Amity Institute of Behavioural Health & Allied Science

Seminar topic– Crisis Intervention in emergency situations: Principles techniques &

challenges

Date: 8.12.2022

Presented By – Saptik Podder Supervised by – Mr. Dipanjan Bagchi

M.Phil Trainee (2nd year) Assistant Professor, AIBHAS, Kolkata
AIBHAS, Kolkata

What is crisis?
“CRISIS” was first used as a specific term in psychiatry by Gerald Caplan & His concept of
crisis was influenced by the theories of his time. It relied on concepts of disease rather than
health and on mechanistic theories from Freud and General Systems Theory regarding
“homeostasis” and “equilibrium”. Caplan’s classic definition of crisis is an upset in the
person’s steady state provoked when an individual finds an obstacle to important life goals.
This obstacle seems insurmountable, at least for a good while, by use of customary methods
of problem solving. However, Caplan’s contribution in emphasising the importance of
preventive care, achieving mastery of the crisis, the social, cultural and material “supplies”
necessary to avoid or resolve a crisis, and his pioneering advocacy of a community mental
health approach.

Crisis Theory
Current Crisis Theory suggests that unresolved bereavement from earlier losses (of a person,
a relationship, security, capacity, and a dream) affects not only one’s later day-to-day
functioning, but also one’s reactions to subsequent crises. It is important for helpers to learn
about the victim’s past experiences with abuse and loss so that helping strategies can be
planned that enhance one’s style of coping. So, crisis is a state that exists when a person is
thrown completely off balance emotionally by an unexpected and potentially harmful event
or difficult development transition.
STRESS AND CRISIS
The major difference between stress and crisis is that a crisis is limited, whereas stress can be
ongoing.

Characteristics of crisis

1. Crisis occurs in all individuals at one time or another and is not necessarily equated
with psychopathology.

2. Crises are precipitated by specific identifiable events.

3. Crises are acute, not chronic, and will be resolved in one way or another within a brief
period.

4. A crisis situation contains the potential for psychological growth or deterioration.

Phases of crisis

Homeostasis or Steady State

Phase I: Mounting tension

habitual problem-solving responses in an attempt to maintain the person's steady
state.
Phase II: Plateau of disorganization
feeling anxious and ineffectual, "at sea", "chaotic" or "going mad"
repetitive abortive attempts at problem solving
stereotyped responses (like "hitting your head against a brick wall")
increased dependence and ventilation need

Phase III: Mobilization of all internal and external resources

maximum arousal, heightened suggestibility, increasing vulnerability to good or poor
advice emergency methods or creative, novel solutions may be attempted, resulting in
arrange of possible outcomes

Phase IV: Adaptation or maladaptation & major disorganization

Crisis resolution: Adaptation to new circumstances. Stability and steady state restored
at equal or higher level (most common outcome)
Maladaptation: Superficial "closure" or reactivation of past crises15 or recurrent
medical symptoms and treatments
Major disorganization: Crisis may precipitate psychotic episodes or affective
disorders if vulnerable.
Types of Crises

Baldwin (1978) identified six classes of emotional crises, which progress by degree of severity.

1. Dispositional Crises: An acute response to an external situational stressor.

For example: dispositional crisis occurs when a house is under fire, or when a partner has an abusive
relationship with another partner.

2: Crisis of Anticipated Life Transitions: Normal life-cycle transitions that may be anticipated but
over which the individual feels a lack of control. These are normative, developmental crises that are
fairly common in our society. They may result from midlife career changes, getting married,
becoming a parent, divorce, the onset of chronic or terminal illness, or changing schools.

3: Crises Resulting from Traumatic Stress: These crises result from externally imposed stress
situations that are unexpected, uncontrolled, and emotionally overwhelming.
Examples are rape, assault, sudden death of a loved one, sudden loss of job status, sudden onset of
illness, accident, war.

4: Maturational/Developmental: Crises that occur in response to situations that trigger emotions

related to unresolved conflicts in one’s life. These crises are of internal origin and reflect underlying
developmental issues that involve dependency, value conflicts, sexual identity, control, and capacity
for emotional intimacy.
Examples are the repeated loss of jobs because of an inability to get along with supervisors, the
intense homesickness or depression of college students away from home for the first time, and midlife
crises.

5: Crises Reflecting Psychopathology: Emotional crises in which preexisting psychopathology has

been instrumental in precipitating crisis or in which psychopathology significantly impairs or
complicates adaptive resolution.
Examples of psychopathology that may precipitate crises include personality disorders, anxiety
disorders, bipolar disorder, and schizophrenia.

6: Psychiatric Emergencies: Crisis situations in which general functioning has been severely impaired
and the individual rendered incompetent or unable to assume personal responsibility.
Examples include acutely suicidal individuals, drug overdoses, reactions to hallucinogenic drugs,
acute psychosis, uncontrollable anger, and alcohol intoxication.
Signs and symptoms of crisis

• Heavy burden of free-floating anxiety

• Depression
• Anger, guilt
• Use various coping mechanisms, healthy or unhealthy.
• Incapable of taking care of daily needs
• Neglect responsibilities.
• Irrational and blame others for what was happened to him.

Levels of crisis

Level 1: Somatic Distress- Biomedical causes, situational problems, health problems, relationship
conflicts, work-related stressors, chemical dependency issue

Level 2: Transitional Stress Crisis- Stressful events that are expected in part of one’s lifespan
development. Examples include premature birth, bankruptcy, divorce, relocation

Level 3: Traumatic Stress Crisis- Unexpected and/or accidental situations outside the individuals
locus of control. Crisis can be life threatening. Examples include disasters, crime victimization, family
violence, child abuse, sexual assault

Level 4: Family Crisis- Issues related with interpersonal and family relationships that are
unresolved and harmful psychologically, emotionally, and physically. Examples include child abuse,
family violence, homelessness, and parental kidnapping

Level 5: Serious Mental Illness- relates from preexisting psychopathology. Examples include
schizophrenia, dementia, and major depression

Level 6: Psychiatric Emergencies-When situations in which general functioning have been

severely impaired. Examples include a drug overdose, suicide attempts, or the acute onset of a major
mental illness
Level 7: Catastrophic Crisis- This level involves 2

Or more level 3 traumatic crisis in combination with level 4,5, or 6 stressors. Examples include losing
all family members in a disaster or multiple homicides

Stages of crisis
The stages of crisis resemble the stages of the grief process. Individuals can skip a stage, can get stuck
in another stage, or can even move back and forth throughout the stages.
The four stages of crisis include: outcry, denial or intrusiveness, working through, and completion or
resolution.

Outcry: The earliest reactions after the crisis event, which are reflexive, emotional, and
behavioral. The reactions can depend on the person. Some examples include panic, screaming,
shock, anger, defensiveness, moaning, flat affect, crying, and hyperventilation.

Denial or Intrusiveness: Outcry can lead to denial, which eliminates the impacts of the crisis
through emotional numbing, dissociation, cognitive distortion, or minimizing. Outcry can also lead to
intrusiveness, which includes the involuntary flooding of feelings about the crisis, such as flashbacks,
nightmares, and automatic thoughts.

Working Through: This is the stage of recovery or healing in which thoughts, feelings, and
images of the crisis are expressed, acknowledged, explored, and reprocessed through adaptive and
healthy coping skills.

Completion or Resolution: This stage can take months or even years to complete. Some individuals
may never even complete this process. This process allows the individual to reorganize their life, and
use the resolution of the trauma in positive meanings of growth or change. Many crisis survivors
reach out through volunteer work to help others who suffer similar traumas.

Crisis Intervention
Crisis intervention is an action-oriented model that is present-focused, with the objective for the
intervention being specific to the hazardous event, situation, or problem that precipitated the state of
crisis. When confronted by a person in crisis, clinicians need to address that person's distress,
impairment, and instability by operating in a logical and orderly process (Greenstone & Leviton,
2002). Crisis intervention now evolved into a specialty mental health field that stands on its own.
Based on a solid theoretical foundation and a praxis that is born out of over 50 years of empirical and
experiential grounding, crisis intervention has become a multidimensional and flexible intervention
method.

Goal of Crisis intervention

As proposed by Lydia Rapoport, crisis intervention is guided by six primary goals, all aimed at
stabilizing and strengthening family functioning. These goals are to:

• relieve the acute symptoms of family stress;

• restore the family and family members to optimal pre-crisis levels of functioning;
• identify and understand the relevant precipitating event(s);
• identify remedial measures that the family can take or that community resources can provide
to remedy the crisis situation;
• establish a connection between the family’s current stressful situation and past experiences;
• initiate the family’s development of new ways of perceiving, thinking, and feeling, and
adaptive coping responses for future use.

Theories of Crisis Intervention

. Crisis intervention is relatively new compared to other forms of therapy. Therefore, crisis theory is
still being developed. Intervention specialists have begun to make connections between the underlying
emotions and circumstances that are common in crisis intervention, no matter what kind of trauma is
causing the crisis. Some of the theories that are developing include:

• Systems crisis theory, which states that all crises have to do with the relationships people
have with one another or their relationship to a traumatic event
• Adaptational theory, which implies that a person who can change their negative attitude
toward a situation can overcome their crisis
• Interpersonal theory, which encourages people to gain personal control of a situation rather
than relying on others for support or validation
• Ecological theory, which deals with crises on a massive scale, usually resulting from a
natural disaster, and considers the impact of the crisis on people as well as their environment

Different models of crisis intervention

In conceptualizing the process of crisis intervention, Roberts (1991, 2000, 2005) has identified seven
critical stages through which clients typically pass on the road to crisis stabilization, resolution, and
mastery
Stage I: Psychosocial and Lethality Assessment
The crisis worker must conduct a swift but thorough biopsychosocial assessment. At a minimum, this
assessment should cover the client's environmental supports and stressors, medical needs and
medications, current use of drugs and alcohol, and internal and external coping methods and resources
(Eaton & Ertl, 2000). One useful (and rapid) method for assessing the emotional, cognitive,
and behavioral aspects of a crisis reaction is the triage assessment model (Myer, 2001; Myer,
Williams, Ottens, & Schmidt, 1992, Roberts, 2002).

Assessing lethality, first and foremost, involves ascertaining whether the client has actually initiated a
suicide attempt, such as ingesting a poison or overdose of medication. If no suicide attempt is in
progress, the crisis worker should inquire about the client's "potential" for self-harm. This
assessment requires

• asking about suicidal thoughts and feelings (e.g., "When you say you can't take it anymore, is
that an indication you are thinking of hurting yourself?");
• estimating the strength of the client's psychological intent to inflict deadly harm (e.g., a hotline
caller who suffers from a fatal disease or painful condition may have strong intent);
• gauging the lethality of suicide plan (e.g., does the person in crisis have a plan? how feasible is
the plan? does the person in crisis have a method in mind to carry out the plan? how lethal is
the method? does the person have access to a means of self-harm, such as drugs or a firearm?);
• inquiring about suicide history;
• taking into consideration certain risk factors (e.g., is the client socially isolated or depressed,
experiencing a significant loss such as divorce or layoff?).

With regard to imminent danger, the crisis worker must establish, for example, if the caller on the
hotline is now a target of domestic violence, a violent stalker, or sexual abuse.

Rather than grilling the client for assessment information, the sensitive clinician or counselor uses an
artful interviewing style that allows this information to emerge as the client's story unfolds. A good
assessment is likely to have occurred if the clinician has a solid understanding of the client's
situation, and the client, in this process, feels as though he or she has been heard and understood.
Thus, it is quite understandable that in the Roberts model, Stage I—Assessment and Stage II—Rapidly
Establish Rapport are very much intertwined.

Stage II: Rapidly Establish Rapport

Rapport is facilitated by the presence of counselor-offered conditions such as genuineness, respect,

and acceptance of the client (Roberts, 2005). This is also the stage in which the traits, behaviors, or
fundamental character strengths of the crisis worker come to fore in order to instill trust and
confidence in the client. Although a host of such strengths have been identified, some of the most
prominent include good eye contact, nonjudgmental attitude, creativity, flexibility, positive mental
attitude, reinforcing small gains, and resiliency.

Stage III: Identify the Major Problems or Crisis Precipitants

Roberts (2005) suggested not only inquiring about the precipitating event (the proverbial "last straw")
but also prioritizing problems in terms of which to work on first, a concept referred to as "looking for
leverage" (Egan, 2002). In the course of understanding how the event escalated into a crisis, the
clinician gains an evolving conceptualization of the client's "modal coping style"—one that will likely
require modification if the present crisis is to be resolved and future crises prevented.

Stage IV: Deal with Feelings and Emotions

There are two aspects to Stage IV. The crisis worker strives to allow the client to express feelings, to
vent and heal, and to explain her or his story about the current crisis situation. To do this, the crisis
worker relies on the familiar "active listening" skills like paraphrasing, reflecting feelings, and probing
(Egan, 2002). Very cautiously, the crisis worker must eventually work challenging responses into the
crisis-counseling dialogue. Challenging responses can include giving information, reframing,
interpretations, and playing "devil's advocate." Challenging responses, if appropriately applied, help to
loosen clients' maladaptive beliefs and to consider other behavioral options. For example, in our
earlier example of the young woman who found boyfriend and roommate locked in a cheating
embrace, the counselor at Stage IV allows the woman to express her feelings of hurt and jealousy and
to tell her story of trust betrayed. The counselor, at a judicious moment, will wonder out loud
whether taking an overdose of acetaminophen will be the most effective way of getting her point
across.

Stage V: Generate and Explore Alternatives

This stage can often be the most difficult to accomplish in crisis intervention. Clients in crisis, by
definition, lack the equanimity to study the big picture and tend to doggedly cling to familiar ways of
coping even when they are backfiring. However, if Stage IV has been achieved, the client in crisis has
probably worked through enough feelings to re-establish some emotional balance. Now, clinician and
client can begin to put options on the table, like a no-suicide contract or brief hospitalization, for
ensuring the client's safety; or discuss alternatives for finding temporary housing; or consider the pros
and cons of various programs for treating chemical dependency. It is important to keep in mind that
these alternatives are better when they are generated collaboratively and when the alternatives selected
are "owned" by the client.

The clinician certainly can inquire about what the client has found that works in similar situations. For
example, it frequently happens that relatively recent immigrants or bicultural clients will experience
crises that occur as a result of a cultural clash or "mismatch," as when values or customs of the
traditional culture are ignored or violated in the United States. For example, in Mexico the custom is
to accompany or be an escort when one's daughter starts dating. The United States has no such
custom. It may help to consider how the client has coped with or negotiated other cultural mismatches.
If this crisis precipitant is a unique experience, then clinician and client can brainstorm alternatives—
sometimes the more outlandish, the better—that can be applied to the current event. Solution-focused
therapy techniques, such as "Amplifying Solution Talk" (DeJong & Berg, 1998) can be integrated into
Stage IV.

Stage VI: Implement an Action Plan

Here is where strategies become integrated into an empowering treatment plan or co-ordinated
intervention. Jobes, Berman, and Martin (2005), who described crisis intervention with high-
risk, suicidal youth, noted the shift that occurs at Stage VI from crisis to resolution. For these suicidal
youth, an action plan can involve several elements:

• removing the means—involving parents or significant others in the removal of all lethal
means and safeguarding the environment;
• negotiating safety—time-limited agreements during which the client will agree to maintain
his or her safety;
• future linkage—scheduling phone calls, subsequent clinical contacts, events to look forward
to;
• decreasing anxiety and sleep loss—if acutely anxious, medication may be indicated but
carefully monitored;
 • decreasing isolation—friends, family, neighbors need to be mobilized to keep ongoing
contact with the youth in crisis;
• hospitalization—a necessary intervention if risk remains unabated and the patient is unable to
contract for his or her own safety (see Jobes et al., 2005, p. 411).

Obviously, the concrete action plans taken at this stage (e.g., entering a 12-step treatment program,
joining a support group, seeking temporary residence in a women's shelter) are critical for restoring
the client's equilibrium and psychological balance. However, there is another dimension that is
essential to Stage VI, as Roberts (2005) indicated, and that is the cognitive dimension. Thus,
recovering from a divorce or death of a child or drug overdose requires making some meaning out of
the crisis event: why did it happen? What does it mean? What are alternative constructions that could
have been placed on the event? Who was involved? How did actual events conflict with one's
expectations? What responses (cognitive or behavioral) to the crisis actually made things worse?
Working through the meaning of the event is important for gaining mastery over the situation and for
being able to cope with similar situations in the future.

Stage VII: Follow-Up

Crisis workers should plan for a follow-up contact with the client after the initial intervention to
ensure that the crisis is on its way to being resolved and to evaluate the postcrisis status of the client.
This postcrisis evaluation of the client can include

• physical condition of the client (e.g., sleeping, nutrition, hygiene);

• cognitive mastery of the precipitating event (does the client have a better understanding of
what happened and why it happened?);
• an assessment of overall functioning including, social, spiritual, employment, and academic;
• satisfaction and progress with ongoing treatment (e.g., financial counseling);
• any current stressors and how those are being handled;
• need for possible referrals (e.g., legal, housing, medical).

Follow-up can also include the scheduling of a "booster" session in about a month after the crisis
intervention has been terminated. Treatment gains and potential problems can be discussed at the
booster session. For those counselors working with grieving clients, it is recommended that a follow-
up session be scheduled around the anniversary date of the deceased's death (Worden,2002). Similarly,
for those crisis counselors working with victims of violent crimes, it is recommended that a follow-up
session be scheduled at the 1-month and 1-year anniversary of the victimization

Seven-stage crisis intervention model is effective when dealing with a diverse

population, and whendealing with traumatic situations. This model adapts easily to different level of
crisis and to different timeframes for intervention.

The ACT model Is a conceptual three-stage framework and intervention model.

The ACT crisis intervention model was also developed by Albert Roberts. He established the model
in response to the September 11th tragedy to offer a framework for crisis intervention specialists to
improve the service they provide patients experiencing trauma.

The ACT model of crisis intervention combines Robert’s seven-step method and the ten-step method
of Lerner and Shelton. It uses three steps to identify and address an individual’s crisis:
 A) Assessment

C) Crisis Intervention

T) Trauma Treatment

A: Assessment/appraisal of immediate medical needs, threats to public safety and property damage-
Triage assessment, crisis assessment, trauma assessment, and the biopsychosocial and cultural
assessment protocols

C: Connecting to support groups, the delivery of disaster relief and social services, and critical
incident stress debriefing-Crisis intervention implemented through a strengths perspective and coping
skills bolstered

T: Traumatic stress reactions and posttraumatic stress disorders -Ten step acute trauma and stress
management protocol, trauma treatment plans, and recovery strategies implemented

Gilliland’s Six-Step Model

Gilliland’s Six-Step Model, which includes three listening and three action steps, is a useful crisis
intervention model. Attending, observing, understanding, and responding with empathy, genuineness,
respect, acceptance, nonjudgment, and caring are important elements of listening. Action steps are
carried out in a nondirective and collaborative manner, which attends to the assessed needs of clients
as well as the environmental supports available to them (James & Gilliland, 2005).

• Defining the problem

• Ensuring client safety & providing support
• Action
• Examining alternatives
• Making plans
• Obtaining commitment

SAFER-R Model

The SAFER-R model of crisis intervention is one of the most commonly used. It relies on the
same principles as the other models but outlines them in a more concise manner. The
acronym SAFER-R stands for:
 S) Stabilize

A) Acknowledge

F) Facilitate understanding

E) Encourage adaptive coping

R) Restore functioning

R) Refer

Lerner and Shelton’s 10 Step Acute Stress & Trauma Management Protocol

The American Academy of Experts in Traumatic Stress (ATSM) is a group of professionals who
provide emergency responders with protocols on how to deal with traumatic events. In 2001, the
president of ATSM, Dr. Mark Lerner, and the director of emergency medical training at a police
academy, Dr. Raymond Shelton, developed a 10 Step Acute Stress & Trauma Management
Protocol for emergency responders to use. The ten steps are:

1. Assess for danger/safety of self and others. Assess if the patient affected by the trauma,
people in the patient’s life or the counsellor themselves are in danger.
2. Consider the mechanism of injury. Determine how the trauma physically or mentally
caused harm to the person.
3. Evaluate the level of responsiveness. Consider if the person is under the influence of any
substance.
4. Address medical needs. Tend to any medical needs present.
5. Observe and identify. Identify the signs of the patient’s traumatic stress.
6. Connect with the individual. After the assessment is complete, the counsellor introduces
themselves and begins to build rapport with the patient.
7. Ground the individual. Discuss the facts and have the client tell their story of the trauma.
8. Provide support. Be empathetic and actively listen.
9. Normalize the response. Validate their response to the trauma and assure them that a return
to normalcy is possible.
10. Prepare for the future. Review the event, anticipate events in the future and provide
referrals.]
ABC Model

The ABC model of crisis intervention is a combination of various crisis counselling experts’ methods
of intervention. It was refined and expanded by Kristi Kanel, who published a book describing the
model in 2014. The ABC model includes:

A) Establishing and maintaining rapport. The counsellor makes an effort to build a state of
trust with the client that allows them to open up and tell the truth about how they are feeling.

B) Identifying the problem. The counsellor uses a series of questions to understand how the
crisis event occurred, the client’s perception of the event, what emotional distress the client is
experiencing in response and how the client is presently functioning.

C) Coping. The counsellor develops a plan with the client to help them cope with their
situation. This includes assessing how they are currently coping and what they can do to
better cope in the future.

Crisis intervention Vs traditional counselling;

There are many differences between traditional counselling and crisis intervention.
However, the overall differences rest in purpose, setting, time, and intervention plan. It
is crucial for professionals to understand the purpose of crisis counselling, as it differs
from that of traditional counselling, in order to intervene appropriately. Simply, the goal
of traditional counselling is to increase functioning, whereas the goal of crisis counselling
is to decrease suffering and increase stabilization in order to refer the client on for longer-
term counselling.

Treatment Planning Differences Between Traditional Counselling and Crisis Intervention

Treatment Plan Traditional Counselling Crisis Intervention
Component

Purpose Increase functioning. Decrease suffering; increase

stabilization.

Referral Source and
Reason
Presenting Problem
and Prioritized List of
All Problems
Indicate who sent the client to
therapy and why the client is
in counselling.
Define the main problem that
the client is experiencing.
Same as traditional
counselling, but indicate if
such reason for referral is due
to a crisis or is a temporary
situation.
Typically, the presenting
problem is the crisis, although
it is important to determine
what issues may have led up to

Working Diagnosis The clinician will develop a
DSM or ICD based diagnosis.
Goals and Objectives The clinician and the client
will develop short-term and
long-term goals and objectives
to make progress in therapy.
These goals and objectives
must be stated in practical and
measurable terms.
Treatment Strategies The clinician will indicate
and Interventions specific theory-driven
strategies and interventions to
progress toward positive
outcomes in treatment. Such
strategies and interventions
should correspond to the
established goals and
objectives.
Client Strengths The clinician and the client
will develop a list of the
client’s strengths.
Possible Barriers to The clinician and the client
Treatment will develop a list of general
events, situations, people, etc.,
that may negatively interfere
with treatment.
the crisis. The clinician must
also contextualize and triage
client problems even though
the client may not see them as
significant. For
example, if the client is
depressed but becomes
suicidal when the depression
increases, the clinician would
view suicide as more pressing
than the depression.
Same as traditional counselling
but more of a rapid crisis
assessment that may require
symptomology to be triaged.
Specific attention will also be
brought to those diagnoses that
contribute to suicide, crisis and
spontaneity (e.g., Substance
Abuse, Borderline Personality
Disorder, Anxiety Disorders,
Mood Disorders).
Same as traditional
counselling, but more short-
term goals and objectives will
typically be indicated when a
crisis occurs.
Same as traditional counselling
but include issues of crisis
assessments, issues of safety
and possible supervision, and
the client’s readiness to change
his/her ability to handle crisis.
Same as traditional
counselling, but specifically
include client protective
factors and strengths that will
facilitate coping with crisis
circumstances.
Same as traditional
counselling, but specifically
indicate events, situations,
people, etc., that are not to be
initiated when a crisis occurs.
For example, typically cousin
Sally is a good resource and

Referral for The clinician will indicate
Evaluation what assessments are needed
to assist the progression of
treatment and what outside
resources need to be consulted.
Criteria for Ending Typically, termination criteria
Treatment will involve a significant
decrease in the presenting
problem symptoms.
Often, a formal termination
process is the protocol and is
explained during the initial
visit. Termination is completed
after issues have been resolved
or after a referral is made that
allows for closure.
Responsible Staff Indicate what staff are
involved in treatment and
include their responsibilities.
listens to problems, but she
does not provide the client
with what is needed when
upset.
Same as traditional
counselling, but also provide
specific assessments for crisis,
protective factors, and other
resources that may relieve
crisis situations. For example,
if a client is in crisis because
he or she lost his or her job, a
career counsellor may be
warranted. Referrals are used
more often, since the crisis
symptoms may mask the
actual presenting issue, which
may warrant a person with
specialized training.
Priority is to decrease the
symptoms associated with the
presenting problem and
then refer the client to long-
term counselling. Termination
often occurs due to referring
the client to another
professional. Appropriate
termination and closure are
often missing in crisis
counselling, since the problem
may not be reconciled at this
point.
Same as traditional counselling
but include specific individuals
and agencies to contact in
crisis situations. Team
approach utilizes numerous
professionals to address the
symptoms and issues related to
the crisis.

Types of crisis intervention Techniques used during crisis

Crisis hotlines
Crisis or suicide hotlines offer immediate support to individuals in acute distress. Since they are
usually anonymous, individuals in difficulty may find themselves less embarrassed than in face-to-
face interaction. Most hotlines are staffed by volunteers supervised by mental health professionals.
Suicidal callers are provided with information about how to access mental health resources in the
community and are encouraged to seek them and to feel hope. Further, some centers will arrange
referrals to clinicians. Typically, crisis hotlines do not offer therapy directly. If a volunteer feels a
caller is at immediate risk, however, confidentiality will be suspended and a mental health worker will
be called to intervene. Although crisis hotlines are numerous, whether they effectively reduce suicide
has not clearly been demonstrated. (Gould, S., et al. “Helping Callers to the National Suicide
Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and
Interventions Implemented.” Suicide and Life-threatening Behavior, August 4, 2015.) Some
researchers fear that the people who call may not be those at highest risk. For many centers a small
fraction of callers appears to represent a large fraction (estimated up to 50%) of the total phone
contacts. A further problem is that there appears to be significant discrepancies in the training of
telephone operators at these hotlines.

Community-based crisis intervention

Hospital-based crisis intervention usually refers to the treatment of people with psychiatric
emergencies that typically arise during a crisis. The aim of this type of crisis intervention is usually
the stabilization of some type of extreme behaviour. Professionals regard patients who are suicidal,
homicidal, extremely violent, or suffering from severe adverse drug reactions or psychotic disorders
as major psychiatric emergencies. In the United States, when individuals appear to represent imminent
danger to themselves or others, they may be admitted to hospital inpatient treatment against their will
for a brief period (e.g., 72 hours). In Canada, one may be involuntarily committed and never receive
treatment. When treatment is administered, however, it is usually in the form of psychotropic drugs
with follow-up outpatient therapy scheduled upon release.

Critical Incident Stress Debriefing (CISD)

Critical incident stress management, also known as debriefing, was developed with the
intention of preventing the development of psychopathology, especially PTSD, after a
potentially traumatic event (Rose et al., 2002). It was developed in 1974 by Dr. Jeffrey Mitchell, a
former firefighter and paramedic, as one component of a broader critical incident stress management
(CISM) program. The debriefing process is recommended to be implemented within the first
24–72 hours after a traumatic event, and the core component is the recounting and emotional
processing of the event. (Rose et al., 2002). However, a systematic review of the literature
found that not only did debriefing not prevent PTSD, it had some potential to be actually
harmful to participants (Rose et al., 2002).

CISD is a structured, one-session group intervention in which survivors' experiences

and emotional reactions are discussed and education and follow-up recommendations are provided.
The usual practice is for the debriefer to provide educational information about stress management
and the normal psychological/physiologic response to acutely stressful situations. Although it is
common for group participants to express profound feelings about an incident they have witnessed or
experienced, CISD is not a group psychotherapy session. Feelings expressed are acknowledged but
not probed by the group leader.
When properly structured and facilitated, these sessions result in participants feeling that they are
experiencing normal reactions to an abnormal event and have the tools needed to manage their stress.
In some cases, CISD affords the debriefer the opportunity to identify individuals who need follow-up
assistance such as referral for psychotherapy.
The formal CISD process consists of seven standard phases:

Step 1: Assess the Critical Incident

The initial stage of CISD primarily involves the team leaders. The people conducting the program
carefully consider the specific situation and the people involved in order to tailor each step precisely
to the needs of the group. When the participants join, team members introduce themselves, explain the
process, and set guidelines.

Step 2: Identify Safety & Security Issues

In this stage, participants are encouraged, but never forced, to open up and provide a brief, factual
account of the event from their own point of view. This is a safe discussion that does not dive into
details or emotions. The purpose of step two is to help people feel safe, reduce anxiety, provide a
sense of personal control, and encourage discussion.

Step 3: Allow Venting of Thoughts, Feelings, & Emotions

This stage begins by talking about what people think about the critical incident. A typical question is,
“What was your first thought or your most prominent thought once you realized you were
thinking?”1 This is done as a group go-around, with each person getting the chance to share. The
discussion transitions from thoughts to feelings and emotions. It’s important that venting and
validation occur so people can share their emotions in a safe, supportive environment.

Step 4: Share Emotional Reactions

This phase is the heart of CISD and focuses on the event’s impact on the participants. Participants can
answer questions such as:

• “What was the worst thing about this event for you personally?”
• “If you could erase one part of the situation, what would you erase?”
• “What aspects of the situation cause you the most pain?”

Through discussion, participants not only process the event but begin to prepare and plan for the
immediate and long-term future. While it is highly focused on reactions and impact, the sharing is less
structured than in the other stages. Each participant is allowed the chance to participate and share
concerns. The discussion continues until all emotions or other issues have been addressed. This stage
helps reduce chronic crisis reactions and returns a sense of control to the participants.

Step 5: Review Symptoms & the Incident’s Impact

During this segment, participants explore and express their symptoms and the effect the incident is
having on them. Leaders might ask, “How has this tragic experience shown up in your life?” or “What
cognitive, physical, emotional, or behavioural symptoms have you been dealing with since this
event?”1 This stage helps spot potential problems with coping and identify people who may need
additional support.

Step 6: Teach & Bring Closure to the Incident

This educational phase helps participants understand their symptoms and effects. It helps them know
that their reactions are a normal response to traumatic events. Leaders provide stress management
tools and other information tailored to the exact incident and specific group involved. This phase
helps people centre themselves and feel more grounded and stable.

Step 7: Assist in Re-Entering the Workplace/Community

As the session draws to a close, leaders review and summarize what has been discussed and learned.
Sometimes, handouts are provided that offer information, resources, and action steps. Participants
have the opportunity to ask questions and make any final statements. The purpose is to help
participants move forward into their deeper healing and recovery process.

What to Expect During CISD Sessions

Critical incident stress debriefing is designed to allow people to talk about the traumatic event
and how it is affecting them. It relies heavily on participants sharing their descriptions,
thoughts, and feelings. It is a safe, non-threatening environment, and while everyone is gently
encouraged to participate actively, no one is ever forced to do so. 1 Everything discussed
during the session is considered confidential.

This intervention is relatively quick, lasting approximately one to three hours depending on
the size of the group and intensity of the critical incident. While CISD is often conducted as a
single session, sometimes groups may meet a few times over the span of several days. The
debriefing process is recommended to be implemented within the first 24–72 hours after a traumatic
event, and the core component is the recounting and emotional processing of the event. It was very
popular for a time and was often made available for both civilians and first responders after large
scale traumatic events; sometimes, it was even mandatory (Rose et al., 2002). However, a systematic
review of the literature found that not only did debriefing not prevent PTSD, it had some potential to
be actually harmful to participants (Rose et al., 2002). The authors theorized that while exposure is an
effective treatment for PTSD, to be discussed more fully later in this article, a single session
intervention such as debriefing does not allow time for habituation and thus, instead may retraumatize
the person and leave them without continued support (Rose et al., 2002).

Is CISD effective?

• FEMA conducted a 3-year study, reported in 2002, to determine the effectiveness of CISD for
firefighters. Across the study, 264 people completed a CISD intervention and 396 did not.
Researchers analysed mental health issues such as depression, anxiety, PTSD, and coping
skills and found no evidence to support the effectiveness of CISD on mental health of
firefighters experiencing traumatic events. (Harris et al.)

• The American Red Cross conducted a study review to determine whether CISD should be
recommended for responders after a traumatic event. Reviewers initially examined studies
conducted between 1966 and 2010 and then re-examined them later, this time emphasizing
studies conducted in 2006 and beyond and analysing them for evidence in favour of and
against CISD. They discovered no significant evidence that CISD is effective in reducing the
risk of PTSD and found that CISD can cause harm by increasing symptoms in people who
didn’t previously experience them and worsening symptoms in those who were vulnerable.
Thus, the Red Cross concluded that CISD should not be used for responders after a traumatic
event.

Risks of Critical Incident Stress Debriefing

Critics of critical incident debriefing argue that it could increase PTSD symptoms due to the intense
recall and personal descriptions expressed so soon after the event. (Mitchell, J.T) There is also some
concern that without proper screening prior to delivery, it may be given to people who either aren’t
distressed about the incident or are too distressed for a group intervention involving shared thoughts
and feelings, thus causing or worsening symptoms.

Additionally, one risk is that some people may think that CISD is enough and fail to reach out for
further help. If it is offered in isolation rather than as part of a larger CISM effort, people aren’t likely
to receive ongoing support and active interventions to further reduce negative mental health
symptoms.
Prominent criticism include:

• Although clear benefits of CISM are still debatable according to the research, (Tracy
E. Wimbush, Christo C. Courban, in Disaster Medicine, 2006) there are definite pitfalls to
avoid when dealing with the psychological impact of disasters:
• Failure to recognize that everyone has some type of emotional response to disaster and
providing support only to those exhibiting the most obvious or dysfunctional responses

• Evaluation and treatment of medical and surgical injuries without acknowledging the
psychological ramifications of a disaster event

• Failing to recognize early warning signs of poor emotional coping; CISM is often an
afterthought to the initial response

• Using CISD as a stand-alone intervention rather than as a single element of the CISM plan

• Having poorly trained or untrained individuals lead CISM efforts

• Some investigations of CISD suggest that counsellors should be more cautious about its use.
Some observers maintain that having people focus on the upsetting event emphasizes the
victimization that has already taken place, rather than people's innate abilities to overcome
these challenges. In other words, CISD may make people feel worse by making them question
their own coping abilities. Some studies of the use of CISD in schools following school
shootings suggest that CISD may be more effective for adults than for adolescents or children.
These studies serve as reminders that a particular psychological intervention may require
further research and modification if necessary.

The Future of Crisis intervention stress model

The critical incident stress field remains a dynamic entity in which improvements and refinements are
made as experience in the field is gained. A high degree of flexibility is incorporated into
the CISM training protocols so that the emergency personnel who provide CISM support services are
able to respond quickly and efficiently to new demands that may arise in the midst of actual traumatic
events.
The last four decades have been fruitful in developing critical incident stress concepts, policies,
training programs, protocols, procedures, strategies, and effective tactics. Additionally, a considerable
number of research projects have offered insights into what is working and why certain procedures are
viewed as helpful for people struggling through critical incident stress reactions.
The future of the critical incident stress field lies in additional research and continued developments
and refinements within the field. Each new research project opens an additional window that allows
crisis support personnel to see their interventions more clearly and to determine what new directions
may be necessary to serve their constituents. It is likely that future research will demonstrate that the
very same principles that have guided the critical incident stress field to date will serve as a
foundation for future progress.
Emergency personnel are the beneficiaries of the widespread support and assistance that is currently
provided through the organized CISM programs that serve them in many communities nationally and
internationally. CISM services reduce sick time utilization, disabilities, and premature retirements
among emergency personnel. These programs enhance personal resistance, resiliency, and the
capacity to recover fairly quickly from overwhelming traumatic events.( J.T. Mitchell, in Stress:
Concepts, Cognition, Emotion, and Behaviour, 2016)

NEED FOR COLLABORATION BETWEEN HELPING PROFESSIONALS DURING

CRISIS

Professional counsellors, psychologists, and social workers are grouped in one category because each
profession can provide short-term or long-term therapy and individual or group therapy. Each state
may allow for a differing scope of practice. For example, some states may allow professional
counsellors to diagnose and treat mental and emotional disorders, while others may not allow this.

These professionals can be helpful in crisis situations by

• Assisting clients in gaining insight into the ways crisis affects their life in a cognitive, behavioural,
and emotional manner over a lengthy period of time.

• Providing specific treatment goals and objectives related to crisis.

• Monitoring and assessing the magnitude of severity of a crisis situation.

• Providing insight into co-occurring mental and emotional disorders and crisis

(e.g., showing a client diagnosed with bipolar disorder how to cope with and monitor crisis).

• Providing specific crisis intervention strategies during a crisis and over a period of time.

• Providing clients in crisis with resources and preventative measures.

• Assisting in alleviating symptoms associated with the crisis.

• Preparing clients to handle future crises.

Some professional counsellors, psychologists, and social workers may specialize in a particular area
that would contribute to helping individuals in crisis.

For example:

• Marriage and family therapists provide support for couples and families and may involve the family
in the resolution of the crisis on a short- and long-term basis.

• Chemical dependency counsellors specifically address the use of drugs and alcohol as a coping
mechanism during crisis.

• Counsellors or psychologists who specialize in treating children, adolescents, adults, or geriatric

populations could specifically address the crisis needs of individuals at a specific age.

Psychiatrists: According to the American Psychiatric Association (2008), psychiatrists are physicians
who have obtained specific training and experience in treating mental and emotional disorders.
Psychiatrists are especially suited to triaging direct and indirect victims in various settings such as,
emergency rooms, intensive care and burn units, general medical floors or inpatient psychiatry units.

Hotline Workers: Hotline workers are often the first point of contact for many individuals
experiencing a crisis resulting from suicidal and homicidal ideation, domestic violence, substance
abuse, and sexual assault. There are hotlines that specialize in specific crisis situations such as those
mentioned previously. There are even crisis hotlines for specific age groups (e.g., a hotline dedicated
to teen callers). Typically, hotline workers are not mental health professionals but volunteers who
have undergone specific training in responding to crises. No matter what their focus, crisis hotlines
play a vital role in assessing, intervening in, and preventing the occurrence of crises (Seeley, 1995).
Crisis hotline workers are essential during a crisis situation to

• Assess the severity of the crisis situation and the lethality of the caller.

• Provide immediate crisis intervention to the caller in an attempt to deescalate the crisis. This is
critical in a crisis situation because the caller does not have to make an appointment with a
professional or wait to get help. Most hotlines are 24-hour services open 365 days a year.

• Provide resources to the caller that may help resolve the crisis (see Table 1.2 for a sample of national
toll-free hotlines that serve those in crisis).

Understanding crisis situation for children:

There are five types of situations or events that may produce stress in children and in turn, contribute
to a state of crisis:

Family Situations—Child abuse, spouse abuse, an unplanned pregnancy, a parent’s desertion, a

chronically ill family member, and lack of social supports are examples of family situations that can
create stress and crises.

Economic Situations—sudden or chronic financial strain is responsible for many family crises, such
as loss of employment, a theft of household cash or belongings, high medical expenses, missed child
support payments, repossession of a car, utilities cut off from service, money “lost” to gambling or
drug addiction, and poverty.

Community Situations—Neighbourhood violence, inadequate housing, a lack of community

resources, and inadequate educational programs illustrate some ways the community may contribute
to family crises.

Significant Life Events -A child enrolling in school, the behaviours of an adolescent, a grown child
leaving the home, or the death of a loved one can also be very stressful life events.

Natural Elements - crises are created by disasters such as floods, hurricanes, fires, and earthquakes,
or even extended periods of high heat and humidity, or gloomy or excessively cold weather.

Parents with Chronic Coping Problems - Many families do not have experience in solving
problems well. Rather, they seem to have continual difficulties in several areas of their life. Indicators
distinguishing the two types of families—those in acute crisis and those in chronic crisis—are
presented in exhibit I.
 Professional school counsellors play a vital role in a comprehensive crisis leadership team (Kerr,
2009) and are key figures in a school building who provide leadership to the school through advocacy
and collaboration. They work to maximize student achievement and also to “promote equity and
access to opportunities and rigorous educational experiences for all students” as well as helping to
facilitate “a safe learning environment and work to safeguard the human rights of all members of the
school community” (American School Counsellor Association, 2008, p. 2). School counsellors
frequently accomplish these goals by providing preventative and substantive programs that are
imbedded in a comprehensive school counselling program.

Given their unique role, school counsellors can be helpful in school crisis situations by using
individual counselling, group counselling and classroom guidance Providing group counselling to
those who have been exposed to crises (e.g., by establishing a support group for students who have
divorced parents) could ease the pain of the initial impact of the crisis and create a support network
among the group members. School counsellors could also provide classroom guidance activities such
as these:

• Preventative programs via classroom guidance activities on crisis, suicide, handling stress,
communication skills, expressing frustration, and the like, which are seen as ways to prevent crises
from occurring.

• Working with families and individuals in the Parent Teacher Organization on ways to prevent,
respond to, intervene in and manage crisis. This will help parents provide supportive care that is
congruent with what their children are learning in school.

• Collaborating with teachers, staff, principals, superintendents, and other school personnel on
preventing and responding to crisis (e.g., by providing school staff with materials and training on
recognizing suicidal behaviour).

Limitation of crisis intervention

Crisis Intervention Is Not a Substitute for Therapy

Crisis intervention only addresses the immediate emergency and is not a substitute for therapy
services. While most crisis hotlines are free to use, it can be difficult for people in rural areas or those
with low income to access and afford ongoing treatment and support. Crisis intervention is a tool, but
no one tool can fix everything. People need access to a variety of resources in order to get the support
that they need.

Crisis Responders May Not Know How to Deal with Every Situation

Not all crisis resources are created equal. Responders do not need an advanced degree or licensure in
order to provide crisis intervention. This makes crisis intervention accessible, as responders can be
trained quickly. However, responders might not feel equipped to manage a client’s needs or have the
knowledge to make appropriate referrals. This occurs most frequently with suicidal clients and can
lead to the client not getting appropriate follow-up care. (Gould MS et al.)
Help Is Limited If a Client Remains Anonymous

Finally, some crisis hotlines allow users to be anonymous. While this can help clients feel more
comfortable sharing, this means that the responder cannot verify their location or put them in touch
with emergency services if the need arises.

Challenges in handling crisis intervention:

Training requirements -The success or failure of crisis intervention depends primarily on the
expertise of crisis workers in a variety of areas.

Preventing burn out - The rates of burnout in mental health professionals have increased in recent
years. Across several studies, it’s been found that 21% to 67% of mental health workers have
experienced high levels of burnout (Morse G. et al.) which leads to decreased empathy, critical, poor
work performance, often disconnected, loss of purpose related to the job and ending up failure to
crisis management.

Ethical and Professional Issues. Jordan (2010) have stated that making an ethical decision in crisis
are compulsory because of its critical and demanding nature of crisis counselling. Therefore, each of
crisis counsellors or helpers should be aware of the local practitioner code of ethics and routinely
practice ethical decision making. Multicultural competences can be challenging as crisis counsellors
or helpers should be sensitive to various cultural norms and behaviours in helping clients work
through the crisis. Counsellors should be aware the differences of culture might lead to different
views. Awareness of various cultures, ethnic, religious and gender issues can be helpful. Therefore, it
is a necessity that crisis counsellors refraining themselves from imposing personal values on clients
(considered unethical). If they fail to respect differences, the crisis interventions may end up as a
failure. practice (Kanel, 2012).

Religion. The data shows that many respondents (counsellors) having difficulty in handling crisis
intervention when they are facing victims from different religions. Some of the respondents stated
that: “.... the victims seem to lost hope and blame the deity for the situations that they are facing...”
This kind of statement made the counsellors feels challenged since clients seems to lost hope and put
the blames on God. Most of the respondents agreed that is challenging when it comes to religions
differences. The respondents also stated that as counsellors they need to have more knowledge about
other religions so that they could overcome the challenge and could help the victims without having
difficulty for having different religions. (Ns Ahmad)

Culture. The results of this research also showed that most of the respondent stated that the other
challenge in handling crisis interventions is culture. “...different culture comes from different family
background. Each of them has their own house rules...” The respondents stated that even families
have their own culture and it affected the way they perceived the crisis situations. The other statement
given by the respondents is that the helpers understanding towards the culture of the victims is also
important. “...the understanding of the differences culture between counsellor and victims is
important.” Most of them agreed that they are having multicultural challenged in handling crisis
interventions and admitted that they need to have better knowledge and understanding regarding other
culture. (Ns Ahmad)

Belief. Respondents stated that helpers tend to be biased and having different beliefs from victims.
They clarify that, beliefs also mean trust that needs to be gain from victims. In crisis situation trust is
one of the important elements to gain from victim before helpers can start the crisis intervention.
“...helpers perceptions tend to be biased based on gender...” There are helpers that might tend to be
biased in terms of belief when it comes to different gender. “.... the challenges to build trust in
clients...” The respondent seems to have difficulty in building trusted relationships between the
victims and the helpers. Some of the victims having trust issues towards the counsellors and this could
interfere with the crisis interventions. “...challenged the helper’s beliefs in handling crisis
interventions to make sure they trust themselves.” Some other respondents stated that the challenged
is from the inside the counsellors themselves. The counsellors need to be sure and have faith in
themselves in order to handle the crisis interventions. These are including acknowledging their
limitations towards the crisis situations. (Ns Ahmad)

Value. Having different values also been stated as one of the challenges faced by respondents in
handling crisis interventions. “...there are conflicts between the counsellors and the clients value.” The
victims tend to feels that they are at lost and might feel that nothings left for them, meanwhile the
counsellors might not have same issues but they told them that they understand the situations. This
makes the victims feel that the counsellors failed to understand or empathized their values as the crisis
did not happen to the counsellors themselves. “...clients tend to be worried towards others perception
when attending counselling session with counsellors.” This statement also means the stigma or the
values from the society itself towards the victims that needs crisis interventions. (Ns Ahmad)

Others. Besides having the challenges as stated, there are other challenges in handling crisis
interventions such as mental illness issues, time constraints, language barriers, confidentiality, level of
educations.

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