely) No! As soon as I do that, those other cops will bum rush me. Long as Im out here they got to pay attention and that News 5 chopper stays up there. Lost my job through no fault of my own and now kicked out. CIT officer: Okay. I hear what youre saying about keeping the evil stuff the housing authority has done to you in the publics eye. However, sooner or later were going to need to get out of the street. Id like that to be sooner since it is 98 degrees out here and my guess is youre getting thirsty and would like to get it settled and get out of the sun. Nobodys going to bum rush you. Its between you and me right now. Thats the way Id like to keep it. Officer Lewis uses basic listening and responding statements that own what is going to happen in the next few minutes. He also states the immediate end goal of the crisis resolution for him as getting out of the middle of the street. He clearly states his intention to listen, get the clients perspective, and do no harm to him while this is going on. While the clients end goal may be completely differentbringing the housing authority to justice in some mannerthe interventionist states from the outset in pretty clear terms what he is going to do. In clear, concise statements, the interventionist creates a line of communication by using open-ended questions, reflection of feelings, and owning statements (all of which you will learn about in the next chapter) that reinforce and encourage the client to tell his story. The major intentional strategy here is allowing the client to cathart but also keeping the client in real time and not allowing the interaction to degenerate into all the perceiving injustices ever perpetrated on him. This introduction stuff may sound pretty simplistic, but in the heat of the moment it is surprising how that can go by the wayside. It may also seem like a once and done deal, but even for a client who has known the interventionist for a long time and is currently out of touch with reality, anchoring the client by stating who the interventionist is, clarifying intentions, and stating what needs to happen is a critical ingredient for a successful intervention. Task 2. Problem Exploration: Defining the Crisis A major initial task in crisis intervention is to define and understand the problem from the clients point of view. This is particularly difficult in the middle of a chaotic situation where there are complex biopsychosocial contributors interacting with one another (Kleespies & Richmond, 2009). Unless the worker perceives the crisis situation as the client perceives it, all the intervention strategies and procedures the helper might use may miss the mark and be of no value to the client. Intervention sessions begin with crisis workers practicing what are called the core listening skills: empathy, genuineness, and acceptance or positive regard (Cormier & Cormier, 1991, pp. 2139). Problem definition of a crisis does not mean going on a psychological archaeological dig to dredge up and sift every artifact of the clients past. Defining the crisis does mean attempting to identify the precipitating event across the affective, behavioral, and cognitive components of the crisis. This task serves two purposes. First, the interventionist sees the crisis from the clients perspective. Second, defining the crisis gives the interventionist information on the immediate conditions, parties, and issues that led to eruption of the problem into a crisis. CIT officer: I understand that the housing authority screwed you over somehow. So tell me what got you so mad and frustrated you needed to get everybodys attention. As Leron angrily expounds on the housing authoritys injustices toward people and himself, Officer Lewis uses an expansion strategy to broaden the clients view of the problem without letting the problem escalate. He restates the clients complaint and follows with an open lead. Inevitably other issues will surface as the interventionist attempts to define the crisis. In the case of Leron, Officer Lewis may suspect that Leron is dependent onalcohol, given the fact that he has two empty whiskey bottles in his hands and is having trouble keeping his balance. He also is now aware that Leron has recently been laid off from his job. While these issues need attention, at the moment the interventionist needs to remain focused on the crisisgetting Leron out of the street and assisting him to access the resources needed to address the eviction from his apartment. The other issues should be placed on the back burner and may well be discussed after the crisis has been resolved. CIT officer: So they lost your application for delayed payment while you wait for unemployment to kick in, then said you hadnt filed and kicked you out. I understand how that could make you so mad. So how about putting those bottles down and stepping over to that shade tree. I see youre sweating pretty hard out here in the hot sun and bet you could use some water. I just happen to have some bottles in my lunch cooler. Ive got a couple of ideas about how to get you out of this predicament. Task 3. Providing Support The third task in crisis intervention emphasizes communicating to the client that the worker is a person who cares about the client. Workers cannot assume that a client experiences feeling valued, prized, or cared for. In many crisis situations the exact opposite will be true. The support step provides an opportunity for the worker to assure the client that here is one person who really cares about you. We believe that providing support occurs in three ways. Psychological Support. First and most immediate is providing psychological and physical support. Deep, empathic responding using reflection of feelings and owning statements about the clients present condition serves as a bonding agent that says emphatically, I am with you right here. In Task 3, the person providing the support is the crisis worker. This means that workers must be able to accept, in an unconditional and positive way, all their clients, whether the clients can reciprocate or not. The worker who can truly provide support for clients in crisis is able to accept and value the person no one else is willing to accept. While Officer Lewis is attempting to get Leron out of the street, he also offers genuine support and help in getting the client out of his predicament with the housing authority. Logistical Support. In a more general sense, support may be not only emotional but instrumental and informational (Cohen, 2004). At times the client may not have money, food, clothing, or shelter. Little psychological support will be desired or progress made until the basic necessities of living and surviving are met. Physical support means giving clients concrete assistance to help weather the crisis. This support comes in many forms, ranging from providing pamphlets to arranging transportation of clients to organizations that have the resources needed to help them to simply giving them a drink of water. CIT officer: I cant imagine what its like not to have a job or a roof over your head. Wheres your family in all this? Leron: Tormeda and the kids done went to her mommas in Arkansas. Nothin to eat and no place to live ceptin the street. Momma took her back cause I aint no account and caint feed em or put a roof over dere heads. CIT officer: The words terrifying and hopeless come to mind. I can see why this might come down to the only solution you can think of. I really do want to help you out with this and get you back on your feet, and I do may be have an idea or two about how to do that. But I dont want to see you arrested and if we dont move this out of the middle of the street so I can share some of my ideas with you, nothing will happen except you going to jail. So you have a choice. Whats your wish? Help getting this resolved or jail? Leron: Jail dont sound good been there, done that. CIT officer: I hear that. I dont want to see you in jail either, so come on over here and lets look at some options. Leron: (walks slowly over to the curb and sets the bottles down) Okay, I be done. I be givin you a shot at dis. I guess I be needin some hep. In this exchange, Officer Lewis forms a bond with Leron. Officer Lewis does not judge Leron, instead he encourages him to stay out of jail. This encouragement helps Leron regain a belief that the situation is not as dire as it seems and may be with help a solution can be found. Encouragement is a critical component in crisis intervention because, for most clients, what they are going through is anything but encouraging. Catching clients even feeble attempts to problem-solve gives them a chance to regain some hope, validates that they still have capabilities, and starts reframing thinking toward a proactive, problem-solving mode (Courtois & Ford, 2009, pp. 8687). Social Support. Third, providing support means activating clients primary support system: family, friends, coworkers, church members, and so forth. For many people in crisis, this primary support system may be absent (a car accident 600 miles from home), fedup with their behavior (lying and stealing from them to subsidize an addiction), or unequal to the task of providing support as a result of the crisis (symptoms of posttraumatic stress disorder). Conversely, clients may feel too embarrassed or guilty to ask for help from their immediate support system such as Sunday school members (loss of job and inability to contribute to their church financially). At such times, the interventionist is not only the initial point of contact and immediate psychological and physical anchor, but also the expert who provides information, guidance, and primary support in the first minutes and hours after the initiating event (Aguilera, 1998; Cohen, 2004). Informational Support. At other times, clients do not have adequate information to make good decisions. The need for informational support is particularly critical in the next step, examining alternatives. One of the best techniques a crisis interventionist can be in command of is the ability to provide information on where, how, who, and what resources clients can access to get out of the predicament they are in. That is particularly true of people who after a disaster are trying to access the basic necessities of living (Ruzek, 2006). Default Task: Safety Safety is a default task that is always operational. Safety is a primary consideration throughout crisis intervention for a variety of reasons that are both physically and psychologically based. The task of assessing and ensuring the clients and others safety is always part of the process, whether it is overtly stated or not. When we speak of safety, we are concerned about the physical safety not only of the client but also of those who may interact with him or her and, just as important, about keeping ourselves safe. Whether by commission or omission, clients often put themselves in hazardous situations as a result of their affective, behavioral, and cognitive reactions to the crisis. Lerons attempt to publicize his plight clearly puts him, the general public, and the officer at risk. While Lerons crisis is with the housing authority, the immediate crisis of Leron in the middle of a main street with two broken whiskey bottles in his hands is a safety issue. Nothing is more paramount in a crisis than ensuring safety. We have personally known three human service workers who have been killed at the hands of clients in crisis. One of your authors could very easily have been added to that list early in his career when he talked a violent juvenile into handing over a gun pointed a foot from his face. He didnt think the weapon would work. After the youth was taken into custody, blanks were loaded in the gun and it fired very well, to the shock of a shaken 24-year-old junior high school counselor who thought he was immortal! There are no dead heroes in this business, only dead interventionists. We will have a great deal more to say on the subject of the interventionists safety in Chapter 14, Violent Behavior in Institutions. Generally, when we think about safety in a crisis, we assume that someone is engaging in lethal behavior toward self or others. But limiting the task of ensuring safety to issues of life and death overlooks many clients whose safety is in jeopardy. The fact is that in much crisis intervention people do not intend to cause harm to themselves or others but engage in activities that have a high potential for that to happen. You can extend the task of ensuring safety to include meeting the daily needs of clients such as finding shelter and food. CIT officer: Leron, I want to keep you safe, man, and the middle of Union Avenue at rush hour is anything but that. I can get you some help not only as far as the housing authority is concerned but also in regard to getting some food in your belly and a roof over your head, but that has to start happening over in my squad car. Otherwise the TAC team will come and take you in to custody and none of that will happen. When did you eat last? Leron: Dont remember yesterday may be no, a couple of days ago I think. Got some stuff out of the back of one of them restaurants on Beale Street. Officer Lewis is working to protect Leron from inadvertently being injured. Food and the offer of shelter are used to entice Leron off the street. This offer makes a clear point that all crisis interventionists need to heed: If a persons basic physical needs are not being met, it is unlikely that the crisis will diminish until those needs are met. Safety also includes assuring clients that they are psychologically safe. As we shall see in Chapter 9, Sexual Assault, many clients who have been subject to vicious assaults by sexual perpetrators have suffered secondary victimization, being revictimized by authority figures, government bureaucracies, religious entities, social service agencies, and, yes, incompetent therapists (Ochberg, 1988). Making it safe for a client in crisis to trust the interventionist comes before everything else and is a critical part of creating the trust and bond necessary to move forward (Courtois & Ford, 2009). Safety is a default task that is merged and subsumed in all the other tasks in the model, from predis-positioning to follow-up.