Crisis Intervention and Trauma Response : Theory and Practice [1 ed.] 9780826196941, 9780826111753

Citation preview

Crisis Intervention and Trauma Response

Barbara Rubin Wainrib, MSc, EdD, is a clinical psychologist and psychotherapist in private pracrice in Montreal, She is also part-time Associate Professor in the Graduate Department of Educational and Counselling Psychology at McGill University, where she teaches courses in both crisis intervention/trauma response as well as psychosocial oncology. She has also taught workshops through the Continuing Education program at the California School of Professional Psychology, She is Chair of the Committee on Crisis Intervention and Trauma Response of the Division of Independent Practice of the American Psychological Association. Dr. Wainrib has had a lifelong interest in human response to crisis and trauma as well as gender issues, and these two led to her interest in gender-related life-threatening illness. In addition to her many professional publications, she has also produced several books. Gender Issues Across the Life Cycle published by Springer Publishing Co. became a selection of the Behavioral Sciences Book Service. She also contributed to Breast Cancer: A Psychological Treatment Manual, edited by Dr. Sandra Haber, also published by Springer. Another of her books, Prostate Cancer: A Guide for Women and the Men They Love written together with Dr. Haber, was published in 1996. Dr. Wainrib received her Masters degree in Clinical Psychology from McGill University in 1959; held staff positions at McGill Teaching Hospitals for the next 15 years, and completed a Doctorate in Counselling Psychology at the University of Massachusetts in 1976. She has acted as consultant to groups and organizations in Canada and the United States, and has run hundreds of programs for skill development both for professionals and lay people. Ellin L. Block, PhD, is Acting Dean of the Division of Professional Field Training and Visiting Professor at the California School of Professional Psychology—Los Angeles. Dr. Bloch was formerly Associate Professor and Director of the Division of Behavioral Science, Department of Family Medicine, University of Cincinnati College of Medicine. She co-chaired the first Task Force on Trauma Response and Research of the American Psychological Association's Division of Psychotherapy. Her clinical practice has focused on the treatment of crisis and traumatic reactions, and she has been a consultant to attorneys, business and industry, professional organizations, and the media on trauma-related events. For her work in community trauma intervention, Dr. Bloch is the recipient of the American Psychological Association's Presidential Citation and the Cincinnati Psychological Association's Distinguished Psychologist Award.

Crisis Intervention and

Trauma Response THCORV AND PRACTICC

Barbara Rubin Wainrib, EdD Ellin L. Bloch, PhD

Springer Publishing Company

Copyright © 1998 by Springer Publishing Company, Inc. All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted In any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, Inc. Springer Publishing Company, Inc. 536 Broadway New York, NY 10012-3955 Cover design by Margaret Dunin Acquisitions Editor; Bill Tucker Production Editor: Pant Lankaf

98 99 00 01 02 / 5 4 3 2 1

Library of Congress ('ataloging-in-Publication-Data Wainrib, Barbara Rubin. Crisis intervention and trauma response : theory and practice / Barbara Rubin Wainrib, Ellin L. Block p, cm. Includes bibliographical references and index. ISBN 0-8261-1175-0 1. Crisis intervention (Psychiatry) 2, Post-traumatic stress disorder—Prevention. L Bloch, Ellin L. II. Title, RC480.6.W32 1998 616.89—dc21

Printed in the United States of America

97-32184 CIP

This book is lovingly dedicated to the memory of my "Grandma Ada": Ada Kaufman Berman It takes only one loving, listening adult to save the life of any child. And also to the memory of the woman who picked up where she left off: Dr. Alexandra Symonds The world breaks everyone . . , and afterward, some are strong in the broken parts. —Hemingway, A Farewell To Arms BW

To Truth's house there is a single door, which is experience. —Bayard Taylor To my Mother and Father, who taught me how to listen and remember; Edward H. Miller, who entrusted his story to me; and Christopher Armando Hernandez, whose story is yet to be told. When one or another extraordinary event occurs in life . . . when a crisis occurs and everything becomes significant, then men wish to be in it, for these are things which educate. —Soren Kierkegaard EB

This page intentionally left blank

Do not believe that he who seeks to comfort you lives untroubled among the simple quiet words that sometimes do you good. His life has much difficulty and sorrow. Were it otherwise, he would never have been able to find those words. —Rainer Maria Rilke

Even if you avoid needless fain, pain and suffering will still come. If the benefits of pain seem hypothetical or even ridiculous to you, ask yourself ivhether you have learned the most and grown the most during the easy times in your life, or whether the quantum leaps toward self-discovery have taken place in times of adversity. Most of us recognize that it is in adversity that we grow most quickly. —Michael Lerner, Choices in Healing

This page intentionally left blank

CONTENTS

Acknowledgments

xi

1

Introduction

1

2

Crisis, Trauma, and You: Theories of Crisis and Trauma

11

3

How We Respond to Crisis and Trauma

31

4

Principles and Models of Intervention

65

5 Assessment for Crisis and Trauma

101

6

Suicide and Violence: Assessment and Intervention

125

7

Putting It All Together: The Pragmatics

157

Index

199

ix

This page intentionally left blank

ACKNOWLEDGMENTS

People ask us how we can tolerate hearing all the painful experiences that our clients share with us. We feel that if those clients have been able to live through these experiences and have been brave enough to tell us about them, we certainly should be able to listen to them. Thus, those most worthy of our acknowledgment are the hundreds of people who have shared their life crises and traumas with us over the years. Their experiences have reinforced our personal conviction about the strength of the human spirit. Through sharing with each other our strong beliefs in the importance of understanding and treating life crisis and trauma, we began the process of collaborating on this book. In the course of that mutual journey we wove a rich relationship that belies the 3,000 miles separating us. We would like to thank Divisions 29 (Psychotherapy) and 42 (Independent Practice) for creating the first task forces on trauma and crisis in the American Psychological Association, which we were privileged to chair. We would also like to acknowledge the professional support of our colleagues Elizabeth Carll, PhD, Chair of the New York State Disaster Response Network; Dan Abrahamson, PhD, and LaurieAnn Pearlman, PhD, of the Traumatic Stress Institute; as well as Jack Wiggins, PhD, Past-President of the American Psychological Association, Dr. Sandra Haber, President of Division 42 of APA is also an important ongoing supportive member of our network. Jon Perez, PhD, has been a longtime support, both professionally and personally. Jon's original contributions to our greater understanding XI

xii

Acknowledgments

of service delivery under extraordinary circumstances have made their way into this book. Not just for his role as technical superhero, retrieving large segments of manuscript lost to cyberspace, but for being there in every quality of support for the major part of Barbara Wainrib's life, we thank Charles Wainrib. Bishop Yarian shepherded us through the process of applying portions of our work in the form of a series of continuing-education workshops held at the California School of Professional Psychology, Los Angeles (CSPP-LA), We would like to thank the student participants both in these classes as well as those in McGill University Department of Educational and Counseling Psychology, and in CSPP-LA's Research Seminars. The participants' interaction and enthusiasm have challenged, inspired, and reinforced us in our work. Barbara Wainrib would also like to thank Andy Hum, PhD, for his invitation in 1978 to teach Crisis Intervention at McGill, as well as Associate Dean Rachelle Keyserlingk and Bruce Shore, PhD, Chair of the Department of Educational and Counseling Psychology who continue to support Barbaras teaching there. Much of my contribution to this book evolved from work prepared for this course. Ursula Springer and Bill Tucker have demonstrated faith in us and in this project from its inception. Their exceptional patience should be applauded. My children, Jeannine and Andrew Wainrib, as well as my son-inlaw, Victor Afriat, and my granddaughter, Rachel Wainrib Friendly form the crucial base of my "being in the world." Both my Rubin sibling as well as my Wainrib siblings are special parts of my life, as is my beloved friend, Elaine R. Goldstein. I also need to make special mention of the Phoenix Phenomenon within my own family, My son Andrew has been the victim of three major traumas in the Los Angeles area within a short period of time: the civil unrest, which destroyed his business; the Malibu brushfires, which took his home and threatened his life; and the Santa Monica earthquake, which eliminated his only other means of support. Yet his wonderful courage, supported by his special friends and loved ones, have enabled him to continue to face each day with new visions and hope.

Acknowledgments

xiii

Ellin Bloch would like to thank Hannah Bloch, Dr. Edward H. Miller, and Patrick Mullahy. Among the many gifts a writer cherishes are the examples set by others. My daughter, Hannah, always evokes the encouragement to aspire, and the certainty that there is strength in the written word. Dr. Edward H. Miller taught me to hear in other victims what I learned, gratefully, from him. And to my teacher, Patrick Mullahy, thanks is long overdue for providing an early professional model of patience, as he sat long hours writing his own books at a kitchen table, and for challenging rne to apply the true meaning of participant-observation in my work, To my friends and colleagues, Lisa Porche-Burke, PhD, and Patrick H. DeLeon, PhD, JD, I express my great appreciation for their steadfast interest and support in my professional growth over many years. And to my friend and colleague, Roy M. Whitman, MD, I owe much, for the many hours we spent working together attempting to illuminate that darkness which our trauma patients inhabited. To my able and enthusiastic assistant, Cher Berry, who took on technological tasks where my own nascent computer skills left off, and who compiled many materials essential to the work, my enduring thanks.

BARBARA RUBIN WAINRIB, EoD MONTREAL ELLIN L. BLOCH, PHD Los ANGELES February 1998

This page intentionally left blank

Chapter

1

INTRODUCTION This chapter covers: • About this book • What is crisis intervention and trauma response: What is special about it? • What is in this book? • A note about the voices in this book

ABOUT THIS BOOK This book is the outgrowth of a happy collaboration between two psychologists who share years of experience, interest, and passion in the fields of crisis intervention and trauma response. Since 1978, one of the authors (B.W.) has been giving a very successful course in crisis intervention in the Master's Degree Programs in Counselling and Human Relations/Family Life Education, Faculty of Education, McGill University, Montreal, Canada. The students in the course have been crisis-intervention workers, teachers, nurses, counsellors, social workers, psychologists, nuns, ministers, lawyers, leaders of self-help programs, and others. During the recent past, the impact of trauma has become more highly recognized, and the field of trauma response has developed. The second author (E,B.) has been identified with trauma response on a national level in the United States and was awarded a Presidential Citation from the American Psychological Association (APA) for trauma response work in the community. Her

1

2

Crisis Intervention and Trauma Response

work with patients, attorneys, physicians, mental health professionals, business and industry, the media, and community organizations and support groups lends variety and depth of perspective to the field of trauma response and recovery. We came together as part of the Committee on Crisis Intervention and Trauma Response of the Division of Independent Practice (APA Division 42) of the American Psychological Association. After collaborating on a number of symposia and presentations, this book emerged as an obvious next step for both of us. Since beginning to work on this book we have also joined forces to teach crisis intervention and trauma response as a continuing education course to licensed psychologists at the California School of Professional Psychology.

WHAT IS CRISIS INTERVENTION AND TRAUMA RESPONSE: WHAT IS SPECIAL ABOUT IT? The changes that crisis intervention and trauma response have brought about in all the helping professions have contributed to important revolutions in the mental health field. Traditional psychotherapy, as well as traditional psychoanalysis, is based primarily on the medical model and makes the assumption that the treatment took place because the patient had a disorder and required the expert knowledge of the "treater," that is, doctor. The assumption was that anyone in psychological distress required specialized treatment to cure an illness by altering a defective personality. Crisis and trauma, however, can cause severe psychological distress to any personality, wholesome or not. But this understanding is relatively recent. One Sunday morning in 1944, B.W. came downstairs to find her mother extremely agitated and trying to reach her Uncle Charlie in Boston, Her Uncle Charlie was the family playboy and, although close to 40, was still a bachelor. When her mother was finally able to disengage herself from trying to get through to Boston, she explained that there had been a terrible fire at a nightclub called the Coconut Grove, and knowing her brothers habits, she was afraid that he may have been

Introduction

3

there. She desperately needed to speak to him to be reassured. She was in an acutely anxious state all that day until she reached him. Little did B.W. know that the Coconut Grove fire was to mark the start of the official history of crisis intervention. Certainly there have always been crisis interveners, well-meaning folks who tried to help when terrible things happened to people. People have always tried to help each other. Often they were very effective but perhaps just as often, not out of malice, but merely out of a lack of knowledge and skills, they created some harm. When the horrible death of a sibling struck a young girl one author knew, well-meaning, but misinformed, relatives said all the wrong things, such as, "You'll have to be a son and a daughter to your parents now." Those casual comments, which relieved the anxiety of those who said them and helped them feel as if they were doing something, fell on the ears of a child who, because of her own crisis of loss, was vulnerable and suggestible. As we will see, she may even have been in a semitrance state. They became more than casual comments and shaped much of her life for a long time. And years later, while waiting for a friend at the emergency room of a large hospital, the other author overheard the goings on in the adjoining cubicle, where a dead baby was brought in by his frantic parents. Here, too, equally well-meaning people were saying, "You'll have another baby," denying the pain and trivializing the parents' experience at that most difficult moment. Today we know that a time of crisis is a time of great vulnerability that can act as a fulcrum, allowing any intervention to carry a great deal of weight, positive or negative. That Sunday morning in 1944, however, was to help change some of those well-meaning, but misinformed, interventions into, we hope, what is today a truly helpful calling. As a result of that fire, Dr. Erich Lindemann, a psychiatrist, was able to follow the relatives of many of its victims. What he found, to his surprise, was that most of them fared well. Those who did not and who developed psychopathological symptoms, did so because they had not gone through a complete cycle of the grieving process. Throughout this book there are references to the concept of loss and its implication both as cause and effect of crisis and trauma. Lindemann's (1944) work is the cornerstone of that concept and the formal beginning of the knowledge about what people who have suffered a crisis need from the helping professions. Lindemann's study taught another essential

4

Crisis Intervention and Trauma Response

principle of crisis intervention: People have a great deal of internal resources with which to cope with a sudden crisis in their lives. Some people will need no external help, whereas for others, a small amount of appropriate intervention can go a long way. However, crisis theory assumes that despite a wellspring of resources, any individual's resistance to stress is finite, so that each person, under certain overwhelming circumstances, may be unable to cope. His work, and the work of Caplan (1964) and others who followed him taught us that crisis does not just happen to "patients." It can and does happen to anyone at any time under the right circumstances. This approach sees an individual's function as a process, rather than an illness. If professionals enter at the point of crisis when personal problems become overwhelming, the client can be helped to attempt better solutions. If this does not happen, the client may develop deviant behaviors as attempted solutions, becoming a "patient" (when the traditional therapist ordinarily would intervene). No one is ever fully exempt from crisis situations as they go through the life cycle. Neither does knowledge of all the crisis and trauma skills in the world protect any one of us from encountering these experiences. Some crises, as you will see, have to do with the life cycle itself, and others are totally random. At any given time, however, the person in tears across from you could be you. The most important development of the approach to crisis intervention is a change of philosophy. Our approach is that of two people working together to help one who is temporarily (and the emphasis here on being temporary cannot be overstated) overwhelmed get through a crisis period. The assumption here is that the person in crisis is a normally functioning individual who is in need of a guide during this trying period. The other assumption is that the crisis is an occurrence that can happen in anyone's life, including that of the helper. Our focus therefore is on the strengths that individuals bring to the crisis rather than on the pathologies that need to be "fixed." At the same time, we are acutely aware of any pathology that may develop as a result of the crisis situation. However, our emphasis is on what clients can bring to the situation to help themselves recover in the most effective way. The impact of this change in philosophy has important implications for the field of psychotherapy. The crisis intervention movement,

Introduction

5

together with the development of the humanistic psychology movement, has in many ways changed the setting, mode of reaction, and power structure of the therapeutic situation. When you add to that the impact of the feminist movement you realize how totally different any kind of therapy session is when one is dealing with someone from these traditions as opposed to a session either with a medically oriented therapist or one from the traditional psychoanalytic approach. This can express itself in the physical setting in which you work, which should emphasize equality, (Some therapists in this field irritate furniture people by making sure that all office chairs are the same height. Have you ever tried to feel comfortable talking to someone who is looking down at you?) Your setting should emphasize comfort and ease, rather than clinical pristineness. If you are doing trauma work, you may find yourself working anywhere; perhaps most effectively around a water cooler, in the ashes of someone's burned-out home, or in the waiting room of an airport where a loved one's plane has just gone down. Your skills need to be and will be entirely portable. Just as your physical setting in working with clients may vary from the traditional, so will the temporal boundaries. The traditional 50-minute hour may expand to 90 minutes or contract to 15 minutes. In addition, there may be the unexpected appearance of loved ones (babies, pets, cousins, and grandparents) or beloved objects (framed photographs, pieces of clothing) that accompany the client to your office. But no matter where and for how long you meet with your client, you must always remember that this is a normal human being faced with a devastating, abnormal, life situation. Psychological assumptions on your part must be that somewhere within this currently upset individual is a healthy life force with a potential for functioning at a much better level than the one that you are presently encountering. You are there to help clear away the debris caused by this crisis and unearth the life force that remains beneath it. You are not a rescue worker who has to salvage the individual. You are a hand extended to help these upset persons regain their balance and continue on their own. Crisis intervention and trauma response are short-term, problemoriented, joint relationships with a goal of producing constructive change in the life situation of the client as quickly and directly as possible. Because communities, as well as individuals, can be in shock,

6

Crisis Intervention and Trauma Response

and necessary assistance must often be mobilized from outside the stricken area, there is also a need to develop psychological expertise in working both in the traditional and the nontraditional environments created by these traumatic situations. We must also be aware of the need to respond to vicarious trauma as it impacts on helpers, secondary trauma as it impacts on family members, and indirect trauma that affects the general population's reaction to the event. Because the media are so often involved in situations of this kind, we also need to know how to work with them for public education. Our work also includes the special skills necessary to follow up on chronic conditions resulting from traumatic experiences. Because the psychological impact of trauma can be experienced in different stages, that is, immediate, short term, and long term, you must recognize the different kinds of approaches and treatment necessary at these different stages.

WHAT IS IN THIS BOOK? This book is unique in many ways. It is the first textbook to incorporate the work of both crisis intervention and trauma response. Although traditionally the two were presented individually, we feel that because crisis intervention is such an important part of trauma response, it is important to integrate the two. In doing so, we have created a new concept, the General Crisis Response, whose subsets are both life crisis and trauma. This new formulation will be found in chapter 2. Another innovation in this work is the presence of exercises to do individually or in class. These exercises include role plays, verbal and nonverbal skill building, and awareness of oneself as a helping person in this field. We believe strongly that adults learn best by experiential learning, and this book has many opportunities for that. Chapter 2 will introduce the reader to the impact of the crisis or trauma experience. It will then present crisis situations that occur developmentally and compare these with trauma situations. It will develop and present a new concept, the General Crisis Response, and

Introduction

7

show how it can be applied to both life crisis and trauma experiences, It will also present our concept of the Phoenix Phenomenon and indicate how this can or cannot be the outgrowth of a crisis or trauma experience. Chapter 3 focuses on the individual. It describes characteristics of a person in crisis or trauma, discusses how people respond to crisis, and what the determinants are of these response patterns. Coping reactions and choices are described, and the concept of victimization is presented. Our Life Transition model, another theme in the book, is then presented, and the chapter closes with a look at children's special needs. Chapter 4 starts with a conceptual framework for our work and reviews intervention models developed by others in the field. It then presents our own intervention model, which uses Relate-Asms-Refer/ Respond (R-A-R) as an overlay. Our own integrated intervention model will cover aspects such as attitudinal relating, technical relating, the interaction between the client's position on the dilation-constriction continuum and the helpers own reactions, the need for awareness of individual and cultural differences, and the ongoing themes of validation and normalization. It introduces another new concept, which is the importance of awareness of the suggestibility of the client during a crisis/trauma situation. After touching on some aspects of assessment (discussed further in chapter 5), it presents a series of pitfalls for the helper to avoid, which can be of great help at any stage of training. The all-important concept of social support systems is introduced here, together with our own model of support. Here we introduce, as well, the importance of information models for the community, which include information, education and training, and consultation. A key element in community intervention is the use of small group interventions, and several models of these are presented, including Critical Incident Stress Debriefing formats for adults as well as expressive art therapy intervention for children, and preparedness training for prevention. The chapter includes several relevant exercises and skill-building techniques for readers. In chapter 5 we present assessment models, which include the basic principles of assessing for urgency, severity, appropriateness of response, status previous to the crisis, and a variety of different types of resources. We will also discuss assessment requirements that are specific to trauma

8

Crisis Intervention and Trauma Response

situations, and give examples of varieties of normative response and behavior. As we then look at varieties of nonnorrnative responses and behavior, we will include a checklist for psychopathology as well as assessment for posttraumatic stress disorder. The chapter also contains important information about community assessment. Chapter 6 focuses exclusively on suicide and violence, two very significant aspects of any crisis or trauma. We introduce many of the myths about suicide as well as demographic statistics and approaches to intervention. We look at special populations, such as adolescents and the elderly, and explore some gender issues and differences in suicide. We then look at violence and see how it, too, is both a stimulus and a response to crisis and trauma. We look at sources of violence, factors in violence assessment, and other relevant factors in understanding, responding to, and protecting oneself from violent behavior. Chapter 7 is our putting-it-all-together chapter. It looks at the pragmatics of actually working in this field. It is heavily experiential and runs the gamut from a review of active listening to a series of verbal and nonverbal techniques, such as anxiety-lowering exercises, anger expression, and sleep exercises. It then moves into the community and gives readers training in both working with the media and building a mental health response team. In doing so, it pulls together all the basic concepts of the book and demonstrates what they look like in real-life situations.

A NOTE ABOUT THE VOICES IN THIS BOOK As you read this book, you will notice changes from time to time in the voice of the writer. Because the book represents the collaboration of two different individuals with unique voices, this is not unusual. In keeping with our respect for individual differences in our crisis and trauma response work, we have chosen to keep the voices unique. Each of us has a different approach, a different way of expressing ourselves, and rather than homogenize both of our voices into one bland sound, we chose to stay with our individuality. One voice is fairly scholarly,

Introduction

9

the other more hands-on. Both are skills you will need as you proceed in this field, where you will find that you have taken our information, distilled it through your own being and personal life experiences, and applied it in your own personal way.

REFERENCES Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Lindeniann, E. (1944). Symptomatology and management of acute grief. American Jouma.1 of Psychiatry, 101, 141—148.

This page intentionally left blank

Ch ap t e r

2

CRISIS, TRAUMA, AND YOU: THEORIES OF CRISIS AND TRAUMA This chapter covers: • Crisis and trauma: The experience • Impact and reaction • Exercise 2.1: Your definitions • Crisis definitions • Types of crisis • Trauma • A new conceptualization: The General Crisis Response • General Crisis Response characteristics • Universal life crisis • Suicide: The exception • Common themes in experiences of crisis and trauma • From victim to empowerment: The Phoenix Phenomenon • A final word about this model • Your reactions

CRISIS AND TRAUMA? THE EXPERIENCE Even as you read these words, your telephone is about to ring. When you answer it, your best friend will tell you that the strange weather you've been having and the greenhouse effect have caused a polar ice cap to melt, and within the next 36 hours, the melting will cause severe flooding that may very well jeopardize your home and your possessions. 11

12

Crisis Intervention and Trauma Response

Imagine that scenario for a moment and try to make it feel real. Now stop. Make a list of what is going on within you as you visualize this catastrophe. What do you feel in your body? What are you thinking? What do you hear in your head? What kinds of reactions did you have? Thoughts

Feelings Bodily reactions:.

IMPACT AND REACTION If you really enter into this imagery and stay in touch with your reactions at the cognitive, behavioral, and affective levels, you will have some indication of your own initial reaction to a crisis or trauma. Perhaps your reactions mirror those of some of our students. These are: 1. I will calm my nerves and put on a happy face and tell myself that nothing is going wrong. 2. She's joking. This can't be real. 3. If it is happening, it won't/can't be happening to me. Things like this don't happen to me. They happen to other people, 4. How dare she start her class this way—how dare this annoyance come into my life! 5. Why is she telling us this? We can't do anything. A typical theme found in the first five responses is that they all carry within them a core of denial. An almost immediate reaction to any

Crisis, Trauma, and You: Theories of Crisis and Trauma

13

situation that will abruptly change your life is the response of denial: "This is not happening; make it not happen!" There is the sense within each of us that we walk around in the world in a protected magic bubble, one that keeps the world relatively stable and predictable. It keeps the terrifying things, the unpredictable things, the life-disrupting things away. Yes, we hurt, we fear, we cry. But the really terrible things in the world—accidents, life-threatening illness, disasters—do not invade our personal bubbles. They happen to other people, but not to us. If or when they do invade the personal magic bubble, they bring about a complete reappraisal of oneself, ones life, and one's way of being in the world. A reappraisal of this magnitude is, at best, difficult to fathom. When life presents an opportunity to reassess oneself under the most comfortable of situations, it is painful, time-consuming, and confusing. When this reassessment and pressure to change erupts on one's consciousness at a time when all or many of one s stabilities have been threatened, it is that much more so. Hence the reaction, "How dare she start her class this way," which in effect says, "Kill the messenger: This foolish person is making an impossibly ridiculous mistake and if I can just eliminate the messenger bearing that mistake, it will all disappear and my life will go on as before." The second half of this reaction is make it yesterday: Make this change be undone and let my life go on as it did before this terrible thing happened. The stop-today-make-it-yesterday theme is one we will encounter often in dealing with people in crisis. The two themes of denial (this is not happening) and undoing (make this not have happened) are defensive reactions that many people will try to use in any life crisis or trauma. Another common reaction is "my heartbeat is increased and my palms are feeling sweaty." This is part of the typical physiological aspect of stress reactions. It demonstrates to us how efficient our body is under great pressure. Our breathing may get faster to direct oxygen to the muscles necessary for mobilization; our body has to be cooled to allow it to metabolize more efficiently, hence the sweaty hands; our blood has to be forced to whatever parts of the body need it, hence the pounding heart. These physiological reactions are immediate, but temporary. They should not continue with the individual throughout the period of crisis, although some or part of them may reoccur until the crisis is resolved.

14

Crisis Intervention and Trauma Response

There are, of course, other reactions that you may have. We would never suggest that there is a stage or level process in reaction to crisis or trauma. We never walk into any situation in a uniform lockstep cadence; a major approach of this book is to keep you aware of individual differences. Every person will respond in the defensive mode typical of their life history. The intellectualizer will say something like, "It's statistically impossible, I have data from quantum mechanics to prove it." The somatizer may threaten to faint. But the initial reaction, before the personal defenses are engaged, is most likely to be denial and undoing.

EXERCISE 2.1: YOUR DEFINITIONS If you saw this exercise as art experience in life crisis, what then is your definition of crisis?

If you saw this situation as a trauma, what then is your definition of trauma??

CRISIS DEFINITIONS Some of our working definitions of crisis are as follows:

1. An upset of equilibrium at the failure of ones traditional problemsolving approach which results in disorganization, hopelessness, sadness, confusion, and panic (Lillibridge & Klukken, 1978). 2. Erik Erikson's (1950) definition is "crisis no longer connotes impending catastrophe . . . [instead it is] designating a neces-

Crisis, Trauma, and You: Theories of Crisis and Trauma

15

sary turning point, a crucial moment when development must move one way or another, marshalling resources of growth, recovery, and further differentiation." Erikson's definition, as you will soon see, referred to what we now call developmental crises, but applies equally well to all life crises. 3. Gerald Caplan (1964), defined crisis as "the state of the reacting individual at a turning point in a hazardous situation which threatens integrity or wholeness." 4. Others have defined crisis as a catalyst that disturbs old habits and evokes new responses, 5. We also like the Chinese approach. Their idiogram for crisis contains two figures. One means difficulty and the other, opportunity.

TYPES OF CRISIS Traditionally, crisis was divided into two groups, developmental crisis and situational crisis. Trauma was defined as a separate, overlapping entity. Rarely have the two been approached as aspects of a spectrum of similarity. When we discussed Erikson's (1950) definition, we made passing reference to developmental crisis. Developmental crisis can be defined, as Caplan (1964) suggests, as an "internally caused situation, which may be due to physiological or psychological upheavals associated with development, biological transitions, role transitions, etc." Thus, these are events in our normal physical and psychological development that can trigger a crisis response. Situational crisis refers to situations that are primarily in the environment. Again, quoting Caplan (1964): 1. The loss of a source of satisfaction of basic needs, such as the death or departure of a loved person, or a loss of bodily integrity, such as a crippling illness 2. The (threat or) danger of such a loss 3. A challenge which overtakes a persons capacities such as a sudden promotion for which he is not adequately prepared, (p. 65)

16

Crisis Intervention and Trauma Response

Gilliland and James (1993, p. 15) said, "a shuational crisis emerges with the occurrence of uncommon and extraordinary events that an individual has no way of forecasting or controlling . , . such as ... automobile accidents, kidnappings, rapes, corporate buyouts and loss of jobs and sudden illness and death.The key to differentiating a situational crisis from other crises is that a situational crisis is random, sudden, shocking, intense and catastrophic." Developmental crises include; 1. Conception or infertility 2. Pregnancy, delivery, birth 3. Infancy and early childhood 4. Adolescence 5. Crises involving sexual identity 6. Mid-life crisis, including career change 7. Retirement 8. Aging 9. Death Situational crises include; 1. Sexual crisis: rape, incest 2. Abortion 3. Suicide 4. Acute or chronic illness 5. Alcoholism and substance abuse 6. Divorce or separation (both from the viewpoint of the individuals and the family) 7. Battered children, spouses, older persons 8. Family crisis 9. Widowhood 10. Accident victims 11. Crime victims 12. Culture shock 13. Runaways 14. Work related: promotion, job loss, moving 15. Hostages

Crisis, Trauma, and You: Theories of Crisis and Trauma

17

Gilliland and James (1993) have developed the concept of existential crisis, which refers to "inner conflicts and anxieties that accompany important human issues of purpose, responsibility, independence, freedom and commitment" (p, 16). Thus midlife crisis, or the crisis of aging when it brings with it remorse and dissatisfaction is in this category.

TRAUMA A traumatic event is always regarded as a uniquely disruptive event in the life of affected individuals, families, and communities. That the event is disruptive is self-evident; what is outstanding is the unique nature of the disruption, one that occurs at different levels, potentially affecting many others beyond immediate victims. Traumatic events strain the ordinary capacities of individuals and communities beyond the point that their resources can tolerate and absorb. Because of the ubiquitous nature of these events, they can happen at any time, anywhere. In theory, everyone is vulnerable, although, in fact, many will never be victims. It is this potential and this unpredictability that together shape the need for emergency preparedness and posttrauma interventions at both the individual and system levels. The range of traumatic events is sweeping: Airline crashes; tornadoes, hurricanes, mudslides, floods and earthquakes; toxic exposure; serial murder, violent assault, war; bridge and building collapse; drive-by shootings; kidnappings, hostage taking, and terrorist bombing. These events are sometimes termed disasters or catastrophes; at other times, accidents, or even acts of God. They have a physiological meaning to those stricken (rapid heartbeat, sweating, dizziness, extreme trembling, lightheadedness, vomiting, fainting), as well as a psychological meaning (confusion, excitability, nervousness, rage, nightmares, emotional numbing, disbelief, feelings of guilt, deep sadness, and fear). At a community level, there may be serious interference with important survival services such as water, electrical power, and emergency medical response, very similar to physiological disruption at the individual level. Communities, too, can be in shock, and necessary assistance must be mobilized from outside the stricken area.

18

Crisis Intervention and Trauma Response

Exposure to these events comes to us daily via the media. An American woman is beaten senseless by a Guatemalan mob imagining she has kidnapped a child. A disgruntled ex-post office employee in Oklahoma walks into his former office, shooting to death 14 coworkers. An innocent afternoon at McDonalds turns into a massacre. These events are ordinarily referred to as human-induced trauma to distinguish them from disasters created by nature. Traumatic events can be further designated or characterized by classifying them as (1) natural: anticipated, (2) natural: unpredictable, (3) human-induced: accidental, and (4) human-induced: deliberate violence. Because the emotional responses to trauma depend heavily on the nature of the event itself, the more carefully the event is described, the better our knowledge of its effects. These events can be further described along the dimensions of single versus multiple occurrence and the relative degree of community, or relatedness, among the victims. Once again, knowledge of these dimensions is critical for the professional involved in psychological assessment and intervention activities. 1, Natural, sometimes anticipated, trauma—floods, hurricanes, tornadoes—may be single or multiple occurrences and almost always occur in communities of friends, neighbors, and coworkers. In these settings, strangers who find themselves victims are usually immediately absorbed into the rescue and care efforts, 2, Unpredictable natural disasters'—earthquakes, some floods and mudslides, some tornadoes—also occur in close communities. However, in these settings, strangers who are visiting may suffer greater panic and confusion because of the lack of forewarning and preparedness. Some communities, like Los Angeles, are aware of this possibility and place detailed instructions for hotel guests on how to respond in case of an earthquake ("Stay away from windows and mirrors ... get under a heavy object, like a desk, and grip the legs of the desk, move with the object"). Unpredictable disasters can occur once, or as with earthquakes, many times over a short period. 3, Human-induced trauma: accidental, can occur in a setting of strangers or to those related by family or friendship ties. The technological disaster at Three-Mile Island, the Kentucky school-bus accident, and the Hispanic nightclub fire in New York are examples of the

Crisis, Trauma, and You: Theories of Crisis and Trauma

19

latter. Strangers can find themselves brought together in airplane crashes, bus crashes, train and subway derailments, and restaurant fires. In Kansas City, the collapse of the Hyatt Regency skywalk affected hundreds of strangers brought together only a short time earlier by the promise of an evening dance at the hotel. Accidental human-induced trauma is always a single event. It can affect one individual, as in an accidental shooting or collapse of an ironworkers beam, or several, as in the sudden four-story plunge of a packed elevator. Accidental does not imply that others may at some point be found criminally or civilly responsible. 4. Human-induced, deliberate violence represents the occasion for probably the greatest individual dread of vulnerability. The victim of a knife-slashing stranger described his feelings this way, "He didn't know me, but he was after me, intently, a human being like me, he wanted to kill me. If he were a bear it wouldn't have been the same, I would just have been his dinner." Deliberate violence may be single, in individual shootings and stabbings, rapes, assault and battery, and bank robberies. It is multiple, in double homicides, workplace murders, and serial killings. Multiple acts of violence can occur in a single community or spread over nations, as in war. Strangers can be bound togedier through these deliberate violent acts: the bombing of PanAm flight 103, the Lebanon hostages, the terrorist bombing of the World Trade Center, and the Tylenol poisonings. Yet, even though the kind of traumatic events described in this section is varied, and differences in individual response depend heavily on different event characteristics, there are nevertheless similarities in emotional responses of victims. In the next chapter we will describe some of the elements involved in the manner of response and how they come into play in determining reactions to a crisis or a trauma.

A NEW CONCEPTUALIZATION: THE GENERAL CRISIS RESPONSE Recent developments in trauma work have brought the importance of trauma into focus. It covers a broad range of experiences, but one of the most important is that it is an experience that is not universal.

20

Crisis Intervention and Trauma Response

Whether we refer to war, earthquake, or sexual molestation, we are not describing a situation that everyone normally expects to experience. If, however, one looks at the lists of developmental and situational crises, one realizes that, at some time or another, almost everyone will have experienced some of the situations on those lists. This has led us to reconceptualize the whole approach to crisis and trauma. Although many who have corne before us have struggled with the parameters of stress, crisis, and trauma, and attempted to integrate these, in keeping with our professional experience we have formulated the following integration that has proven most helpful in our clinical work. We have therefore developed the concept of the General Crisis Response, which contains elements of shock, denial, disbelief, undoing, pain, loss, and confusion. Within the General Crisis Response, crisis would be seen as universal and trauma as particular. By saying that crisis is universal we do not insist that every human must experience it. But chances are that as people go through their lives, they will certainly experience some or many of these life crises. Our position is, however, that any of these experiences also carry with them the potential for growth and change— albeit uninvited—in people's lives. With that as a basis, we now consider both life crisis and trauma as subsets of the general crisis response; whether one or the other is more or less severe is probably subjective. How one reacts to either is very much a question of resources—internal, interpersonal, and community, and perhaps spiritual—as well as the ability of the individual to access them. As well, there is some research to suggest that methods of coping with stress and survivor personalities can be identified.

GENERAL CRISIS RESPONSE CHARACTERISTICS The General Crisis Response is evoked by an unexpected situation and has the following characteristics: 1. At the cognitive level: Problem-solving abilities and coping mechanisms are temporarily overwhelmed.

Crisis, Trauma, and You: Theories of Crisis and Trauma

21

2. At the psychological level: A temporary state of shock may be followed by denial, confusion, fear, terror, sadness, emotional numbing, disbelief, excitability, and restlessness. These reactions can upset the individual's psychological equilibrium. 3- At the physiological leveh General stress reactons such as changes in heartbeat, respiration, and excessive sweating may occur (see Table 2,1). The quality and form of the individual's response will be a function of the interaction of the individual, the event, and the environment, as we shall see later in this chapter. It will also relate to previous history, developmental stage, and other risk factors. All of these concepts will be developed in this and following chapters.

UNIVERSAL LIFE CMSIS Another aspect of crisis and trauma is the degree to which the subject involves others in the crisis. Crisis workers have seen that trauma, for example, frequently activates many people within the victims community, either as the trauma is occurring or soon afterward. For example, if your house burns down, your neighbors will be immediately aware of it and in most cases will become involved in your experience. In other kinds of crisis, this may take more time. For example, if you are experiencing a midlife crisis, people in your immediate environment may perceive some changes in your behavior before you have actually articulated the crisis. There may be, in effect, a longer lead time between the time of incubation of the crisis and the time of outcry to others. Although all experiences of crisis and trauma eventually involve response from others, this appears to exist on two continua. The first is whether the response comes only from the individuals close support system (family and friends) or whether it comes from members of the general community. The second is a continuum of internal/external, which is reflected in the degree to which an individual becomes aware of and reveals the discomfort to others (the concept of incubation to

TABLE 2.1 Trauma and Crisis as Subsets of the General Crisis Response; A Comparison of Characteristics Trauma Characteristics

Life Crisis Characteristics

• A catastrophe, always an • A potentially catastrophic, uninvited extraordinary situation shared with turning point in ones life. Although few others; not a universal often universal, the experience itself experience. is solitary, and the individual feels that he/she is alone and unique, » Almost always evokes public alarm: • Rarely seen by others, it may disrupt sometimes disrupts temporarily the individual's life but the general the social fabric. social fabric continues unaffected. • An event (or series of events) that * evokes enactment of specific social roles, e.g., "victim," "hero," "bystander," Also brings together in some manner others in certain occupational roles: relief workers, government officials, lawyers, detectives, etc.

The life-crisis event causes people around the subject to mobilize and respond to him/her in roles that may be new for them. It also involves contact with people in both lay and professional roles in a variety of "helping" modalities.

« The event itself is sometimes • predictable/foreseeable (e.g., approaching hurricane), sometimes recurrent (e.g., seasonal), but most often not. The event is often random, arbitrary.

Although frequently anticipated, this does not help to prepare the individual: the life crisis is experienced as shocking, unexpected, and as something that happens to others, but not oneself.

* Almost always life threatening and always connotes a loss or impending loss.

« Can sometimes be life threatening. Always implies a loss of ones life as it had been prior to the crisis. Life will never again be the same.

• Element of human choice almost always absent; almost always sudden.

• Rarely is there any choice involved, and choice of spontaneous reaction is almost always absent.

22

Crisis, Trauma, and You: Theories of Crisis and Trauma 23

23

expression, or outcry). The list below has been annotated accordingly, Situations that involve immediate response from others have been labeled external, those that require an incubation period have been labeled internal. Applying our new concept, the following items would be considered as universal life crises: 1.

Unwanted pregnancy or infertility—internal (proceeds over time) 2. Complicated pregnancy, delivery, birth—external 3. Parents with complicated infancy, adoption—external 4. Early childhood (illness, extreme separation)—external 5. Adolescence — adolescents existential crisis—internal — adolescent's behavior changes—external 6. Crisis involving sexual identity—internal 7. Midlife crisis, including career change—may originate as internal but moves to external 8. Divorce or separation—-starts internal, moves to external 9. Retirement—starts internal eventually become external 10. Family crisis—external 11. Acute or chronic illness such as AIDS, and cancer—internal 12.

Widowhood—external

13. Addictions—-starts internal, becomes external 14. Aging—equally divided between internal and external 15. Death—external Again, using our new concept, the following would be examples of traumatic experiences: 1. 2. 3. 4. 5. 6. 7.

Rape, incest Violence Serious accidents Natural disasters War Terrorism Severe work-related experiences (violence, downsizing)

24

Crisis Intervention and Trauma Response

8. Hostage-taking 9. Life-threatening illness

SUICIDE: THE EXCEPTION Although suicide was previously listed as a skuational crisis, we are including it in the universal-life-crisis category. The potential for suicide is present in any situation of crisis or trauma. We shall see more about this in chapter 6,

COMMON THEMES IN EXPERIENCES OF CRISIS AND TRAUMA Although crisis and trauma differ along a number of dimensions, they also share certain important characteristics. For both, a three-part schema is useful for conceptualization of the individual's experience and the response made to it. The simple format of (a) individual, (b) event, (c) environment helps to categorize and classify aspects of both crisis and trauma. This format resembles the public health triad, (a) host, (b) agent, (c) environment, and serves to separate, for both the clinician and the investigator, responses and variables that would otherwise overlap, be misidentified, or confused with one another. In this schema, for example, one can identify widowhood (crisis) and criminal assault (trauma) as events that have an impact on both the individual and the individual's environment. The event itself may be single or multiple. The event may be the proximate or remote cause of the individual s current psychological difficulties. It is extremely important to keep in mind that neither crisis nor trauma exists without an identifiable event or series of events. For example, schizophrenia is not a crisis or a trauma; however, dealing with the early stages of this disorder and learning of the diagnosis can constitute a crisis for the patient's family.

Crisis, Trauma, and You: Theories of Crisis and Trauma

25

The individual affected by the crisis or the trauma may be one of many, or alone, and affected directly or indirectly by the event, Widowhood may constitute a crisis not only for the woman whose husband has died, but also for her children, who have not only lost their father but who may now face a rearrangement in their living circumstances and finances to accommodate this change. In the same way, a person injured in an explosion is a direct victim of a trauma; at the same time, bystanders and eyewitnesses can be severely affected, One need not be present at the scene to suffer traumatic stress, having viewed a close relatives injuries within moments after the injurious event (Nolan & Ursin, 1982). Although families and entire communities may be affected at once by any single event or an event series, we emphasize use of the term individual in this schema to underscore the importance of each person's unique experience of the event and the importance of that person's individuality in expressing their thoughts and emotions and working through the crisis or trauma. The most critical part of the affected individual's environment is other people. Although the helper makes note of structural or functional aspects of the environment altered by crisis or trauma (a damaged home, a work space lost through retirement, the addition of ramps and grab-bars for a newly handicapping condition), what should be highlighted are the roles that others play in the individual's time of crisis, how they respond (or avoid responding), including the helpers themselves. Are others supportive? Intrusive? Demanding? Pragmatic? Silent? Although the event represents the occasion for distress, the environment of other people can be seen as exacerbating or as mitigating this distress. The helper needs to be aware that the nature and kind of environment determines the outcome of coping equally with what the individual brings to the situation and the kind of event endured. In fact, in the case of trauma, the environment of other people as potentially deleterious has been called "the second trauma" or "the gratuitous assault." It is common for those affected by crisis and trauma to construct a safe zone around themselves (Bloch, 1991; Lindy, 1986). By habit, and out of anxiety, they create a boundary within which they live, and across which only certain others may pass. Consciously or not, selected people may be privy to their feelings and dilemmas, while others are

26

Crisis Intervention and Trauma Response

(inexplicably to them) shut out. At times, the safe zone has a quite tangible expression, as in the case of a victim of a criminal assault whose home resembled a small fortress: not only were double locks put on every door, but every door also required a key from the inside to get out of the house (Bloch, 1991). It is equally common for an intense, sometimes frantic, search to begin for understanding what has happened. The defining characteristic of a crisis or trauma is the absence of a cognitive framework and accompanying frustrations in attempting to gain one that will be useful. People usually turn immediately to sources that have been helpful to them in the past, only to discover often that these now will not work. Thus, part of the crisis response and the trauma response are the always-present questions, "Why?," "Why me?," "Why him/her?" Another common response to crisis and trauma is the review of one's own behavior: "What if I had said this, instead of that? What if I had done this, instead of that?" The individual posits a hypothetical self as a means of trying to undo the event that is causing intense pain. This review of behavior may be a mechanism for attaining the illusion of control over essentially uncontrollable events. Responses to crises and traumatic events are normal responses to abnormal situations. They include thoughts, feelings, and behaviors that cut across age groups, as well as responses specific to adults and those that are specific to adolescents and children. In a later chapter we will discuss reactions specific to different developmental stages. It is worthwhile noting several paradoxical responses to crisis and trauma. These are responses one would not ordinarily associate with confronting painful events and circumstances, but these occur nonetheless: 1. Difficulty in letting go once the crisis has passed and been resolved; a feeling of letdown or boredom compared with the energy and adrenaline release associated with dealing with the crisis. 2, Feelings of depression and annoyance at routine tasks and role responsibilities temporarily suspended or delegated to others during the crisis; heightened awareness of the more mundane details of daily living.

Crisis, Trauma, and You: Theories of Crisis and Trauma

27

3. Positive feelings of self-confidence, accomplishment, even euphoria at overcoming difficult obstacles; sometimes resulting in overconfidence, faulty judgment, and impatience with others when feelings are extreme. Although a crisis or trauma has passed, certain residuals, including these paradoxical responses, may be evident in the affected person's behavior. There is no particular end point for the resolution of a crisis or traumatic event. Years may pass, and an individual develops a new insight about the impact of a significant, upending experience. Additional crises or traumas may occur, superimposing themselves on prior crises and their resolutions, and thereby changing the individual's behavior. What the helping professional sees is simply a slice in time, a person, a defining event, and a surrounding environment of which the individual is an integral part. Negotiating that slice of time with the client, accompanying the client on his or her journey, is a process with a sometimes quite arbitrary end. The question of how long to work with the victim of crisis or trauma has not been satisfactorily resolved in the scientific literature. Because of inherent difficulties in conducting intervention research with affected persons, clinical and observational data on crisis and trauma have thus far outstripped research data. It is therefore wise in working with clients to view their recovery as a process to which you can sensitively contribute, whether in a single meeting or in months of meetings. One important goal of such a process is assisting the individual in moving from the position of a victim to that of a person who begins to feel empowered.

FROM VICTIM TO EMPOWERMENT: THE PHOENIX PHENOMENON Our own experiences with the lives of clients, as well as our own lives, have led us to the concept of the Phoenix phenomenon, which is the ultimate goal of empowerment. The Phoenix, as you may recall, was a mythic bird that had the capacity to resurrect itself, to rise from its own ashes. Our work has shown that the impact of life crisis or trauma

28

Crisis Intervention and Trauma Response

can provoke either a positive or negative response that has the potential for change in the direction of one's life. Part of the process is that the crisis makes one reassess one's life. Some people may find at this junction that they are really content with their life as it was before the crisis, and that they cherish that. These people will do their best to reconstruct their lives in the same format after the crisis. This may, however, not always be possible, as we will see in our discussion of mourning in the next chapter. Ursano, Grieger, and McCarroll (1996) citing the work of Card (1983); Sledge, Boydston, and Rahe (1980); and Ursano (1981) conclude, "for some people trauma and loss actually facilitate a move toward health. . . . A traumatic incident can become the center around which a victim reorganizes a previously disorganized life, reorienting values and goals" (Ursano et ah, 1996). Again, Ursano et al. (1996, p. 444) citing Holloway and Ursano (1984) report that "Traumatic events appear to function as psychic organizers (thought glue), like affects, cognitions, and behaviors are later expressed after symbolic, environmental, or biological stimuli." The circumstances of the crisis, whether it be loss of a loved one, a life-threatening illness, or the destruction of one's home, may make the "make it the way it used to be" wish just that. People who react that way may need support and direction in reconstructing their lives, even if they would like them to proceed as they had been before the event. For others, however, the crisis will magnify those elements in their life that have been causing them subliminal distress, which may have previously been unacknowledged. For those people, given the right combination of resources, the crisis can become a catalyst for a significant, positive, life change, (We will explore the range of these resources in the next chapter.) This capacity for growth from crisis is what we refer to as the Phoenix phenomenon. We will mention it often as we go along.

A FINAL WORD ABOUT THIS MODEL At any given time in an individual's life, he or she may experience either a universal life crisis or a traumatic event. The two are never

Crisis, Trauma, and You: Theories of Crisis and Trauma

29

mutually exclusive, and in fact, may interact. Research on the impact of cancer, for example, has shown that response to this experience is significantly affected by the developmental stage of the patient, and one's age or developmental stage places certain limits on the capacity to respond in adaptive ways to traumatic events. One can also be going through a developmental crisis such as adolescence at a time when trauma strikes. For some people, a traumatic event can also precipitate an existential crisis. A very broad dramatic example of this is the character of Schindler in Schindler's List. As he becomes aware of the horrors of the Nazis whom he had befriended, he reappraises his own personality and behaves in a very different fashion.

YOUR REACTIONS In reading the remainder of this book, try to put yourself into the potential scenario of each experience. This is not a course in abnormal psychology where we ask you not to diagnose yourself on every page. Life crisis and trauma are different. They can, and do, happen many times during everyone's life. The more you can truly understand and feel the experience of life crisis, the more adept you will be at helping others to deal with it.

REFERENCES Bloch, E. L. (1991). Post-traumatic stress disorder: Treatment approachavoidance—an illustrative case. Psychotherapy, 28, 162—167.

Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Card, J. J. (1983). Lives after Vietnam. Lexington, MA: Lexington Books. Erikson, E. (1950). Childhood and society. New York: Norton. Gilliland, B. E., & James, R. K. (1993). Crisis intervention strategies (2nd ed.). Belrnoot, CA: Brooks/Cole. Holloway, H. C., & Ursano, R. J. (1984). The Vietnam veteran: Memory, special context and metaphor. Psychiatry, 47, 103—108.

30

Crisis Intervention and Trauma Response

Lillibridge, E.M., & Klukken, P. G, (1978), Crisis intervention training. Tulsa, OK: Affective House. Lindy, J. D. (1986). An outline for the psychoanalytic psychotherapy of posttraumatic stress disorder. In C. R. Figley (Ed.), Trauma and its wake (Vol II, pp. 195-212). New York: Brunner-Mazel. Nolan, V. E., & Ursin, E. (1982). Negligent infliction of emotional distress: Coherence emerging from chaos. Hastings Law Journal, 33, 583-621. Sledge, W. H., Boydston,}. A., & Rahe, A, J. (1980). Self-concept changes. Archives of General Psychiatry, 37, 430-440. Ursano, R. J. (1981).The Vietnam era prisoner of war: Precaptivity personality and development of psychiatric illness, American Journal of Psychiatry, 135,315-318. Ursano, R. J., Grieger, T. A., & McCarroII,}. E, (1996). Prevention of posttraumatic stress. In B. van der Kolk, A. McFarlane, & L. Weisarth (Eds.), Traumatic stress (pp. 441-463). New York: Guilford.

Chapter

3

HOW WE RESPOND TO CRISIS AND TRAUMA This chapter covers: * Responses to trauma and crisis * The concept of victimization * Determinants of response to crisis and trauma * Coping reactions * Choices * Exercise 3.1: Personal experiences * Risk factors * The phenomenon of loss * The life transition model * Exercise 3.2: Mourning and confusion * Children's special needs

RESPONSES TO TRAUMA AND CRISIS I felt I was possessed. All / did was run around in the house, screaming, —Jane R.> first hearing that her youngest daughter bad been abducted^ raped, and murdered. Time practically stood still, I felt I was in a slow-motion film, —Robert L., shot in his car at a stoplight. He wouldn't pick up the violin for 2 years after the fire. —Anne K.> daughter of a musician performing the night of a supper-club fire that killed 165. 31

32

Crisis Intervention and Trauma Response

The last time I was happy was the morning of December 21. , , . I who never before took anything stronger than an aspirin now take antidepressants and antianxiety drugs, shored up by therapists, —Susan €., whose only child died in the bombing of PanAm flight 103. I couldn't go around people much. Mostly, I stayed to myself. I couldn't take it that after a month or two people were saying, "You should be over this, you should be glad you're alive, you can always build a new house." No one realized the memories there. —Terry /?., who lost her home of 30years in a tornado. Somewhere deep down inside me, even though 1 knew it couldn't possibly be truef I felt I'd never be afraid of anything, ever again. Anything could happen to me or my family, and I never, ever would be afraid. —David K., who survived a plane crash. The doctor said that the surgery on my wife's cancer was a failure and that there was nothing more that they could da, I felt as if I was in a bad movie, and everything around me had come to a halt. —-James G., husband of a cancer victim

The responses to traumatic events and crises are normal responses to abnormal circumstances. Nothing can ever truly prepare a person for such events, and there are no predictors for how well or how severely any given individual will react. Victims represent a normally distributed population and will always include those who adjust with mild, moderate, and intense reactions (Wilkinson & Vera, 1989). Some victims respond with few reactions, others with many more. The individual's response repertoire may appear in its entirety within days of the event or may emerge over months following that event. It is almost always impossible to predict who will cope quite well and who will become psychologically impaired. It is, however, generally true that most trauma victims are able to use their own resources and those offered by others, while a much smaller percentage cannot adequately recover and needs specialized treatment if diagnosed with posttraumatic stress disorder (American Psychiatric Association, 1994). In spite of the variety of differences among natural and humaninduced traumatic events, people respond in some remarkably similar ways. The earliest record of clinical symptoms arising from a state of

How We Respond to Crisis and Trauma

33

severe stress is probably that described in a 1766 French officer who had a weakness in one arm and a speech impediment, no doubt arising from the fright of combat (Wilkinson & Vera, 1989). A majority of the earliest observations about psychological trauma comes from the battlefield, each war bringing with it new terminology from those attending the soldiers. At first, the symptoms were viewed in a dominant medical context. DaCosta (1871) described cardiac symptoms in Civil War soldiers; in 1919 Lewis described similar symptoms during World War I as "Soldier's Heart and Effort Syndrome" (Wilkinson & Vera, 1989), The symptoms of dizziness, a rapid heartbeat, extreme trembling, lightheadedness, tingling sensations in the arms or hands, and excessive perspiration no doubt present then still appear in inclusive lists of the general symptoms of traumatic stress. It was during World War II that a psychological basis was first utilized to explain a variety of combat-related symptoms. Combat neurosis then became a focus for psychiatric treatment. Although most of our earliest observations and documentation of trauma response have emerged from the soldiers experience, the concept of civilian trauma began to be recognized quite early in this century in marked psychological reactions in victims of railway accidents. Slowly, over the years, clinical data and research gathered from hundreds of traumatic events around the world document a constellation of reactions to and psychological consequences of catastrophes that are common to individuals in all societies: • «

Emotional numbing Disbelief

• * * « » * *

Sleep disturbances, nightmares, night terrors in children Anger and irritability Flashbacks, intrusive thoughts Sadness Forgetfulness and loss of concentration Fears of "going crazy" Survivor guilt; loss of feeling secure in the world; loss of trust in others; a sense that life is out of balance

• •

Increased alcohol and drug use Social withdrawal

34

• • • « • » • • •

Crisis Intervention and Trauma Response

Excitability, restlessness, and nervousness Pain complaints; flu and coldlike symptoms Minimization of the traumatic incident Hypervigilance Feelings of shame, despair, hopelessness Feelings of invulnerability; "spoiling for trouble" Dizziness, trembling, lightheadedness Rapid heartbeat Feelings of euphoria (Framer, 1990)

In addition, after a shattering event, victims may describe an alteration in time perception (see the example at the beginning of this chapter), extraordinarily vivid recollections of detail (a button on the floor of the airplane aisle, the texture of a coat sleeve one has grabbed in the dark), and, overall, a sense of an irrevocably altered self or personal identity. Victims of catastrophe have visited the edge: When they return, they are different from others in having undergone the experience, and sense that they are outsiders.

THE CONCEPT OF VICTIMIZATION What makes a traumatic event traumatic for its victims? Much depends on the nature of the event. By definition it must be one that threatens death, serious injury, or poses a threat to ones physical integrity. It may be an event of this kind that one witnesses or hears about regarding a close family member or associate. The degree to which one is victimized and the risk of psychological consequences rises with event-related factors such as lack of warning, degree of uncertainty and duration of threat, nighttime occurrence, proximity to the event, and hazardous properties of the postevent environment (Myers, 1989). Specific individual characteristics also influence a person's sense of having been victimized. People who have been victimized in the past and have not recovered usually suffer more. Children, and those unable to escape rapidly, including disabled persons, often suffer deeply. On the other

How We Respond to Crisis and Trauma

35

hand, contrary to what you might expect, the elderly victim is not likely to suffer to a greater degree than other adults. Men and women probably suffer to an equal degree, although women in our society are more likely to express their emotions and talk about the experience. The concept of victimization is built on numerous percepts and empathic emotional responses experienced over time and is dependent on personal exposure to traumatic events. This exposure arises from direct knowledge (oneself, a family member, a friend, or a coworker has suffered a traumatic event) or indirectly through the mass media, which familiarizes us, often very graphically, with what it means to be a victim. Some victims are endearing, like the sole child survivor of an airplane crash several years ago. Others are occasionally threatening (Charles Bronson, in his role in the movie Death Wish). There are victims one can identify with more readily than others, depending on the critical incident and how the victim personally responds to it. There are those about whom one has approach-avoidance feelings. And there are those who are criticized: "How could they have remained in their beach house when everyone else was evacuating because of the hurricane warning?" Part of the concept of victimization is the belief that victims are sometimes responsible for their misfortune. Child victims, as a rule, are exempt from this belief. Victirnhood and helplessness are linked attributes, but in actuality the picture is more complex. While a victim may be helpless in many respects, he/she is not always passive. A victim may be angry, stoic, or physically and emotionally agitated and energetic. Likewise, the victim may be silent or talkative, calm or hysterical, decisive or indecisive (Bloch, 1987). Feelings and experiences are coped with and expressed, by both children and adults, in myriad ways, as the following stories told by child victims of war attest: What is it? What is it? An earthquake? A game? I'm afraid. The boom of the cannons. The thudding. This is war. Black daggers are drawing closer to me. I'm falling into a hole. This is a real war. A fire is burning in my house. A bullet has hit me in the back. The blood is streaming. My hair stands on end and FEAR overtakes me. I often go into a. magical world. I blink my eyes. I am a little dove. I'm

36

Crisis Intervention and Trauma Response

flying . . . I am carrying a message: Peace, peace to all (A. Barath, personal communication, April 12, 1993; Barath, 1994).

Concepts of victimization develop and change with increased professional experience in working with victims. They change with growing empirical knowledge of how individual attributes intersect with particular kinds of traumatization, leading to lifelong feelings of victimization or feelings of survivorship. There is a significant role the helping professional can play in altering the often stereotypic notion of the victim from one of inevitable and long-term helplessness to empowerment. Understanding some of the ways in which these reactions develop is crucial to the work of helping professionals, and we will attempt to look at some of these now.

DETERMINANTS OF RESPONSE TO CRISIS AND TRAUMA No one consciously decides how they will or will not respond to a life crisis or a trauma. An individual's response will be determined by personality type, accrued life experience, and way of seeing the world. As well, cognitive commitments at a rational level and certain unconscious childhood decisions may contribute to an individual's reaction. Cognitive commitments are defined as "rigidly held beliefs unmodified by context" (Langer, 1994, p. 28). They form a background for the ways in which we perceive and react to the world. All of these contribute to the client's initial assessment of potential resources in responding to the crisis.

COPING REACTIONS Richard Lazaruss (1983) work on stress and coping can be very be helpful here. Lazarus has shown us that:

How We Respond to Crisis and Trauma

1, 2, 3,

37

People have individual differences in vulnerability to stress, People have individual differences in their strengths in relating to adversity. People have different coping competencies,

Lazarus sees psychological stress and coping as the product of an ongoing person-environment relationship. He feels that an individual, faced with a potentially stressful situation, makes a cognitive appraisal: The individual evaluates what is happening based on the personal agendas brought to the situation and on a sense of availability of one s own resources. He found three kinds of appraisal: 1. Appraisal of harm or loss (I have been damaged). 2. Appraisal of threat (I may be damaged), 3. Appraisal of challenge (I can do this: focus on growth). These functions are generally present in crisis and trauma cases as well. Clearly the response to this appraisal depends on the individuals immediate inventory of personal and interpersonal resources. When we discuss resources, the four areas we refer to are internal resources, interpersonal resources, community resources, and spiritual resources, The individual's flexibility, as well as the ability to reach out for help, will be important determinants in one's coping skills. These will also affect the perception of a threatening situation as either threat or challenge. The interesting conundrum is that if an individual perceives a lack of adequate resources of support or flexibility, the crisis situation may appear overwhelming and destructive. However, those sources of support may be available if the individual is able to access them, and the potential then exists for the situation to be seen as a challenge rather than a threat. As we shall see, the ability to connect fully with one's resources may well be dependent on decisions that were made when one was very young, or cognitive commitments that lock one into a particular view of the world. An example of how cognitive commitments function is the degree to which people conform to arbitrary rules about norms and values they learned as children, such as "the fork goes to the left of the plate" (Langer, cited in McCarthy, 1994). Concepts of how the world is supposed to be can be violently shaken

38

Crisis Intervention and Trauma Response

in trauma and crisis, and the ability to be flexible and alter ones expectations is essential.

CHOICES In their fascinating book about personal involvement in the treatment of cancer, Simonton, Simonton-Mathews, and Creighton (1980) give us an important understanding. They tell us that Experiences in childhood result in decisions to be a certain kind of person. Most of us remember a time in childhood when our parents did something we didn't like and we made an internal pledge, "when I grow up I'm never going to be like that." Or a time when some contemporary or adult did something that we regarded highly and we made an internal pledge to behave in a similar way whenever we could. Many of these childhood decisions were positive and have an overall beneficial effect on our lives. Many of them on the other hand, do not. In some cases, these decisions were made as a result of traumatic or painful experiences. If children see their parents engaged in terrible fights, for example, they may make the decision that expressing hostility is bad. Consequently, they set rules for themselves that they must always be good, pleasing and cheerful, no matter what their real feelings may be. (p. 61)

The Simonton concept is very similar to that of cognitive commitment. They feel that when one locks oneself into these decisions and sets up rigid rules about them, that person is seriously limited in his or her ability to cope with stress, particularly when it appears in clusters of multiple stressors. Their conclusion is that when an individual feels trapped by a limited ability to respond to stressors, one of the outcomes can result in the development of cancer. Despite all the research that has shown that people who are effective copers use a variety of different coping styles (again, the flexibility function), often in our crisis and trauma work we will feel the frustration of seeing a client rigidly adhere to a single mode of response to the situation. We sit and listen as the person recounts ways in which coping is merely repetitive varia-

How We Respond to Crisis and Trauma

39

tions on essentially the same response pattern. We ask ourselves "Why does this person not hear this resistance to considering alternate options?" We may find ourselves thinking, "If this were me dealing with this situation I would do such and such and feel much better in no time." We need to understand what allows a person to respond one way and what prevents him or her from responding in another. Because the individual in crisis is human and therefore essentially no different from the professional, professionals can use an awareness of their own processes to help them better understand and respond. How any of us copes, and does or does not decide to do something about a difficult situation often relates to what the Simonton concept describes as one's own childhood decision. When I have asked my students to go back to their own childhood experiences to see if there was a specific sentence that reflected their childhood decision about how to react to the world, they came up with a wide variety of sentences. Here are some of them: * * * * * * * * * * * * * *

Keep a stiff upper lip. Always be brave and never complain. I can do it by myself. Anger is bad. I'm not allowed to fail. I'm a survivor, I can do anything. I've survived, I mustn't ask for anything more. Someone will help me. Whatever I undertake, God will provide it. You can't be beholden to somebody else. Always talk about it. Things will work out. It's meant to be. Other peoples problems come first.

Imagine yourself in a situation where your house has just been blown away. You desperately need help from other people. Yet your childhood decision may be one that negates that. This adds further conflict to an already overstressed psyche. Some of these sentences like "someone will help me" and "always talk about it" give permission to

40

Crisis Intervention and Trauma Response

ask for help from others. Others, like "keep a stiff upper lip," "always be brave and never complain," "I can do it by myself," make the person feel the imperative to deal with everything alone. Still others, like "other people's problems corne first" are injunctions to be helpful to others rather than oneself. Some, like "always talk about it," give permission to openly express emotions, where others, like "anger is bad," obviously do not. Some sentences give permission to be flexible, while others lock the individual into a rigid position.

EXERCISE 3.1: PERSONAL EXPERIENCES Note for exercises: If these are done in class and shared in dyads, certain basic rules of listening should be in effect. Be mindful of the luxury of being fully heard and try to be truly available to your partner. Perhaps one way to do this is to prepare what you want to say about your experience in advance and make some notes. That way your mind will be clear to focus on your partners material, rather than on your own preoccupation with what you will say when your turn comes.

Exercise 3.1 A Think back on your own life to your childhood. What statement can you remember that comes to your mind about how you are supposed to respond to the world, or, more specifically how you are supposed to respond to difficulty. Is it a statement that allows you to ask for help from people or some other power? (For example, "Whatever you undertake, God will help you"), or is it one that limits your coping in difficulty (for example: "Big boys don't cry")? Give yourself a few moments to think about this sentence. Then write it down here.

How We Respond to Crisis and Trauma

41

Exercise 3. IB Think back to the last time you had some significant transition in your life. This may have been a change in a relationship, in your school situation, or in your job. It may have been a loss of someone or something important to you or the threat of that loss. Close your eyes. Let your mind go back to that experience in your life. Think of what happened and of your response to the experience. Did you allow yourself to ask others to help you or did you have to keep a stiff upper lip, What feelings and thoughts do you associate with that experience?

How did you respond to the situation? How do these reactions, feelings, and thoughts relate to the childhooddecision sentence you listed above? Was your method of coping successful? If not, how?

not successful?

Did it allow you the flexibility to do whatever you needed to do to respond successfully to the situation? What would you have needed to do to give yourself permission to try other coping approaches? ,,,, To what extent did your approach allow you to reach out and seek support? Did you feel adequately supported during your time of transition?

42

Crisis Intervention and Trauma Response

What would you have needed to feel better supported? What within yourself would you have to change to facilitate better access to support? How difficult would it have been for you to give yourself this permission? Exploring some of these issues within yourself will give you some idea of what is involved in an individual's personal response to a crisis situation. If you do this exercise in a class situation, it may be helpful to share your responses with a partner and then discuss them with the group. Thus you can once again see, and one hopes respect, the vast variety of individual differences that people have and understand even further the variety of responses that you can encounter in dealing with crisis and trauma. You can also see that, although you know that effective coping requires flexibility, it is often very difficult to elicit it in ourselves.

RISK FACTORS Let us look at some of the other elements that determine an individual's response to crisis or trauma. There are a variety of sources of risk factors. These include risk factors related to the individual, risk factors related to the role and role overlap, and risk factors related to the event, Risk Factors Related to the Individual Individual responses to extreme stress vary in terms of specific risk factors present in the individual or the individual's life at the time of the crisis (Myers, 1989):

How We Respond to Crisis and Trauma

43

1. Age and developmental phase. Skill level and degree of life experience may be a risk factor, as in the case of children, who do not have the capacity to understand and rationalize what has happened and may not have the verbal ability to describe their experiences; or older adults, who might be physically or mentally impeded in their ability to reach out and use available resources. 2. Health. Poor health, recent ill health, or mental illness may impede obtaining access to medical care, especially during natural disasters and their aftermath. 3. Disability, Impaired mobility, sight, hearing, or speech may place one at risk of not obtaining needed supplies for recovery. 4. Preexisting stresses. Recent job change, financial worries, relocation, family changes, and problems may increase risk because of cumulative stresses and impaired social support systems, 5. Previous traumatic life events. Successful outcomes may have resulted in coping strengths and survival skills. Unsuccessful outcomes or emotional reactions not worked through may leave individuals vulnerable to maladaptive coping and strong emotional reactions to the current stressors. 6. Strength of social support system. Absence or loss of social and psychological support systems can place individuals at risk. 7. Coping skills. Described earlier, poor coping skills or maladaptive coping efforts (such as excessive drinking) indicate that an individual is at risk. 8. Expectation of self and others. Family members needing care (e.g., small children, relatives with health problems) may add to a victim's stress. High self-expectations can put an individual at risk for a sense of failure and loss, should their efforts prove unsuccessful. In addition, the way a victim responds and behaves during and after a traumatic event is often unlike how that person imagined. 9. Status of family members. If separated at the time of crisis, severe stress and sometimes possible injury to the individual may occur in attempts to locate them. 10. Ethnic and cultural milieu. Language barriers may endanger individuals as well as interfere with their ability to obtain or use services and supplies during a traumatic event. Recent immigration may leave an individual without family or social support.

44

Crisis Intervention and Trauma Response

11. Interaction between the individual's occupation and the event. Individuals are at higher potential risk when their occupation intersects with the traumatic event (e.g., air-traffic controllers on duty at the time of an airline crash; physicians who inadvertently find themselves at the scene of a disaster). 12, Perception and interpretation of the event. How the individual perceives an event will affect the level of stress experienced and coping effectiveness. For example, individuals who believe they were at fault may suffer severe guilt and depression (adapted from Myers, 1989). Although not an exhaustive list of risk factors for the individual in crisis, the preceding descriptions provide a glimpse of the complexity of individual variables that affect the ways in which people respond to crisis and trauma. It is important to keep in mind that any given individual may respond quite differently to various crisis points during a lifetime. We will discuss this later in chapters 4 and 5 on assessment and intervention. It is especially important in matters of intervention because although an individual's past response to a life crisis may be a guide to that individual's behavior in a current crisis, it is by no means a firm predictor. Not only must individuals be assessed for their particular risk factors, but these must be placed in context with the roles each one plays in the critical event.

Risk Factors Related to the Role and Role Overlap When we think of people in crisis, we empathize with them as individuals, others who are suffering. We also try to comprehend the events that may threaten to overwhelm them, events that are sometimes unpredictable, puzzling, or even vicariously threatening to us in our own lives. When we widen the context of understanding the individual in a crisis situation, another dimension becomes apparent, that is, in a crisis situation, individuals play personal (often universal) roles and/or occupational roles, or both. The context of understanding a crisis or traumatic event widens beyond the immediate victims once we enumerate the potential roles played by those who have, broadly speaking, an interest in the event.

How We Respond to Crisis and Trauma

45

All traumatic events and certain crises bring forward role-related activities that impinge on the victims. In turn, the victims react in idiosyncratic ways to those embodying the roles. We might arbitrarily divide a traumatic event into two distinct time periods: impact and immediately postimpact; and phase-two impact. Within these time periods, the following roles may be enacted: Time I - Impact and Immediately Postimpact Victim(s) Eyewitnesses Bystanders Paramedical personnel Medical personnel Rescue units (police, fire, specialized units) Media (reporters and camerapersons) Time 2 = Phase Two Impact Red Cross (and other service agencies) Mental health professionals Clergy Morgue personnel Funeral directors Medical personnel Government inspection teams Media Detectives Attorneys Employers Government officials Insurance companies and their agents The importance of understanding these roles is twofold. First, victims' experiences of the crisis event are in part defined by their interactions with and responses to the persons filling these roles. Their trauma may be eased by a sympathetic clergyman or a television reporter who holds their hands or by a bystander who locates a missing child. Their trauma may be intensified by ambulance-chasing attorneys, the long

46

Crisis Intervention and Trauma Response

delays in filing insurance claims, or an intrusive and pestering journalist. Some crime victims suffer a second assault, with attendant difficulties in coping, when they become part of a slow and imperfect justice system, feeling angry at the judge, the prosecutor, and the defense attorney. Second, every person who occupies many of the roles listed above is potentially a secondary victim of the crisis and a target of intervention for the helper. Just as in the case of more direct victims, stressful events evoke sometimes strong, negative emotional reactions in secondary victims. Risks of maladaptive coping arise in the course of performing their various roles: seeing grotesque images (e.g., body parts), hearing unpleasant sounds (screams, cries), listening to the upsetting details of victims* experiences, burnout due to long hours without personnel substitution, being called upon to assist in an unfamiliar role (e.g., mental health professionals assisting paramedics or walking through temporary morgues with survivors identifying bodies of loved ones), and dealing with the generalized stress of others, if one is in a management or oversight role during the crisis. Role overlap can sometimes occur, to the temporary detriment of one's emotional well-being. For example, a television news anchor, on-air without breaks during the 1989 San Francisco earthquake, movingly described the experience of fatigue, rear for her own safety, and the burden of maintaining calm reporting on the events, in a studio with few lights, confusing information, and intermittent aftershocks (Yeh, 1990). Roles are also enacted during crisis events on a personal level that have nothing to do with occupational roles. These roles and an understanding of them are most often conveyed to us by the print media and via television and probably occur universally. The most prominent of these is, of course, the role of victim, which is composed of numerous behaviors (Bloch, 1987). Yet another is that of hero, the person who rescues the victim from disaster. An interesting insight into the hero comes from the disavowal of this role by many who have risked their own lives. Following a winter plane crash in the Potomac River, a bystander jumped into the icy river to save the life of a woman. When asked about his risk-taking, he simply replied, "God said, 'Eeny, meeny, miney, mo, and you're mo,' so I jumped in." The bystander is also an important role, as well as the eyewitness, both of whom can internalize the event as a whole and describe it to others. Heroes,

How We Respond to Crisis and Trauma

47

bystanders, and eyewitnesses may be secondary victims and suffer guilt, anxiety, and other conditions (for example, nightmares) as a result of what they have observed and experienced. Occasionally, there is a hero-victim role overlap that creates emotional strain within the individual, particularly when the response of others emphasizes heroic aspects and ignores victim status. The individual then feels compelled to act in a reciprocal fashion, while suppressing and repressing traumatic stress responses. Finally, it is worthwhile for the helping professional to be alert to the possible interactions between personal and occupational roles. The personal role of victim, hero, bystander, or eyewitness may have a temporary or even long-term negative impact on one's customary occupation or job duties; the impact may, however, be even more central and poignant when the occupation is the one engaged in at the time of a traumatic event. A violinist who was one of the last musicians to escape the Beverly Hills Supper Club before it burned to the ground in 1977 (killing 165 people including a number of his fellow musicians) refused to pick up a violin and play for 2 years following that catastrophe. In addition, lest one underestimate the centrality of one's occupation, job talents, or calling to one's identity, there is the further example, from the same fire event, of the musician who left the club safely only to return to get his instrument case and die in the room in which he had earlier been playing (Lindy, Green, Grace, & Thchener, 1983).

Risk Factors Related to the Event Apart from intrapersonal and interpersonal dynamics and the roles played by individuals in a crisis, certain properties of the event itself play a decisive part in the recovery process. Each event has its own unique characteristics (one earthquake is never exactly like another; one on-the-job accident is not the same as another accident, even at the same work site). Some of these characteristics, however, pose a greater risk to people in terms of psychological impact. All other things being equal, the higher the risk properties of the event, the less individuals are able to successfully cope with the situation and its aftermath. Risk properties include;

48

Crisis Intervention and Trauma Response

1. Lack of warning, A disaster or life crisis that strikes without warning produces the maximum psychological impact. 2. Abrupt contrast of scene. An abrupt change of reality that is difficult to comprehend (e.g., airplane debris and bodies raining down on a sunny, peaceful neighborhood) increases the trauma for persons experiencing it. 3. Innocence of setting. The impact of trauma is greater when it occurs in entertaining, relaxing, playful settings (e.g., the Hyatt Regency skywalk collapse during a dance; the San Ysidro McDonalds restaurant massacre). 4. Type of disaster. Technological disasters are usually more stressful than natural disasters. 5. Nature of the destructive agent. If the cause of the trauma is clearly perceived and well known (e.g., a river that periodically floods), it is less psychologically disturbing than an agent that is invisible and whose effects are unknown or delayed (e.g., chemicals or radiation), 6. Degree of uncertainty and duration of threat. High degrees of uncertainty regarding recurrence, or further trauma, and outcome of rescue attempts are more traumatic than crises with fairly predictable outcomes. 7. Time of occurrence. Ordinarily, traumas occurring at night may be more psychologically disturbing than ones occurring during the day, due to inability to orient oneself to the scope and danger of the situation in the darkness, 8. Scope of the event. The more damage, injuries, and deaths there are, the greater the intensity of psychological impact. 9. Personal loss or injury. The degree of loss—injury to self, injury or death of loved ones, loss of home or job, or items of personal significance and meaning—and the duration of loss are important factors of risk. 10. Proximity to the event. Regardless of personal loss or injury, where one is located relative to the event is of importance (e.g., hiding during a murderous rampage; observing one's neighbors home destroyed in a storm while one's own remains untouched; watching a war unfold on television). In general, the closer the proximity, the higher the risk. 11. Traumatic stimuli. Prolonged or extensive contact with dead or injured; deaths of babies or children; and unusual or distressing sights, sounds, or smells all increase the impact of trauma.

How We Respond to Crisis and Trauma

49

12. Human error. Traumas perceived as having been preventable can generate intense emotional reactions, making it difficult for victims to cope successfully and recover (adapted from Myers, 1989). In general, crisis events carrying the greatest psychological risks are sudden, life-threatening, and human induced. Summary In addition to individual coping styles and skills, the choices—particularly childhood decisions and personal rules for behavior—that people make when they respond to crisis situations, the perception of the event as a threat or a challenge to one's psychological integrity, and certain important risk factors influence how people respond to crisis and trauma. Understanding the persons experience means taking into account these risk factors. The risk factors on all dimensions (individual, role related, and event related) may be viewed as triggers for maladaptive coping behaviors. As we have previously mentioned, persons in crisis represent a normally distributed population. Knowledge of the effects (on adjustment, coping, and recovery) of these risk factors allow us to better appreciate and predict where a given individual might fall in such a distribution. Human nature being what it is, there are individuals coping well who have nevertheless been exposed to serious risk factors on all dimensions. This is why expectations about the determinants of response to crisis cannot follow a single formula but must evolve creatively, the professional holding quite a number of variables in mind and excelling at listening to the individual's experience.

THE PHENOMENON OF LOSS The phenomenon of loss is often central to the person in crisis. Loss always implies separation, and depending on the nature of the crisis event, the separation is either temporary or the loss irrevocable. Separation anxiety is one of the earliest, most primal fears we experience

50

Crisis Intervention and Trauma Response

as human beings. When mother is out of sight she ceases to exist for the baby, whose response can range from wide-eyed surprise to panicky screams. As adults, we have grown to adapt to separations (because they are often followed by reunions) and adjust, sometimes painfully, to losses. In a serious crisis, a close family member may be lost to death; the physical wholeness or former self of an injured loved one may be gone; or there may be loss of ones home, workplace, or school. There are events during which irreplaceable possessions may be damaged or lost, mementos, family photographs, furnishings that, often only after their disappearance, highlight their meanings in terms of our continuity with ourselves and our personal historical past. In economic crises, jobs and Income may be lost on extremely short notice, with sudden separation from work partners and reliable daily routines. Intangibles may also be counted among the possible losses: The loss of feeling safe and secure in the world, absence of a former self-confidence and sense of self-reliance, and a precipitous decline in one's trust in others. Loss is both an event risk factor and a personal appraisal of harm, often causing the greatest degrees of suffering among people in crisis.

THE LIFE TRANSITION MODEL Dorothy, an attractive, extremely successful, 48-year-old woman came into my office and, before she could even tell me why she had come, was flooded with tears. She wept and wept and then finally said, "He left me. I eanie home from a trip and his clothes closet was empty. He never even discussed it. He just left me a note saying that he had moved out. Twenty-five years of marriage, two grown children. We had done everything together, built a very successful business, traveled, entertained, lived our lives together, and now he's gone. I don't understand. Why did this happen?" And then she burst into deep, mournful sobs, and could not stop. The voice on the other end of the telephone said, "I am a close friend of Laurie's, and I know that she has been seeing you. I just thought you would like to know that, a few hours ago, her husband killed himself." After phoning to confirm that it was acceptable to Laurie, I went to her house. She sat mute, unmoving, zombie like.

How We Respond to Crisis and Trauma

51

In chapter 2 we talked about the initial response to crisis: the sense of denial (make it not be happening) and undoing (make it yesterday). We described the image of a protective bubble that everyone carries around in an effort to stave off the possible horrors of unexpected crisis. What happens after this protective bubble bursts and one moves past the initial reaction of shock, denial, and undoing? What can the professional expect to see as a person starts to corne to grips with a crisis that has totally upset his life and overwhelmed the sense of ability to problem solve and cope? We cannot stress often enough that individuals will react in their own person-specific way. However, there are some characteristics that are seen frequently enough to place them within a common structure, a model. The model we find helpful in assisting others in moving through life crisis is one that Bridges (W. Bridges, personal communication, October 22, 1976) has discussed in relation to life transitions. Originally developed in 1905 by an ethnographer named Van Gennep, our experience has been that it mirrors the response to life crisis. It has three stages; mourning, confusion and reemergence of a new identity. As you read this material, try to think back to the most recent transition in your own life, perhaps the one you used in exercise 3.IB, See how you responded to these three stages of transition.

Mourning In the previous section we made reference to the impact of the phenomenon of loss. Mourning, the first stage in Van Gennep's (I960) model, is an expression of that loss and is one that is difficult for many in this culture to recognize. Mourning is generally thought to be an end product, not a beginning. But mourning is the necessary transition out of crisis or trauma. Social mores teach us to ignore mourning or hope it will go away. Nevertheless, whether the crisis is one of positive change or negative loss, there is always some mourning necessary. Much as one thinks "make it yesterday," when first confronted with the crisis situation, the reality is that yesterday will never again exist. Support for mourning may be difficult to cull in a society that endorses aphorisms such as "smile and the world smiles with you." The way we

52

Crisis Intervention and Trauma Response

were before the crisis struck is gone. We must acknowledge that there are parts of ourselves that will no longer exist, there are roles that will never again be our own. Even if the crisis is a positive, developmental one, mourning is still appropriate. At graduation, one gives up the bittersweet experiences of the starving student days; marriage is a final farewell to the halcyon single life. At the birth of a first child, the freedom and lack of responsibility of the early days of marriage become history. A life change creates this reality. Life as it was will simply never again be the same. This is what we referred to at the end of chapter 2, where we pointed out that sometimes it is impossible to go back to your life exactly as it was before the crisis. And this reality necessitates a recognition of loss, of giving up, of sadness, and mourning. This sadness must be sanctioned, not as pathology, but as the pain of a growing edge. It is the medium out of which a changing life will reemerge, It is the pain of the life force in temporary darkness. The life force is still within, but it must be cleansed to reemerge, Because sadness is shunned in our society it is often much too quickly medicated. The overtranquilization of much of our population reflects this. Sadness makes the people around us feel impotent, reaching for the prescription pad allows the helper to reconnect with his imagined professional power. But this sadness of the transition/crisis/ trauma is a real and necessary mourning, an important cleansing farewell, a sense of closure on those things that are no longer in our lives. Crisis and trauma workers must learn to be comfortable with sadness and to be able to condone its expression. They must each explore their own life histories to understand how they feel about dealing with sadness. Perhaps you grew up in a family with much pain, and your role was to be the entertainer or to make the sadness somehow go away. That may set the stage for your own need to make the client smile at all costs, lest you feel you have failed. Or perhaps you grew up in a home where no one expressed sadness, no one ever cried. You may secretly be feeling that someone who indulges himself in sad feelings or weeping is somehow inferior. Neither of these reactions will be helpful in your crisis and trauma work. You will have to explore your own reactions and develop a tolerance, a comfort with other peoples mourning. And this in no way means turning into a stone-faced replica of Sigmund Freud, Don't be afraid of your own sad reactions. In crisis

How We Respond to Crisis and Trauma

53

and trauma work, shedding a tear together with your clients is not a sin. It serves only to reinforce the validity of the clients' pain. It demonstrates to them that, although you remain strong and competent and able to lend your strength to them at this difficult period, you, too, recognize their pain. Individuals in crisis will, in their own way, go through a mourning, if both their environment and their personal way of being condone it. Both Dorothy and Laurie, in addition to being in a state of shock as their bubbles burst, were beginning to experience mourning, each in her own way. Dorothy, however, was also experiencing confusion, the next stage.

Confusion Van Gennep's second stage is confusion. The word itself is frightening. It is often associated with madness, deterioration, or other negative states of mind. Confusion is another area of discomfort for many people, both helpers and clients. But helpers must learn to tolerate the manifestation of confusion. A colleague once said that confusion was the beginning of learning, and often it is just that. But rather than seeing it in that light, you may regard confusion as creating a lack of control, something you may fear within yourself. Or it may make you wonder about the sanity of the client. Here too, you will have to develop a capacity for comfort with this unusual state of being. Sometimes confusion may occur simultaneously with the sadness. Bridges (W. Bridges, personal communication, October 22, 1976) describes this stage this way, "this feeling is different from missing what's been left behind or being afraid of what's ahead. This is a feeling of being utterly and absolutely alone in a gap of existence,'" If you look back at times in your life when you had to make important decisions, you will remember that long before you knew what you did want you knew what you didn't want. And although these times may have felt confusing and difficult, you may nevertheless have had the luxury of time and space in which to explore alternatives. When a time of decision is thrust upon you, with no opportunity for planning you will be left only with knowing what you no longer

54

Crisis Intervention and Trauma Response

have, what you do not really want. You may very well feel yourself floundering, lost in an unknown space, perhaps with no sense of direction. You may feel like a balloon that has lost its ballast, and the possibility of drifting away into this unknown place can be very frightening. This is Bridges' "gap of existence"—no old ballast to hold on to, no future goal that can yet be seen, knowing only that the way things were has disappeared, not yet seeing a clear path or a new direction. Although support is very important at all stages of crisis work, during this stage of confusion it is most essential, Perhaps here, a difference between life crisis and trauma becomes most evident. Because trauma often evokes public alarm, the victim may have a sense of rightness or validation of his experience by others. Thus an essential element of support already exists, and intervention makes use of this by group debriefings and other techniques. However, secondary intervention may have to focus on individual needs, and the fear that "everyone else may be better at coping with this situation than I am" may still be present. In universal life crisis there is a greater sense of "I must be crazy" because of the isolation, and because generally first stage intervention is with the individual, secondary intervention may be most helpful in a group of people with similar experiences. Hence the importance of support groups of survivors of life crisis, such as Alcoholics Anonymous, the Widow-to-Widow programs, Parents without Partners, and so on. At this stage, clients are frightened that their lives are in turmoil, and afraid that they may be crazy. It is crucial at this point to help clients to hang on to all stabilities, because these may no longer be apparent to them. Your role here is to help your client focus on what stabilities still exist because it is still too frightening and confusing a time to try to focus on what may or may not be possible in the future. Aggravating fears of craziness during this period is isolation, created out of fear of revealing craziness or confusion to others. Your client may be convinced that everyone else in the world would handle this situation in a less confused state. It is here that the presence of validating support from you, as helper, and from a support system of friends, relatives, or acquaintances that you will help to activate (as well as from the community at large) is absolutely essential. And the appropriate quality of this support, particularly at this time, is crucial.

How We Respond to Crisis and Trauma

55

Loss, Confusion, and Anger Loss and confusion are often seen as anger. Of the various expressions of suffering loss, none is often as intense as anger—-or as problematic to the help-giver. The angry individual feels unreachable and sometimes appears irrational and occasionally self-destructive. If we can see beyond the anger, pain, and sadness to the anxiety that they cover, if we can hear those panicky screams of the child, we are in a position to truly confront this emotion. One sees in victims the urges to harm, to destroy those responsible for their loss. It is extremely important for the helpers to let the victim know that they are not afraid of the victims destructive impulses, and that the specifics of what the individual is thinking and feeling need to come above ground. This is illustrated in the following transcript of a portion of a therapy session in which the therapist is meeting for the second time with an older couple whose 30-year-old daughter has been abducted, raped, and murdered. The suspect has been caught and jailed: Wife (W)s

If somebody doesn't get to him, my husband is apt to. And that's what scares me, I don't want him to go after them. See, the jail is on one side of the street and the courthouse is on the other so that he has to cross the street. That's dangerous.

Therapist (T): You're going to kill him. (This hypothesis is immediately stated to the husband.) Husband (H);

I'd love to.

T;

Yes...

H:

Just like pulling a switch, I'd be the first one to pull the switch.

TJ

Do you think he would do it? (The victim may deny, therefore the question is directed to the spouse. The victim then responds as if challenged.)

H:

You think I wouldn't? Would your Dad if something happened to you. Would he do it?

Ts

Hard to say, hard to say. I know how he'd feel. What he'd

56

Crisis Intervention and Trauma Response do I don't know. (Therapist expresses understanding of victim's feelings but uncertainty about his response.)

Ws

You see in anger and frustration you do a lot of things that you wouldn't ord . , ., I, an ordinary person that lives an ordinary life, when something violent happens you don't know what happens to that person. They become completely unscrewed and you do things you ordinarily wouldn't do.

H:

You can't tell her that, I think she knows that.

T:

Yes, gun carrying is a popular response to this, by the way. (Therapist now believes victim has a gun and tests this hypothesis.)

W;

Oh, yes.

Ts

People start carrying guns, waiting for a chance.

H:

Well, the FBI tells you ...

W:

I told him not to be angry . . .

H;

"Mr. S," he says, "I carry a gun." "If I were you or anybody else I'd tell them carry a gun." When the FBI tells you that then you start to wonder what the hell is going on. . . . I mean if you have to strap one to your leg and carry it every place you go.

Ts

Where's yours? (Therapist works against discomfort, trying to bring this out in the open.)

H:

I haven't started carrying one yet.

T:

You have one at home?

HJ

Oh, I have several . . . I know a lot about guns, had them in the Navy. I got guns you can put on wheels. They're big enough to blow the whole car away.

T;

Cannons.

H:

Cannons, right.

The meaning of the losses suffered must also be confronted by the helper. To the victim/survivor, loss may be experienced with ambiva-

How We Respond to Crisis and Trauma

57

fence if the relationship to the lost object is not harmonious or pleasant. Individuals may therefore express shame or guilt as well as sorrow. All of these emotions are considered part of the process of inevitable mourning. Into the mourning process often comes confusion, uncertainty, bitterness, and frustration. The helper must be willing to elicit and tolerate questions that have no ready answers ("Why did this happen to him? To us?") and questions whose answers reach beyond one's areas of knowledge and expertise. In the aftermath of the Beverly Hills Supper Club fire in Kentucky, a psychiatrist accompanied a survivor as she searched for relatives among bodies laid out in a nearby temporary morgue. "Please," she said to him, "tell me if a person's soul goes right to heaven when they die or does it have to stay here?" The psychiatrist reflected silently on this, thinking to himself that this was a theological question for which he was completely unprepared, yet he sensed from the woman that she knew this but wanted a response nonetheless. So he replied, "I'm certain that the soul goes directly to heaven," whereupon the woman looked visibly relieved and grateful for this answer (L. Spitz, personal communication, February 20, 1978). In the context of brief psychotherapy with the older couple described earlier, both husband and wife struggle with the question, "why?"; HJ

. . . I just think our daughter was in the wrong place at the wrong time.

W; But why, why? Hs

It could happen to you or anybody else.

W: But I keep saying why. H:

Well I don't know why. I can't tell you why and nobody else can tell you why.

T:

Your question is why. Why what? Can you be more specific?

Ws Why did this happen? Ts

Why did it happen?

W: What was the reason? T:

To her, or to you?

58

Crisis Intervention and Trauma Response

W: To her. No, me I can take, but I don't want to see her. She must have gone through hell. She had to, T;

So why her . . .

W: Why was it her? T:

And not, , ,?

W: Not somebody else. It, it, I'm being cruel but why was it her at that time? I'll never understand it. I'll never get an answer from her or any of them. She may be happy, I don't know. I don't know if there is a heaven or not. I question a lot of things now which I shouldn't do 'cause I was raised to believe in God, but if God wanted to take her, there would have been a quicker, easier way. Not this cruel.

As this vignette illustrates, part of the process of working through a traumatic experience calls into question basic beliefs the individual has about life. A number of authors have described one central belief as that of a just world. A crisis or trauma disrupts the bedrock of a belief in a just world: how persons respond to crisis will in the long run depend much on how they perceive their newly configured world and their place in it, especially their relationship to others,

Identity This is the third stage of the Van Gennep transition model. With the working through of the sadness and the confusion in its various manifestations, there will emerge, slowly at first, a new sense of identity. The person in crisis will gradually reveal a sense of a new beginning, a new image of who he or she is. When the impact of a crisis hits an individual it feels like an enormous crater of internal pain. Gradually, slowly, the wound heals, a bit at a time. As a client said "I can't believe that there are now some periods of a few hours during the day when I actually don't think about it." As the persons new self does emerge he or she may often want to broadcast this in some public way. Often I see people changing their names at this stage, or asking to be referred to by a new title. When this new identity starts to emerge, the crucial part of your work as a helper has passed. It will not, however, develop overnight. The helper must maintain patience, consideration, a strong hope system and a good

How We Respond to Crisis and Trauma

59

capacity for ambiguity to arrive at this point. As a client recently said, "First you know who you're not, and then you know who you are." This phase of new identity also correlates well with the "mastery" phase in trauma response. The "mastery" concept demonstrates that, having worked through the healing process after trauma, clients are frequently seen taking leadership roles in helping other victims to heal. For example, a rape victim may lead a group for survivors of rape, or an AIDS patient may work with a political advocacy group to release new AIDS medications, and so on.

EXERCISE 3.2s MOURNING AND CONFUSION 1. Think back to the transitional period that you used in Exercise 3,1B. Can you discern periods of mourning and confusion in your reaction to that transition? 2. How comfortable are you with sadness in yourself in other people What response does it provoke in you? 3 How comfortable are you with confusion in yourself in other people What response does it provoke in you? Discuss in dyads and share with the class, If you have discomfort with either sadness or confusion in yourself or others, if you have a need to make them go away to tidy them up, if

60

Crisis Intervention and Trauma Response

you experience anxiety or fear when you are dealing with individuals who are sad or confused, you will have to do a lot of personal work to develop a better tolerance for these feeling states. Persons in crisis are particularly sensitive, and their own discomfort level is great. What they need from their helper is the reassurance that what they are experiencing is right on target for their stage of transition and not something to be hurried away. Those in crisis are having a hard enough time struggling with their own fears of possible "craziness" or experiencing some kind of "breakdown," without any subtle hints from the helper that what they are feeling must be pushed away or hurried through. Our job is to facilitate their movement through a crisis, but it is also to respect the organic quality of these feelings and to allow them the time and space to be expressed and worked through before they can move on.

CHILDREN'S SPECIAL NEEDS We have been describing reactions of both adults and children to crisis. However, at different developmental levels, children need and, in turn, respond to different types of intervention. As with adults, previous life history can be a significant risk factor in a child's response to crisis. Bruce Hiley-Young (1992) of the National Center for Post Traumatic Stress Disorder has found that "children whose parents were either divorced or separated . . . suffered more serious symptoms (from the trauma). These children warrant special attention and we recommend that future community intervention projects target this high risk group." Children are very sensitive to changes in their environment, particularly a change so significant as having to leave their home, even temporarily, or when a mother or father leaves home. Typically, children's behavior is most likely to alert you to any difficulties they are experiencing, as children often do not verbalize these feelings and thoughts. Also children are more likely to exhibit changing feelings from day to day and even from moment to moment (Perez, 1990). The following guidelines (Perez, 1990) assist in understanding children's special needs.

How We Respond to Crisis and Trauma

61

Preschool Age (1-5 Years) This age group is particularly vulnerable to changes in their routine and environment, as they are the most dependent on the assistance and help of others. They will probably be more affected by separation from the primary caretaker. Furthermore, this age group does not have the mental, verbal, or emotional skills to cope with this type of situation. This age group responds to: • increased attention — physical contact (hugs, kisses, holding hands) — realistic reassurance • being listened to — assistance and awareness by teachers or daycare staff

Early Childhood (Ages 5-11) This age group is more likely to exhibit regressive types of behaviors, which may include bedwetting, thumbsucking, using transitional objects such as blankets or stuffed animals, crying, whimpering, and clinging. Youngsters may also resist returning to school or other activities and they may also begin to fight with their siblings and friends more aggressively. This age group responds to: • increased attention • firm but understanding insistence and assistance to return to normal activities • education about what is happening with family members in words they can understand • encouragement to express their feelings (fear, sadness, loss)

Preadolescents (Ages 11-14) At this age of development, peer relationships and group reactions are important. Children of this age are more able to express their feelings and understand the crisis situation. Clear, direct information and facts

62

Crisis Intervention and Trauma Response

about the crisis are helpful as long as this information is thoroughly discussed in ways the child can understand. Preadolescents need: * reassurance * temporary lowering of expectations at home and school * encouragement to: — engage in activities with others — be physically active — talk about their feelings

Adolescents (Ages 14-18) This age group's interests are closely tied to those of their peers. Often withdrawal, isolation, and depression are seen with adolescents. They may also become less responsible, more demanding, rebellious, and competitive. They may become frustrated and angry with the adults in their lives. Physical complaints are commonly seen. Adolescents need: * * * »

to talk about their feelings and frustrations encouragement to reengage in activities to socialize with friends education about the crisis situation encouragement to become active in family communication

Adolescents also benefit from rituals around the experience of the trauma, and they can be encouraged to create their own ritual. For example, at a high school, a well-liked young man was killed in a car accident. His friends gathered together to spend a day doing many of the things he enjoyed most, hiking, being outdoors, and the like. Afterwards they held their own memorial service where they talked about him and described their feelings about him. They ended the service by saying that getting on with their own lives was the best way they could honor his death. It is important to support this age group in its choice of symbolic expressions.

How We Respond to Crisis and Trauma

63

REFERENCES American Psychiatric Association, (1994). Diagnostic and statistical manual of mental disorders (4th ed,). Washington, DC: American Psychiatric Press. Barath, A, (1994, August). The children speak: Artandpoetry from the Croatian war. Invited address presented at the annual meeting of the American Psychological Association, Los Angeles, CA. Block, E. L. (1987, August). Victim-bystander behavior: Learning new roles from television newscasts. In E.L. Bloch (Chair), Television as a creator of social crisis attitudes. Paper presented at the annual meeting of the American Psychological Association, New York, NY. DaCosta, J. M. (1871). On irritable heart: A clinical study forum of functional cardiac disorder and its consequences. American Journal of Medical Sciences, 61, 17-52. Framer, M. (1990, August). When the earth stopped shaking: Psychologists role in disaster relief. Invited address presented at the annual meeting of the American Psychological Association, Boston, MA, Hiley-Young, B. (1992). Trauma reactivation and treatment: Integrated case examples. Journal of Traumatic Stress, 5, 545—555. Lazarus, R. (1983). Cognitive theory of stress, coping, and adaptation. Cape Cod Seminars: Eastham, MA. Lewis, T. (1919). The soldier's heart and effort syndrome. New York: Horber. Lindy, J,, Green, B. L., Grace, M., & Thchener, J, (1983). Psychotherapy with survivors of the Beverly Hills Supper Club fire. American Journal of Psychotherapy, 37, 593-610. McCarthy, K. (1994). Uncertainty is a blessing not a bane says Langer. APA Monitor, 25(9), 28, Myers, D. G. (1989). Mental health and disaster: Preventive approaches to Intervention. In R. Gist & B. Lubin (Eds.), Psychosocia I aspects of disaster (pp. 190-228). New York: Wiley. Perez,}. (1990). Responses to prolonged stress and trauma. Unpublished document adapted from "Operation Homefires." Los Angeles: Lifeplus Foundation. Simonton, O. C., Simonton-Mathews, S. X, & Creighton, J. L. (1980). Getting well again. New York: Bantam. Van Gennep, A. (1960). Rites of passage, Chicago: University of Chicago Press. Wilkinson, C. B., & Vera, E. (1989). Clinical responses to disaster. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 229-267), New York: Wiley.

64

Crisis Intervention and Trauma Response

Yeh, E, (1990, August), Reporting live from San Francisco; Anchoring news of the earthquake. In L, Porche-Burke (Chair), Victims of natural disasters: Aftermath of the San Francisco earthquake. Symposium conducted at the annual meeting of the American Psychological Association, Boston, MA.

Ch ap te .

4

PRINCIPLES AND MODELS OF INTERVENTION This chapter covers; * Defining crisis intervention * General orientation « A conceptual framework « Other intervention models » Our model * Discussion of model * Pitfalls to avoid * Exercise 4.1 » Help for the helper * Intervention models for communities in trauma * Small-group intervention models for trauma

DEFINING CRISIS INTERVENTION Although every text on this subject has a definition of its own, we feel that Parad and Farads (1990) definition is as all encompassing as is necessary: A process for actively influencing the psychosocial functioning during a period of disequilibrium in order to alleviate the immediate impact of the disruptive stressful events and to help mobilize the manifest and latent psychological capabilities and social resources of persons directly affected by the crisis {and often the key persons in the social environ-

65

66

Crisis Intervention and Trauma Response

mem) for coping adaptively with the effects of stress. The principal aims of clinician's intervention are: *

to cushion the stressful event by immediate or emergency emotional and environmental first aid and » to strengthen the person in his or her coping and integrative struggles through immediate therapeutic clarification and guidance during the coping period, (p. 4)

GENERAL ORIENTATION The intervention models that we will present in this chapter refer to the basic processes of interaction between the helper and the client. These processes apply whether dealing with a transitional crisis or a natural disaster, and whether the individual is seen alone or in a group. In trauma, as in crisis, the essential need of the individual is the same. The principle behind crisis intervention and brief therapy approaches for traumatic stress is that the individuals symptoms are not viewed as signs of personality deterioration or disintegration, but rather as signs of experiencing a period of transition that will be relatively brief in duration. The primary goal is to help individuals, couples, and families to manage the stressful transition period and to reinforce and introduce skills they may need to deal with future stresses. This model dovetails well with victims' perceptions of themselves: they see themselves as requiring assistance, but do not see themselves as mentally ill. The individual needs the opportunity to tell as detailed and unbroken an account of the event as possible. As the sessions progress, more details emerge and others drop out. Defending maneuvers should be joined, not challenged, unless these pose immediate serious harm to the victims or those around them (Bloch, 199la). Statistical probabilities ("The chance that this will happen to you again is one in a million") should never be offered in reassurance. From the victims own psychological standpoint, once something has happened, it can always happen again. The self-concept is a useful focus for therapy: The part

Principles and Models of Intervention

67

of the self that has been injured or lost; aspects of self-blame and how these can be used constructively to help protect oneself and others in the future (Frieze, 1987); and the relinquishing of certain parts of the self, for example, one's sense of invulnerability. Part of the victim's work in the therapy consists of becoming acquainted with the redefined, newer self. Many victims report that friends and relatives assure them that one day they will be "back to your old self." But once a tragic event has occurred, there is no going back, and the self is always altered in some way. The individual should be encouraged in empowering, action-oriented approaches to recovery. Some join peer support groups or speak before community groups about their experiences. Others keep journals and scrapbooks. Some write articles for or letters to newspapers. The close friend of a crime victim expressed her outrage at the criminal justice system in a letter to her local newspaper: "I look forward to the day when these two suspects are convicted of cold-blooded murder . . . trying this suspect as a juvenile only sends the message that it is acceptable to put a gun in the hands of any individual under the age of 18 and tell them to shoot." Some victims become involved in legislative and policy efforts. Parents of children killed by airbags banded together to make their losses public and to secure changes in the laws and directives applying to airbag use with children. Still others raise the issue in therapy of contacting attorneys to pursue lawsuits. In the therapy setting, victims need to feel safe in expressing a wide range of emotions, fantasies, and plans for action. Creative expression, selfreliance, and connecting with others who will listen and understand should always be encouraged. These individuals are demonstrating the "mastery" concept introduced in chapter 3. Helping others or speaking out aids them in their own recovery.

A CONCEPTUAL FRAMEWORK Most helping professionals work within one or more conceptual frameworks for their perceptions and reactions to clients. Generally

68

Crisis Intervention and Trauma Response

speaking, a traditional clinical assessment tool, such as the DSM-IV (American Psychiatric Association, 1994) or some other diagnostic tool plays this part. However, as we have said repeatedly throughout this book, the people we will meet in crisis and trauma situations are responding to circumstances rather than pathology, which makes these criteria less appropriate. However, a conceptual framework is important to clarify the helper's work and make it more effective. Before we appraise intervention models, we will introduce a framework that students and practitioners have found helpful. Although all people are created equal, they are also created uniquely. Being ever mindful of uniqueness and individual differences, we are still able to find certain consistent patterns of cognition, affect, and behavior. Recognizing these clusters can provide the helper with a perceptual set. We will see the value of this set as we discuss interventions at the Relate, Assess, or Refer levels. Lillibridge and Klukkens (1978) dilation-constriction continuum gives us a broad look at the extremes of behavior, cognition, and affect that are likely to be encountered in intervention. By understanding these differences, the helper can fine tune reactions to increase their appropriateness. Many clinicians automatically make these corrections, but often attention to this can be overlooked in the pressure of a crisis situation. By using this approach, professionals are able to assume a more appropriate response based on individual needs. Remember that while the characteristics on this chart are at either end of each continuum, it is the rare person who will present as a pure form of either extreme. The student will probably find herself or her client at some middle place along the line, but it is important to understand the difference in expected behavior at either end of the continuum, because each end of the continuum requires a different kind of approach by the helper. The student will find it helpful to keep these concepts in mind as we discuss intervention models and interventions. With this continuum approach, you will start to see the necessity for knowledge of a broad spectrum of approaches and techniques. Once again the breadth of human differences is emphasized. If you, as helper, have only one string to your bow, or even just a handful, your helpfulness will be severely limited (see Figure 4.1).

Principles and Models of Intervention

69

The characteristics of a person in crisis at the cognitive level will run the gamut from Dilated __________ to __________ Dilated characteristics; disorganized thoughts chaotic thinking much confusion

Constricted

Constricted characteristics: preoccupied with problem ruminative obsessive And need from the helper:

to clarify thinking be specific identify the problem

suggestions of viable alternatives working solution

Af the affective level, the characteristics are Dilated

„ ,„.,,

to

Constricted

overemotional no attempt to control expression

Holds feelings in

And need from the helper attempt to focus on specific feelings work with cognitive material

help in any way to express feelings

At the behavioral level, the characteristics are to

Dilated acting out excessive behavior inappropriate for that person

Constricted paralyzed immobilized withdrawn

And need from the helper reaiity-oriented problem solving

FIGURE 4.1 1978).

help to stimulate movement, do things

The dilation-constriction continuum (Lillibridge & Klukken,

On page 86, you will find some exercises on your response to the extremes of this continuum. We suggest that you do these exercises individually, in groups, or in class.

OTHER INTERVENTION MODELS Many writers and researchers in this field have found it helpful to generate models to express their ideas about the intervention process and, in turn, facilitate teaching. Several of the models we have studied over-

70

Crisis Intervention and Trauma Response

lap to a certain degree, yet each adds some new understanding for us. We will briefly list the models we feel are most relevant and then describe our own, which is an integration of some of the others as well as an evolution of our own thinking over the many years of working in this area. References are cited at the end of the chapter. If you are interested in exploring the other models in greater detail, you will be able to do so, We draw here on the work of Roberts (1991), Gilliland and James (1993), and Puryear (1981), as well as our own to integrate all the elements we have found significant and effective in this work. The Roberts model is of much value to our understanding, and offers a good basic orientation to the crisis-intervention approach. However, by not including the differences in the spectrum of personality types, such as that presented by Lillibridge and Klukken (1978), we feel that it does not fully meet the needs of our conceptual model. A summary of Roberts' model follows: 1. 2. 3. 4. 5. 6.

Make psychological contact and rapidly establish the relationship Examine the dimension of the problem to define it Encourage an exploration of feelings and emotions Generate and explore alternatives and specific solutions Explore and assess past coping attempts Restore cognitive functioning through implementation of action plan 7. Follow up

Gilliland and James Model The Gilliland and James (1993) model incorporates other important elements in the crisis worker's function by understanding the importance of what the worker brings to the situation. These include personal perception, life history, past experiences, culture, trauma, and personal biases. These elements are very important, because no one of us is either an automaton or a tabula rasa. Crisis workers are human beings with pasts that incorporate personal, interpersonal, and cultural histories. Although this past can often create a special sensitivity in its owner, it can also alter perceptions and

Principles and Models of Intervention

71

create blindspots—areas where these experiences have caused ones vision to be clouded. Although some professionals in this field may believe that life experience in and of itself provides a special understanding of some crisis issues, it is equally possible that these experiences may leave the worker with too much unresolved emotional involvement or a preconceived, potentially prejudicial vision. Thus, we do not believe, for example, that the experience of having been an alcoholic or an incest victim in and, of 'itself authorizes anyone to become an alcoholism or incest counsellor. In addition to proper training in any of the mental health areas, much psychological work must be done by those who have traumatic experiences in their pasts. Each worker must be sufficiently aware of her/his own blind spots to understand her/his limitations and respond appropriately. Each worker needs to understand the kind of situation in which she/he cannot be effective, and should she/he find herself/ himself in a blind-spot area, she/he then needs to refer the client on to a colleague. For example, consider the case of a psychologist who witnessed the accidental death of a sibling while she was a child. For many years she was uncomfortable with issues of childhood death and had to refer these cases to colleagues. Eventually she did her own work m therapy and was able to work as a competent professional with this kind of case. Other students we have worked with have reported that because their own life experience had included severe trauma, as in wartime experiences, they were unable to sympathize with what they considered lesser traumas. Thus, when presented with the scenario of a college student who had been abandoned by her one friend and was suicidal, they could not identify this as a crisis situation. Still others have become aware of long-suppressed traumas in their own background that slowly emerged as a result of exposure to other peoples experiences. In one of our classes, during a demonstration of nonverbal expressions for anger, one student suddenly had a flashback to severe childhood abuse. Others have responded this way to presentations on rape and incest. The Gilliland and James model, in outline form, follows: 1. Recognize individual differences 2. Assess yourself 3. Show regard for clients safety

72

4. 5. 6. 7. 8. 9. 10. 11. 12.

Crisis Intervention and Trauma Response

Provide client support Define the problem early Consider alternatives Plan action steps Use the client's coping strengths Attend to client's immediate needs Use referral resources Develop and use a network Get a commitment

Puryear's Principles One of the most helpful models we have found in teaching in this area has been that of Puryear (1981), Perhaps because it was one of the earliest and most inclusive, we have found it to be very helpful. As you will see as we go on, it, too, has certain lacunae, for which we have attempted to make corrections in our own integration. Puryear's principles, in outline fashion, follow; 1. Immediate intervention 2. Action: actively participate and direct the process of assessing situation and formulating action plan 3. Limited goal: minimal goal is to avert catastrophe; basic goal is to restore hope and growth 4. Hope and expectations: instill hope into the situation by appropriate attitudes and expectations of clients 5. Support 6. Focused problem solving: determine the problem, then do appropriate planning and design action steps 7. Enhance self-image 8. Encourage self reliance

OUR MODEL We borrowed some concepts from all of these models and integrated

Principles and Models of Intervention

73

them with our own to present the following set of principles of intervention. Our model integrates much of the work of our colleagues cited previously and adds to it two aspects of our framework. The first is the general model of relate-assess-refer/respond, and the second is our adaptation of the dilation-constriction continuum.

Relate-Assess-Refer/Respond We subdivide the relate factors into two types: attitudinal and technical. The attitudinal aspects of relating will be carried through all three aspects of the intervention, that is, relate, assess, refer. These are defined below, as are the technical relating concepts. Technical concepts include aspects such as problem definition and solving, action and activities, approaching support networks, and so forth. Technical relating may be put into effect after the assess portion is achieved. Our model, in outline form, follows:

Relate

A. Attitudinal relating 1. Establish initial relationship and create a safe place 2. Adjust relationship approach on basis of dilation-constriction; encourage emotional reactions for constricted and cognitive expressions for dilated 3. Check your own reactions to the situation and the client 4. Pace appropriately and shift if necessary (mirror-pace-shift) 5. Validate and normalize 6. Respect individual and cultural differences 7. Create a climate of hope 8. Avoid trivialization 9. Be conscious of suggestibility B. Technical relating 1. Reinforce strengths and raise the clients self-esteem 2. Encourage self-reliance 3. Define your own role 4. Clearly define the problem and expand problem solving 5. Explore the clients past coping strengths to enhance selfimage

Crisis Intervention and Trauma Response

74

6. Teach a new skill, coping mechanism, or approach 7. Jointly design activities 8. Support Assess Assess for

1. Urgency 2. Severity 3. Appropriateness of response 4. Status previous to experience 5. Resources • internal • external * community * spiritual 6. Goodness of fit of severity and resources Refer 1. Community resources 2. Other professionals

DISCUSSION OF MODEL Atdtudinal Relating The individuals you are working with may be experiencing confusion, numbness, severe stress, fear, and a sense of overwhelming danger. Problem-solving mechanisms may be on overload, and self-perception, as well as perception of the world around them, has just been shaken to the core. They may have tried, or may be trying, to resolve this difficult situation in ways that can prove to be counterproductive and may find themselves going around in circles and not getting anywhere. They may feel that they have everything under control, but in reality they may be overlooking something of great importance. Your initial

Principles and Models of Intervention

75

contact must be reassuring and validating but not trivializing, supportive but not smothering, respectful of their needs with knowledge that you have to guide them to realistic solutions. You must also consider your power to create suggestibility. As Puryear (1981) tells us, "help to face reality in manageable doses. Facts must eventually be faced but will not necessarily all be heard until ready" (p. 37). Let us look first at some of these special demands on the listener in crisis situations. Establish Initial Relationship and Create a Safe Place Carl Rogers* (1951) basic concepts of empathy, unconditional positive regard and nonjudgrnental warmth, should be basic to any work you do, and we will look at these in greater detail in the training chapter. But if your armamentarium of skills is limited only to this approach, you will not be effective in this work. You must be prepared with a wide variety of skills and approaches. Crisis is no time for traditional leisurely exploration. The client is in great pain and you must be able to take an involved, active, engaged stance in the relationship. This requires access to a broad range of skills so that you can connect and collaborate quickly with the client. Intervention skills must therefore go far beyond traditional active listening. You may need to employ techniques from other modalities (such as Gestak, Bioenergetics, Psychodrama, and so forth; see chapter 7) to be effective. The goal of effective listening is to create a safe environment, both around the client and within the clients own being. As Carkhuff (1971) says, we need to provide "a sanctuary of solitude, a moment of respite for a world closing in." In an earlier chapter we described the need of trauma victims to create a safe place after the incident. The worker can facilitate that safe place construction by an appropriate presence. Chapter 7 has some examples of ways in which the helper can do this, Adjust Relationship Approach on Basis of 'Dilation-Constriction As we have seen previously, the dilation-constriction continuum helps us to recognize that because people respond differently the helper must be prepared to do the same. Thus, the individual who is dilated needs thought clarification, problem identification, and help in organizing a

76

Crisis Intervention and Trauma Response

focus to bring feelings under control and to focus. The constricted person, on the other hand, needs viable alternatives to the rumination that may be present, help in any way to express feelings, and stimulation of some kind of movement in the service of problem solving. The helper's experience with each of these people will be quite different, and awareness of this difference must be made as soon as possible in the interaction, Check Your Own Reactions to the Situation and the Client Maintain the position that the clients experience is a normal reaction to an abnormal situation. If you sense that this is not so, assess your own perceptions, and check yourself for judgmental reactions. Then reassess the degree of reality testing you see in the client. Workers in this area need to adapt a rapid automatic scanning device to keep in touch with their own reactions as they are in close touch with the client. One quick way to do this is to stay in touch with your body: locate an area in your body that you generally associate with tension, and tune in to that area as you work. If you discover any unusual discomfort, you need to assess your reactions further. Earlier we alluded to the concept of the blind spot, and this could be one source of tension. Another may be overidentification with the situation. Unlike traditional therapy, the client here is experiencing something that could be happening or has happened to the helper. Maintaining a clear boundary between what belongs to the client and what belongs to the helper in a situation like this may be difficult, but not impossible. Practice in scanning will help to develop that skill. This issue is covered further in chapter 7. Pace Appropriately and Shift If Necessary While you will feel pressured to work quickly, you must always remember that the client sets the pace. Particularly in crisis work, where you may be meeting your client near the site of a disaster or in a hospital waiting room rather than at a voluntarily scheduled appointment in your office, you must be extremely sensitive to his timing and readiness to discuss the situation. The concept of mirror-pace-shift

Principles and Models of Intervention

77

(MPS) ties this all together. By appropriately mirroring the client's reactions (and we emphasize that the key word here is appropriate) and assuming an appropriate pace, you can facilitate the clients shifting to a more effective response. Validate and Normalize Throughout this book we have been emphasizing this point, but it can be reiterated here, too. The literature on trauma and crisis emphasizes the importance of helping clients to understand that they are dealing with an abnormal situation rather than an abnormality in themselves, that is, to normalize the situation (Ochberg, 1991). Therefore we must, whenever realistically possible, validate the clients' feelings and reduce their fears that they are crazy or foolish. We must emphasize the fact that the situation is abnormal, but that the client remains a normal person reacting to that situation, "Provide a supportive situation for the client to face the pain . . . and understanding acceptance of feelings—feelings need to be experienced, expressed and validated" (Puryear, 1981, p. 38). Respect Individual and Cultural Differences Understanding the diversity of our North American culture requires some knowledge of how different cultures respond both to crisis and to the concept of a helping person. Some groups will feel shame at the thought of sharing their pain with strangers, others will welcome it. The helper needs to be able to perceive the degree to which the client's behavior may be bizarre, deviant, or conforming not just to North American standards but to standards of his/her group—the values of his/her social class, ethnic group, and so on. Create a Climate of Hope The client's life, or some part of it, has just been shattered. The worker represents some hope that perhaps there is a safe corner in the world. The client's trust in the world has been shaken, if not shattered, by the experience. The worker needs to help reinforce what hope

78

Crisis Intervention and Trauma Response

remains or reinstate new hope in the client. As Puryear (1981) says, "promise nothing but expect a great deal" (p. 30). Understand as well that you cannot provide a magical cure, but that together you will explore possibilities that will improve the situation. Work with the assumption that the client will function well and that together you will problem solve successfully. While maintaining an attitude of optimism, be sensitive, however, to the degree of the client's pain. Avoid being simplistic in your approach and recognize the demands being made on the client at this time, Avoid Trivialization Lazarus (1983) and others have pointed out how easily we can fall into the trivialization trap and how debilitating that can be to the client. When faced with a client's pain, our own need to make it disappear may surface as ways that may appear helpful but are, in effect, trivialization. We often hear people in these situations attempting to undo the pain by saying, "It will get better" or "You can have another child (pet, house, etc.)" or "Don't worry, I know everything will be alright." The client hears this as a minimization of his/her emotional needs and a glossing over of the distress. It will, at the least, lead to a "Yes, but" response from him/her, and, perhaps even more significantly, an eventual withdrawal from the helping relationship, as his/her sense of legitimacy is questioned. As this happens, he/she feels inadequate because the pain continues and is not acknowledged, creating a feeling of failure and unworthiness. Perception of reality is undermined. Be Conscious of Powers 0fSugge$tion We must also be aware of the power of the worker at a time of crisis. Crisis, whether physical or psychological, makes people highly suggestible, and, some (ASCH, 1994) would suggest, actually puts them into a trance state. An unwitting reinforcement of a potentially negative outcome can create the expectancy and the possibility that this outcome will develop. For example, in a physical emergency, if a doctor tells a patient that a wound will probably hurt for 10 days, chances are that because of suggestibility and the creation of expectations, the

Principles and Models of Intervention

79

wound will truly hurt for 10 days. Clients in crisis often want to know "how long will this pain continue?" We need at this point to honestly tell them that we cannot predict that answer. If we underestimate the time, we collude with reinforcing their own sense of inadequacy: "Other people feel better in 2 weeks but I can't seem to do that." If we overestimate the time, we may be setting them up to feel bad longer than they really need to,

Technical Relating Although there is no prescribed timeline for any of these functions, some of the following, technical relating may sometimes occur only after the assessment has been done. Reinforce Strengths and Raise the Client's Self-Esteem No matter how poorly clients may perceive themselves, it is important for you to focus on the strengths that you see and to reinforce them. Even if you have difficulty in finding anything to reinforce, at the most minimal level, you can reinforce the clients bravery in speaking to you or seeking you out to talk to. Although this may seem simplistic and trivial it can be of great importance. Often in crisis and trauma situations people will suffer pangs of self-blame: "Why did I let him go out?," "Why didn't I check the furnace?," etc. What self-esteem they may have had may easily be eroded at this time. Even your earnest attempts to reinforce their strengths may be very difficult for some persons to accept. In order to understand the injunction that many people in our society have about accepting compliments or hearing good things about themselves, we have provided a "plussing" exercise that can be done in class or in any groups of two. In discussing this exercise you will come to realize more fully the difficulty involved in hearing or expressing good things about yourself. In his training in Values Clarification, Dr. Sid Simons (personal communication, 1975) refers to this phenomenon as having a vulture on your shoulder that has been trained to punish you whenever you think or say good things about yourself. For many of us our experience in schools may have reinforced this dictum, and well may have been told that it is not acceptable to

80

Crisis Intervention and Trauma Response

"get a swelled head." But crisis is a time when it is necessary to help the client hang on to all of his/her strengths and stabilities, and the worker s job is to help the client reconnect with these strengths and stabilities and to refocus from the crisis-induced position of harm, fear, and isolation, to one of reconnecting with the functional, preincident self. If the helper can focus on positive aspects of the client, as opposed to pathology, it will not be difficult to find positive things to reinforce. As we pointed out earlier in discussing loss and confusion, here, too, the worker has to train himself to a level of comfort. If the worker cannot tolerate receiving or giving positive attributions, this cannot help the client. Encourage Self-Reliance At a time of crisis it is easy for the client to feel helpless and dependent. As Puryear (1981) points out, under stress we all wish for a magical mommy to make things better. However, if you try to play "Magic Mommy," it will not only encourage dependency, but will end in failure. No one is capable of being the totally magical parent. About the closest that one of us (B.W,) ever got occurred during a personal crisis, when after a long and painful meeting in another city, she left to go to the airport. On the way, she stopped in at a little food shop hoping that some chocolate would make it easier. There she found and bought a small package of brownies with the wonderful label "Magic Mommy Brownies." They were certainly a treat and she did feel better, but the problem was still hers to resolve. Puryear, and others, also remind us that encouraging dependency lowers the client's self-esteem in the long run (see also Rescuer Triangle). As Parad (1965) says, "do only what the client cannot absolutely do himself, and no more" (p. 24), Clients do, however, respond well to a reward system, and the best reward is one that they can earn by themselves and thus strengthen their own sense of self-respect. One way to do this is to have the client make a goody contract. This requires him to make a list of all of the things he would consider positive reinforcers that are realistic and attainable. This can include things like going swimming, meeting a friend for lunch, or taking a quiet walk. Contract with the client to do as many of these things he considers possible. One of the basic concepts

Principles and Models of Intervention

81

in Assertiveness Training is the concept that each independent achievement reinforces the sense of self and leads to greater strength for the next hurdle. Each dependency behavior leads to lowered self-esteem and more difficulty in the future. Crisis is a time of great vulnerability and emphasis on building strengths can be a powerful influence at this time. Define Yonr Own Role After having checked your own reactions to the situation and the client, you need to be clear about what you can and cannot do and communicate this to the client. As Puryear (1981) tells us, "you are not an expert in living who knows how other people should live, and can see how others should solve their problems" (p. 36). If you see an easy, simple solution watch out, you've missed something unless it is simply a matter of locating information, or lack of knowledge, as, for example, "where can I find a list of Alcoholics Anonymous meetings?" Puryear (1981, p, 36) said, "you are an expert only in the process," Clearly Define the Problem and Expand Problem Solving Again, your approach to this will vary depending on where the client is on the dilation—-constriction continuum. In either case you need to clarify the problem at hand, that is, not "my life is over," but "where can I sleep tonight" or not "I'm going to kill my husband," but "I have to find a divorce lawyer." Explore a joint approach to examining alternatives and solutions to the problem. This would involve: • Naming the problem (described above) • Exploring alternatives • Chunking, simplifying the issues as much as possible while being sensitive to the client's pain. By chunking the problem, that is, breaking it down into doable segments, it becomes less formidable. Chunks also allow the client a sense of success over closure, rather than a protracted period of frustration because the entire situation has not changed. If, for example, a client tells you, "My house has burned down. I don't know where to turn-—I can't see how I will ever recover the loss of my

82

Crisis Intervention and Trauma Response

most beloved possessions. I don't know how much insurance I have. I don't know what will become of me," the helper can easily start to feel as overwhelmed as the client. It is important at this point to help reframe the problem so that the client can feel that something is being done, and that she/he can make some immediate change. It might be helpful to direct her/him toward focusing on immediate needs, such as a place to sleep tonight. This will not solve any of the very overwhelming problems, but it will give some sense of accomplishment and a feeling that she/he has some control over one area of her/his life. This "chunk" can provide closure for the client, and some sense that she/he is not totally adrift. * Explore the possible consequences of each solution (example: If I move into my friends house, how will it affect our relationship?") • Try out the solution. If it feels comfortable, the problem is solved, if not, repeat the process until a greater comfort level is achieved. Explore the Client's Past Coping Strengths This topic is dealt with at greater length in chapter 5. The major point here is to tune into the patients own strengths as resources to apply to the present situation. Often at times of upheaval we lose track of those very abilities that we have successfully developed in our lifetime, and need help in remembering past capabilities. A person in crisis may also feel like a failure for having made some wrong decision or having taken a wrong turn that somehow created the noxious situation. This kind of thinking can lead to an attitude of despair, of blame on self and others, or of displaced sadness that emerges as anger at others. Sometimes a simple exercise like the "Ten Things" exercise on page 88 can break this cycle. This exercise refocuses clients' self-perception, reminds die client tJiat there are in fact good things about him/herself, and that he/she is worth recovering. Often we suggest having the client take the list along with him and refer to it from time to time, or turn it into a mantra, which can be repeated and used when die stress level becomes too high. Teach a New Skill, Coping Mechanism, or Approach Give the client something to take away. It is important for the client to leave the first contact with you with a sense that something concrete

Principles and Models of Intervention

83

has been done. In a world where little concrete security appears to exist, the client needs to feel that a new road has been opened, that there has been some shift in the experience, that something additional has been achieved, that something has been changed. This can take the form of additional information, new resources (see below) or even a stress-reducing exercise. Examples of these will be found in chapter 7. They can range from a relaxation exercise, to cognitive refraining, to methods of connecting with resources. A very simple visual-imagery exercise, such as the following, can be very helpful: "Close your eyes and breathe comfortably. Now visualize yourself as you were before this terrible thing happened to you. What would I see if I saw that person? What would she/he be doing? What would she/he be feeling?" After a few moments of this, the helper can change the imagery to "How can you see yourself after all of this is past?" Helping the client to apply some of the strengths she/he has indicated in the "myself before the crisis" exercise and applying these to the "myself after the crisis" can be very effective. Jointly Design Activities The more active the client is, the more empowered she feels, particularly in time of distress. Active assignments help normalize life and make her feel more in control of life. Getting information on a FEMA loan or researching divorce lawyers or surgical approaches will make her feel that she has some input into her life. Jointly design an action plan. Behavioral planning, particularly for weekends, can be very valuable at this time. Weekends are often a time when all social services are closed, and on Sunday, in many cities, even libraries are not available for distraction. With suicidal cases in particular, it is important for the client to design a plan of activity or involvement with other people, particularly over the weekend. Support Help clients understand the level of support required at this time and assess the available support. Although we touched on this subject in chapter 3, it is sufficiently important to review again at this point. It is

84

Crisis Intervention and Trauma Response

sometimes helpful to have the client focus fully on potential support sources by writing a list of all the people the client knows, many of whom may be overlooked at this time. Then you can help to categorize them according to a method that we have developed (Wainrib, 1976), which has been found to be very helpful. Our definition of support is "access to the quality of relationship necessary at a given time," What this means is that although there may be many people available to the client at the time of crisis, if the quality of their relationships is not appropriate to the client's needs, support will not be perceived by the client. Relationship needs take a variety of different forms, which we have designated as levels one (casual), two (informational and instrumental), and. three (validating, intimate, spiritual). Casual support in our model may just be that of someone who says "hi" to you, and may in the course of a normal day seem insignificant. However, if you can imagine yourself in a situation where there is no one else in your milieu, and you are suddenly greeted warmly, you can understand how important this can be. Instrumental support is provided by those people with whom you share a group experience or a task. These may be people in your church, synagogue, or class, or people with whom you work. At a time of crisis, this can include the emergency worker, rescue team, the librarian that you seek for more information, or your neighbor who shares your immediate experience. Level three relationships are the most intimate in quality of relationships. These are the most difficult relationships to create and cause the greatest pain at their loss. Crisis may touch deeply at this level. However, if you have an intimate person available to you at the time of crisis, but what you require is information that this intimate person does not possess, then the necessary support is not available. The essential concepts in understanding support are both appropriateness and availability. Understanding these concepts can be very helpful in clarifying clients' needs. Another important aspect of support is the degree to which the person reaches out to access support (an issue we touched on in chapter 3), and the crisis worker can be of great help in this respect, as long as the worker checks the client's progress in accessing and utilizing support. If necessary, be available yourself as a member of the network, but only for a limited time and with clear boundaries. Where the suicide potential is high, you may need to be available at any time.

Principles and Models of Intervention

85

Assess In chapter 5, we will examine assessment at greater depth. The issues we will consider are as follows: UrgencySeverity Appropriateness of response Status previous to experience Resources « internal » external • community * spiritual Goodness of fit of severity and resources Refer Keep a list of community resources (everything from support groups to divorce lawyers) available as an adjunct to your work with the client, If necessary, and only if necessary, help the client make contact with these organizations. Remember that resources in time of crisis include interpersonal networks, community groups, and spiritual sources. Refer to a more appropriate professional when you have reached your level of competence.

PITFALLS TO AVOID 1. Telling the client what to do. One of the essential pitfalls to avoid is what Puryear (1981) warned us about. That is, that you do not have answers, but you do understand the process. You understand how people react at times of crisis and trauma, you can differentiate between the normal and the pathological, and you can facilitate the positive aspects of clients' journeys from despair to hope. You cannot, however, ever tell them what you think they should be doing.

86

Crisis Intervention and Trauma Response

2. Dazzling. Some clinicians, particularly those less experienced, have fallen into the trap of trying to appear brilliant and dazzling. They may be motivated by trying to impress the client or perhaps by trying to convince themselves of their own abilities. In the course of doing this, they may attempt to come up with what appear to be wonderful solutions much too soon. As a result the solution may be quite inappropriate. If the helper tries to appear dazzling, this focus may cause him/her to overlook some important aspect of what the client needs. Remember, the client is the star of this drama, not the helper! No mortal can consistently be both dazzling and also empathic. 3. Playing rescuer. Be aware of the "Drama Triangle" in which the three positions are rescuer, victim, and persecutor. If you view another individual as a victim and feel they are unable to function without your rescuing efforts, then you have assumed the role of rescuer. The drama triangle is one in which you play all three roles before the drama is played out. Thus, if you start as rescuer, you will eventually be perceived as persecutor, as the client feels strong enough to resent your rescuing and may turn against you, putting you into the victim role. 4. Personal revelation. You may, at some time in your life, have have had an experience that is similar to that of your client. Part of you may want to jump in and say, "I've been there, and here I am, proof that one can survive this experience." On the one hand, this can, under the right circumstances, sometimes provide good modeling for the client. But, and this is probably the more prevalent reaction, your own experience may make you appear powerful to the client, who can be very fragile at this time. This perception can set off the client's sense of feeling pain and worthlessness. He may respond with, "sure, you could do it, but I can't," and feel inadequate and self-punitive. This topic is developed further in chapter 7.

EXERCISE 4,1 Dilation—Constriction As you read the descriptions of the differences between dilation and constriction you may have thought, "Oh, I'd rather work with a dilated

Principles and Models of Intervention

87

person. I can have easy access to their affect and direct them comfortably," Or perhaps, instead, "I'll be better with the constricted types. I'm like that myself, and I'll know just what to do." Here are two scenarios. As you read them, imagine that you are the crisis intervention worker. Get in touch with your own thoughts, feelings and body language. Consider yourself in this scenario: The door to your orifice is flung open and in walks a burly, 45-yearold man, 6*2" tall, weighing about 250 pounds. His face is red and his breath smells vaguely of alcohol. As he sits down he says, "the M—F— ers fire nie and tell me to come here ! Here! As if you can do anything! All my life I've been on this job and now they tell me mortgages cost too much and they can't build houses any more. Big deal. And how am I supposed to pay my mortgage and feed my wife and kids?" He gets up, stomps around the room picks up some things on your desk and says, "I could tear this place apart. I could tear the bosses apart with my bare hands. Twenty-five years of hammering nails and I could rip this place apart," How do you feel as the crisis worker? Frightened of his physical strength? Unsure of how to proceed? Get in touch with your own fears, limitations, and areas we will call blind spots, places you prefer not to touch, people who frighten you. Understand what the extremes of dilation can look like and feel like. Now consider this scenario: You are called into a hospital room where a 70-year-old woman sits beside an empty bed, recently occupied by her husband who died a few hours ago. She is withdrawn, immobilized, silent. She will not respond to anything anyone says to her, nor will she leave the room. How does this scenario make you feel? How do you respond to someone who will not use words? If you've come this far in the academic system, words are probably

88

Crisis Intervention and Trauma Response

very important to you. We will spend more time on this in chapter 7. Get in touch now with how uncomfortable you may feel with this extremely constricted person. Which scenario is more frightening for you to deal with? What do you need to change these feelings?

Plussing Work in dyads. For the first 3-minute segment, A tells B all the positive things he can think of about A. They then exchange feedback on how the experience felt and switch roles, B now spends 3 minutes telling A all of the positive things about B. After feedback is exchanged and the experience is processed, A then tells B all of the positive things A observed about B; this is then processed and the roles are reversed.

Ten Things The goal of this exercise is to shift the thinking from the negative, angry, blaming mode to one that is more positive. This simple exercise comes from asserriveness training and asks the client to write down 10 things that the client likes about herself. At the moment the client is asked, she may feel this is an overwhelming demand, but with encouragement this can be done. The list can include personal characteristics, physical characteristics, activities (as long as they emphasize the self; not, "I like riding" but, "I like myself while riding," etc.)

Visual imagery, as well as the sleep exercises, will be found in chapter 7.

HELP FOR THE HELPER As a helping person working with people experiencing trauma, you will eventually become prone to vicarious trauma. You have been exposed to

Principles and Models of Intervention

89

many terrifying experiences that could easily have been part of your own life, and maintaining boundaries is crucial. However, it can become increasingly difficult with exposure, Herman (1992) discusses the experience of traumatic countertransference in helpers, and many people who have worked in this field have corroborated her findings. Saakvitne and Pearlman (1996) differentiate between secondary traumatization and vicarious traumatization. While the former refers to those people who are connected to the direct trauma patient, vicarious traumatization "refers to the cumulative transformative effect on the helper of working with survivors of traumatic life events." The authors continue, "we are all profoundly changed by the work we do with survivors of trauma . . . (both positive and negative) , . . (and ) we (also) believe that all trauma workers must be aware of vicarious traumatization and its effect" (p, 17). Their book Transforming the Pain can be very helpful to trauma workers dealing with their own vicarious traumatization. Debriefing the debrieferis another regular step in the work of the trauma team, as you will see in chapter 7. It is important for you to have access to many of the kinds of resources that you would recommend for your clients. A viable support system, with people who can really hear and understand your experience, is essential. This may often include a professional as a central piece of the system. Supervision by a more senior professional can also be of great value in maintaining your full function. As well, many of the stress-reduction skills that we suggest as we go through the book should be adapted for your own use. This serves a dual function. First, it is easier to recommend something that you have tried and is not completely foreign, and second, it helps to maintain your own stress level at a better functional level.

INTERVENTION MODELS FOR COMMUNITIES IN TRAUMA Like individuals, communities that are traumatized may suffer from denial (Bolin, 1989) or profound overreaction to threat. The community of military dependents during the Persian Gulf war experienced a

90

Crisis Intervention and Trauma Response

perceived threat of combat that created traumatic stress reactions among family members (Bloch, Zimmerman, Perez, Embry, & Magers, 1991). For the first time, deployment and the conduct of war were presented in "real time" to the television viewing audience, sparking anxiety reactions not only among families of the military, but also among other community members. Certain ethnic groups, particularly Muslims, experienced a wide range of emotions stateside—not the least of which was fear of reprisal. At the other end of the continuum of possible responses is denial, or underestimation of threat. In a White, middle-class suburb of Louisville, Kentucky, in a manicuredlawn community unaccustomed to crime, neighbors walked and drove by a dead body lying on a front lawn next to garbage cans, between the hours of 7 a.m. and 2 p.m., rnisidentifying it as a "mannequin" or a "statue.™ The body was bloodied and in plain view of the passersby, a number of whom had stopped momentarily to take a closer look before walking on (Harris, 1994). The peril of denial is the underestimation or minimization of potential serious harm. Profound overreaction may, on the other hand, throw the community into a panicked, confused, disorganized state. One segment of the recovery environment for communities is the therapeutic community (Bolin, 1989) and how effectively it functions. The mental health professional may play a number of important roles in the therapeutic community: direct service; consultation to community organizations; delivery of psychoeducational services and resources; conducting group debriefings; and administrative functions in conjunction with the delivery of services. In general, beyond direct-service delivery, the professional is useful to the community by using one, or all, of a three-pronged approach.

Information In order to educate the public about the nature of the traumatic event and anticipated emotional and behavioral reactions, the most effective means is through the mass media and community group education. The functions of information dissemination are to reinforce existing knowledge and coping skills (the first thing lost in a crisis is common sense), to offer new information, and to dispel rumors. Information

Principles and Models of Intervention

91

may be given about the normal and expected psychological reactions to the crisis, tips on coping (both for adults and children), and the availability of mental health assistance. Television and radio interviews, newspaper articles, PSAs (public service announcements), and speakers' bureaus are effective, as are creative approaches such as informational flyers inserted in supermarket and liquor store bags and inserts in utility bills (Myers, 1989). Public education messages need to be frequent, consistent, and simple to understand. They need to be relevant for daily life and concerns. They must incorporate and reflect cultural and ethnic needs, as well as meet the needs of the disabled. Your PSA is of no use to the hearing impaired without closed-captioning. Advice to seek help, without transportation information, is often useless to the mobility-limited population. And, whenever possible, your educational messages should be timed immediately following the crisis, when most people are receptive to hearing new information.

Education and Training Education and training can be organized for groups of service providers responsible for interacting with and meeting the immediate and longterm needs of victims (Bloch, I991b, c). These groups include the Red Cross, the Salvation Army, local social service groups (including those associated with religious organizations), public health agencies, physicians, the clergy, the police and fire departments, and funeral directors, Examples of topics one might cover in meetings or short workshops would be: * The myths and realities of human behavior in traumatic situations " Responses/reactions of adults, adolescents, and children following disaster * Mechanisms for individual and family referral for mental health counseling * The needs of families, and especially children, who are geographically displaced, or separated, during a time of trauma * The needs of special groups such as older persons and those with disabilities

92

Crisis Intervention and Trauma Response

• Understanding and coping with one's own reactions as a helper or caregiver during times of crisis. Education can also be provided for "naturally occurring" groups in the community, where previously unaffiliated people are brought together out of common concern or interest and united in the goal of providing relief and resources to those stricken (Bloch, 1991d; Kramer, Bloch, & Grace, 1991). A number of such groups form postcrisis associations and continue their work of prevention in the community, Examples here include neighborhood support and action groups, atrisk groups already formed (e.g., Parents of Murdered Children), and neighborhood crime and disaster preparedness networks. Because knowledge, both clinical and empirical, is rapidly expanding in the areas of crisis intervention and trauma response, these groups may welcome speakers and stand-by assistance to enhance their current efforts.

Consultation Consultation services can be delivered to community organizations and agencies, to the media, and to naturally occurring groups. These are almost always homogeneous groups that may request either process consultation or program consultation. Process consultation assists the group in becoming aware of organizational processes helping and/or hindering service delivery. Program consultation provides technical assistance, staff training, and assistance on specific projects designed to meet the goals of the group.

SMALL-GROUP INTERVENTION MODELS FOR TRAUMA Although traditional counseling and psychotherapy models focus on individuals and family as targets of intervention, in crisis intervention and trauma response work the small group becomes a natural and highly efficient focus. The small group can function as the target of

Principles and Models of Intervention

93

either prevention or intervention approaches, thus mitigating the more severe mental health consequences associated with traumatic experiences. Small group work has been used effectively with both adults and children. In most cases, the group is a "naturally occurring" one, that is, those in the group are joined by common experiences they have faced, or may face in the future, and although not related to one another, they are nevertheless bound together as coworkers, classmates, parents, or neighbors. Adults One of the most widely used small group interventions is the Critical Incident Stress Debriefing (CISD). It was originally formalized by Mitchell (1983) to be used with relief personnel at the scene of disasters.

The model and its variations have since been used with other groups victimized or secondarily victimized by traumatic events. Empirical data on the effectiveness of this and other similar group debriefing techniques indicate that these debriefings may not accomplish all that is claimed (Raphael, Wilson, Meldrum, & McFarlane, 1996; Linton, 1995). Nevertheless, Mitchell's method and its variations continue to be used in numerous settings and to be regarded as a s-uccessful way in which to bring people together to share and understand mutual, distressing experiences. There are four types of CISD: (1) The On-Scene or Near-Scene Debriefing, (2) The Initial Defusing, (3) The Formal CISD, and (4) The Follow-Up CISD. The Formal Debriefing is used most often. It is led by a mental health professional, follows a set format consisting of six separate segments, and lasts 3 to 5 hours. The debriefing ordinarily occurs about 24 hours postcrisis. The six segments of the process are: 1. 2. 3. 4. 5. 6.

Introductory Fact phase Feeling phase Symptom phase Teaching phase Reentry phase

94

Crisis Intervention and Trauma Response

The stages of this process introduce the groups purpose and rules of confidentiality; the objective and subjective experiences of the group members; physical symptoms, psychological symptoms, or both; a psychoeducational component delineating stress response syndromes and emphasizing normalization of traumatic reactions; and a wrapup, which allows participants to reenter and gain some closure (see McLain, 1996), Crisis debriefing has been used with juries following murder trials (Feldmann & Bell, 1991), with disaster relief workers following earthquakes (Armstrong, O'Callahan, & Marmar, 1991), with law enforcement workers following homicides (Sewell, 1993), and with health care workers following patient death (Lane, 1993—1994), One of us (E.B.) conducted a 1-hour group debriefing of electrical workers at a plant near Cincinnati, Ohio following the sudden workplace death of a 37-year-old female coworker who died of a heart attack. The group was predominantly male and taciturn about expressing feelings. After 15 minutes, however, group members began to share their experiences, during which a vivid picture of the victim, and failed attempts on the part of her coworkers to save her life, emerged. The group became emotionally more connected, expressed support for one another, and together planned memorial remembrances for the victim and her family. The group expressed appreciation to the plant supervisor for his support and for arranging for the debriefing. While more research is needed in determining beneficial outcome, the crisis debriefing technique seems adaptable to a variety of populations and appears to be intuitively sound (McLain, 1996).

Children Mitigating stress and emotional disturbance among children experiencing traumatic events has been the objective of a number of prevention and intervention efforts. Children do not have the same sense of personal control over their lives as adults and, at the younger ages, lack the cognitive abilities to process what has happened to them. Also, because of their developmental stage in the life cycle, they rarely have other experiences with which to compare the present, disturbing one. They cannot say to themselves, "other events like this happened to me

Principles and Models of Intervention

95

in the past, and when they happened I did these particular things to make myself feel better." Younger children, in particular, have difficulty verbalizing their feelings and mental images, Of the many small-group interventions used for children, two creative approaches are described here, Expressive Arts Therapy as Intervention Expressive arts therapy weaves artistic methods into clinical work. Drawing, painting, dance, music, and poetry may all be used to encourage children to express what they have experienced (Azarian & Skriptchenko-Gregorian, 1993; Barath, 1993; Barath, Matul, & Sabljak, 1994; Bloch, 1993; Shilo-Cohen, 1993). It is a multimodal, actionoriented approach. From the shyest children who need a medium of expression to the most boisterous children who need a creative structure within which to express themselves, the arts provide a nonthreatening avenue for healing. One model, the Cooperative Disaster Child Program entitled Listen to the Children, uses volunteers who travel throughout the country to work in emergency situations. Puppets, music, painting, and movement are used. Another model, The Bay Area Arts Relief Project, utilized over 100 artists and therapists working in school settings to provide assistance for children 5 to 13 years old. Over 500 children were reached through this project following a massive firestorm in the Oakland, California area, which affected six schools (B. Kazanis, personal communication, April 10, 1994). Preparedness Training as Prevention Both single-family fires and earthquakes have been events identified by Jones and his colleagues (Jones & Ampy, 1991; Jones, Ollendick, Mclaughlin, & Williams, 1989; Jones, Ollendick, & Shinske, 1989) as subjects for preparedness training in children. Because panic in children may occur when they do not know what to do in unexpected situations of danger, their behavior may result in reactions that endanger them. This places children at higher risk for physical danger. When the probability of greater danger increases, so does the probability of ensuing

96

Crisis Intervention and Trauma Response

psychological harm. In an effort to reduce both physical and emotional injury, preparedness training programs in a small-group setting have been successfully employed, Simulated conditions for both fires and earthquakes were presented to groups of children (usually no more than five at any one time) in a series of studies carried out by Jones and his colleagues 0ones & Ampy, 1991; Jones, Ollendick, Mclaughlin et al., 1989; Jones, Ollendick, & Shinske, 1989). In general, the scene was set for the children, and the trainer modeled and articulated the appropriate behaviors. The children then practiced those behaviors and were given basic knowledge about the danger and how to avoid or master it. All the children were assessed both before and after training and compared with children not receiving training. In all instances, the children who were trained performed better than their untrained counterparts in the posttests. The authors of these well-designed studies conclude that this kind of preparedness training, called "rehearsal plus," can be applied to dangerous conditions "where reasoned action is needed." Because both anxiety and fear can create fatalities in dangerous situations, training may avert this scenario. The training can, of course, be expanded to include other situations in which children feel quite vulnerable and lack the skills to either protect themselves or to escape. For the most part, children in our society have been regarded as naturally vulnerable, and that it is the responsibility of adults to protect them in situations of danger. In reality, however, children are less vulnerable when given the cognitive and behavioral skills they need, and can, when necessary, act responsibly and independently in the absence of adults. With increasing numbers of single working parents and dual-income parents, and with increased mobility of children (sometimes through unsafe environments), many school-aged children are on their own for certain portions of the day. Equipping them with the skills they need to protect them from trauma is a gift they readily receive and demonstrate that they can use successfully.

REFERENCES American Psychiatric Association, (1994), Diagnostic ami statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press.

Principles and Models of Intervention

97

Armstrong, K., O'Oaliahan, W., & Marmar, C, R. (1991). Debriefing Red Cross disaster personnel: The Multiple Stressor Debriefing Model. Journal of Traumatic Stress, 4, 581-593. Azarian, A., & Skriptchenko-Gregorian, V. (1993, May). Post-traumatic stress disorder in young victims of disaster and their treatment. Paper presented at the National Children's Mental Health Conference, Seattle, WA. ASCH: American Society for Clinical Hypnosis. (1994, March), Training workshop. Houston, TX. Barath, A. (1993). Psychological and educational help to schoolchildren affected by war. Unpublished manuscript, UNICEF Progress Report I. Barath, A,, Matul, D., & Sabljak, L. (1994). Korakpo korak do oporavka. Zagreb: UNICEF. Bloch, E. L. (1991a). Post-traumatic stress disorder: Treatment approachavoidance—An illustrative case. Psychotherapy, 28, 162—167. Bloch, E. L, (199lb, March). Children affected by the Middle East crisis. Inservice training program presented at Central Psychiatric Clinic, Child and Adolescent Division, Cincinnati, OH, Bloch, E. L. (199 Ic, March). Family issues for active duty military and activated reservists, Inservice training program presented at the Veteran's Administration Social Work Service, Cincinnati, OH. Bloch, E. L. (199Id, August). Approaching war, abating stress: Psychology in action in the community. In E. L. Bloch (Chair), Psychology in action during the MidEast crisis: Strategies of intervention. Symposium conducted at the annual meeting of the American Psychological Association, San Francisco, CA. Bloch, E. L. (1993). Organizing responses to civil disturbances: New models for practitioner intervention. In B. Wainrib (Chair), Trauma responses: What practitioners can learn from recent disasters. Symposium conducted at the annual meeting of the American Psychological Association, Toronto, Canada. Bloch, E. L., Zimmerman, A. C., Perez, J. T., Embry, D., & Magers, H. (1991). Report to the Senate Committee on Veterans Affairs: The mental health needs of Operations Desert Shield and Desert Storm veterans and their dependents. Bolin, R. (1989). Natural disasters. In R. List & G. Lubin (Eds.), Psychosocial aspects of disaster (pp. 61-85). New York: Wiley. Carkhuff, R. (1971). The art of helping, Amherst, MA: Human Resources Press. Feldmann, T. B., & Bell, R. A. (1991). Crisis debriefing of a jury after a murder trial. Hospital and Community Psychiatry, 42, 79—81.

98

Crisis Intervention and Trauma Response

Frieze, I, H, (1987). The female victim: Rape, wife battering, and incest. In G, R. Vandenbos & B. K. Bryant (Eds,), Cataclysms, crises, and catastrophes (pp. 109-145). Washington, DC: American Psychological Association. Giliiland, B. E., & James, R. K. (1993). Crisis intervention strategies (2nd ed.). Belmont, CA: Brooks/Cole. Harris, G, (1994, December). No one thought bodies lying near curb for hours were real. Louisville Courier Journal, p. Al. Herman,]. L. (1992). Trauma and recovery. New York: Basic Books. Jones, R. T,, & Ampy, L. A. (1991). Earthquake preparedness training, Unpublished manuscript. Jones, R. X, Ollendick, T. H., Mclaughlin, K. J., & Williams, C. E. (1989). Elaborative and behavioral rehearsal in the acquisition of fire emergency skills and the reduction of fear of fire. Behavior Therapy, 20, 93-101. Jones, R. T., Ollendick, T. H., & Shinske, E K. (1989). The role of behavioral vs. cognitive variables in skill acquisition. Behavior Therapy, 20, 293-302. Kramer, T, Bloch, E. L, & Grace, M. (1991, October). The development of self-help groups for Persian Gulf families. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Washington, DC. Lane, E S, (1993-1994). Critical Incident Stress Debriefing for health care workers. Omega, 28, 301-315. Lazarus, R. (1983). Cognitive theory of stress, coping and adaptation. Eastham, MA: Cape Cod Seminars. Lillibridge, E.M., & Klukken, P. G. (1978). Crisis intervention training. Tulsa, OK: Affective House. Linton, J. C. (1995). Acute stress management with public safety personnelOpportunities for clinical training and pro bono service. Professional Psychology, 26, 566-573.

McLain, S. L. (1996). Critical incident stress dfbriefing: A review. Unpublished manuscript.

Mitchell, J, T. (1983). When disaster strikes . . . the Critical Incident Stress Debriefing process. Journal of Emergency Medical Services, 8, 36-39. Myers, D. G. (1989). Mental health and disaster: Preventive approaches to intervention. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 190-228). New York: Wiley. Ochberg, F. M. (1991). Post-traumatic therapy. Psychotherapy, 28, 5-15. Parad, H. J. (1965), Crisis intervention: Selected readings, Milwaukee, Wl: NY Family Service Association of America. Parad, H. J., & Parad, L. G. (1990). Crisis intervention (Book 2). Milwaukee, Wl: NY Family Service Association of America.

Principles and Models of Intervention

99

Puryear, D, A, (1979). Helping people in crisis, San Francisco: Jossey-Bass. Raphael, B., Wilson, ]., Meldmm, L, & McFarlane, A. (1996). Acute preventive interventions. In B, A. van der Kolk, A. McFarlane, & L. Weisaeth (Eds.), Traumatic stress (pp. 463-479). New York: Guiiford. Roberts, A, R. (1991). Conceptualizing crisis theory and the crisis intervention model. In A. R. Roberts (Ed.), Contemporary perspectives on crisis intervention and prevention, Englewood Cliffs, NJ: Prentice-Hall. Rogers, C. R. (1951), Client-centered therapy, Boston: Houghton-Mifflin. Saakvitne, K., & Pearlman, L. A. (1996). Transforming the pain. New York: Norton. Sewell, J. D. (1993). Traumatic stress of multiple murder investigations. Journal of Traumatic Stress, 6, 103-118. Shilo-Cohen, N. (1993). Israeli children paint war. In L. A. Leavitt & N. A. Fox (Eds.), The psychological effects of war and violence on children (pp. 93-107). Hillsdale, NJ: Erlbaum. Wainrib, B. (1976). A tri-kvel model of human support and its applications. Unpublished doctoral dissertation. University of Massachusetts, Amherst, MA.

This page intentionally left blank

Chapter

5

ASSESSMENT FOR CRISIS AND TRAUMA This chapter covers: * Purposes of assessment * General orientation to assessment * Assessment for trauma « Normative responses and behavior * Nonnormative responses and behavior * Community assessment * Other assessment approaches » Research

Crisis intervention is an essential part of all trauma response, and, although the assessment principles for crisis intervention are part of trauma assessment, the latter has additional requirements as well.

PURPOSES OF ASSESSMENT It is important for the practitioner to be as clearly aware as possible of the purpose of the assessment. Assessments of clients in crisis may be to determine immediate risk status, planning for longer-term psychological intervention, establishing the need for pharmacological intervention, or making a specific diagnosis of posttraurnatk stress disorder, 101

102

Crisis Intervention and Trauma Response

At a community level, assessments of community resources and educational resources may be required. Because of the potential overlap of services during a crisis—whether individual or communitywide—one good rule of thumb is to clarify with the referral source the exact reasons for the referral. This saves the client from numerous and repetitive assessments and allows the practitioner to develop a focus for the assessing process and determine what kinds of records (documentation) to keep. A medical referral has a different slant than a referral from an attorney. In trauma work, other referring parties may include insurance companies, employers, community organizations (e.g., battered women's shelters), family members, and schools. Crisis events present unique situations in the assessment arena because of the potential convergence of interested parties on the individuals being assessed. Some of these parties pay for the assessments and subsequent interventions; some are very interested in the data gathered. It is always wise to raise the question, "who is my client?" and to clarify confidentiality issues with everyone involved. In general, regardless of whether you are being paid, the individual or group being assessed is entitled to the protection of confidentiality of information unless that right is waived by written consent or by mutual agreement. For example, during a group assessment requested by management at the workplace, the group may ask you, the assessor, to give summary feedback or recommendations to management leaders. The other exception is the assessment of children. In this case, information is expected to be conveyed to adults responsible for their welfare.

GENERAL ORIENTATION TO ASSESSMENT Our general orientation to assessment, as our orientation to all the work covered in this book, is that the process must be collaborative. Assessment itself is necessary not only so that the worker can get critical information, but to ascertain that the client really needs helping, and if so, the kind and quality of helping that is appropriate. Jumping

Assessment for Crisis and Trauma

103

in to help without ascertaining that help of the variety you are offering is what the client needs or wants is of no value. Respect for the clients needs is, at all times, of primary concern, and until you jointly ascertain what those needs are, this cannot happen. Clients need to be made to feel that they are a part of the assessment process, respected for their contribution, and are not pigeon-holed into some predetermined category. Throughout this book we have emphasized that in the final analysis it is people who can determine the outcome of a crisis or trauma. People who wish to be helpful must therefore be trained to respond appropriately. Any intervention in crisis or trauma must be sensitive, respectful, and reflect good training. This includes assessment. An insensitive or inappropriate intervention can become an incidence of secondary trauma, a second hurt to the person already hurt. The initial crisis or trauma itself has already shaken the individual's sense of trust and belief, and clients may hope and expect the people around them offering help to be more understanding. Poorly handled assessment can shake that sense even further, and perhaps, irrevocably. In general, assessment needs to be brief, immediate, and focused. Its goal is to determine the urgency of the crisis, the degree of psychological injury that exists, as well as the degree of resilience in dealing with this injury. The focus needs to be on the immediate situation, with information about how the client responded at the cognitive, behavioral, and affective levels. The helping person cannot rely on appearances alone. One person may be quite calm and staid, yet may be harboring intense emotional reactions that can appear unexpectedly in a variety of forms. Another may look very emotional but may be able to integrate and deal with the experience fairly comfortably. Assessment must be made not only to determine the current status of the individual or group but the potential for future harmful and resilient reactions as well. Urgency Urgency needs to be determined both objectively and subjectively. In general, if there is immediate danger to life, either the client s or other persons' involved urgency level is at its highest. If the client is the victim of assault, or if questioning yields a potential for suicide, homicide, or

104

Crisis Intervention and Trauma Response

violent behavior, this client's needs are considered very urgent. Equally urgent is a sense of the person as being psychologically or physically disabled. This is another area that cannot be left to chance. For example, your immediate reaction to hearing that John has taken time away from work for what has been described as a midlife crisis may be that there is little sense of urgency. You may feel that he will have to go through a period of recognition of the realities and limitations of what he can and cannot expect from his life. He may then go through the stages of mourning, confusion, and reemergence. However, assessment needs to determine whether John's mourning may be more significant than you can see on the surface. You will have to discover whether his despair at feeling that he will never again be able to achieve the success and happiness that he has been programmed for is so great that he has considered suicide. Perhaps this despair is about to be turned against his wife, whose need to live close to her family and resistance to being transferred may now be seen as the reason for lack of success. Is she now in danger? Can John's sadness become rage and potential violence toward her?How about his superiors at work or his fellow workers, some of whom have been promoted above him? If this sounds like a trailer for a soap opera, it is, unfortunately, very real, and only open collaboration with John will give you these answers and help you determine the urgency of his need. Severity To have a clear picture of the impact of the crisis itself, it is important to have a sense of how well the client was functioning just prior to the crisis. It is also important to determine how realistically and appropriately the client is responding. Appropriateness, severity, and levels of reactions must be seen both objectively and subjectively. For example, if your cat is caught in a tree, you would probably not think that this merits being deemed a crisis. However, if you are 87 years old, live alone with no support system, and your cat is your only friend, then this certainly can qualify as a crisis. Sometimes, in a disaster situation, something that may appear insignificant to the response team may have great meaning to a survivor—as for example, the loss of a child's favorite teddy bear, described only as "Banky," whose name needs to be translated to the relief worker.

Assessment for Crisis and Trauma

105

Resources After determining the urgency, degree of impact of the crisis or trauma situation, its severity, as well as the appropriateness of the clients response, determining the client's resources is the next important function of brief assessment. These fall into four categories: 1. Internal 2. External 3. Community 4. Spiritual Internal resources refer to the clients history in dealing with previous difficult situations and a general measure you will make (see p. 114) of the client's functioning at the cognitive, affective, and behavioral levels. Simple questions like, "Tell me about the last time something very difficult happened to you. How did you deal with it? Was that helpful? If not, what would you have done differently? Do you think you could try that now?" can give you a quick sense of this function, External resources refers to the quality, appropriateness, and availability of the client's support system (see chapter 4) as well as the client's willingness or ability to access it. Perceived support, that is, whether or not the clients see themselves as having access to support, is more significant than any objective measure of support. Community resources may often depend on you, the crisis worker. You need to be able to know what exists to help the client at this time and make an appropriate referral. In disaster situations, much of the communal support may be built in due to the shared experience of many people and the spontaneous outreach behavior that is observed when a disaster strikes. However, individual crisis situations may add loneliness and fear of abandonment to the client's reaction, and the helper needs to address these issues realistically by having knowledge of sources of community support that are appropriate. In a course at McGill, student presentations about specific crisis situations include providing the class with an annotated, updated collection of community resources in the area on which they have presented. It is important that these resource lists be updated annually because many of the resources are funded by grants that terminate and are often not refunded.

106

Cribis Intervention and Trauma Response

Spiritual resources is a relatively new category in this type of work. There is a growing body of research (Oxman, 1995) that indicates that a belief system, whether in a traditional, organized religious faith or not, can have significant effects on health status and life expectancy in people with life-threatening illness. This work alerts practitioners to the importance of an individual's spiritual resources in any life crisis or trauma. At the same time, the worker must be cognizant of the fact that any trauma or crisis is a crisis of faith, that anyone with a spiritual belief system may ask, "How could (whatever is the higher power) do this to me?," and the worker must be prepared as well to consider this issue. It is important, as well, to have some sense of the goodness of fit of the person's needs and resources. Having many resources in an area that is not of immediate help in the crisis shows little goodness of fit. Resources, of course, must be appropriate to the current needs. Checking for goodness of fit will help you to recognize the areas in the client's functioning that are adequately supplied, as well as those that require direction from you. You can then help the client to understand the needs and to find more effective resources.

ASSESSMENT FOR TRAUMA Traumatic events pose a unique set of challenges for assessment, Factors inherent in the nature of the event and the affected population have an impact on accessibility to victims and on the establishment of group norms, or normative behavior, of the victim population. The event itself may be one in which reaching the victims is extremely difficult (e.g., mudslides, earthquakes) or communication is poor or disorganized so that those affected do not know what, if any, services are available and where to go to obtain them. Accessibility is sometimes a function of the age of the population, with elderly persons often hesitant to come forward to be identified as having health-related or financial concerns following a disaster (Myers, 1989). Local community outreach efforts and clear communications can often overcome problems of accessibility. Broadening accessibility is an often overlooked

Assessment for Crisis and Trauma

107

aspect of assessment, but one that is critical in determining accurate base-rate data. If we assess only those individuals physically capable, psychologically sophisticated, and emotionally healthy enough to negotiate a chaotic situation and present themselves for assistance, our objective norms for assessing these individuals will be skewed. The assessment of traumatic reactions requires the dual assessment of victim and event. No other diagnostic category requires as explicit a delineation of the parameters of the events affecting the individual and his or her place within it. Was the victim at the center of the event? A bystander? An eyewitness? How much, and in what ways, would we expect the victim to suffer emotionally relative to the event? Would we anticipate that those avoiding or escaping a traumatic event would do well? Following the Chowchilla school-bus kidnapping, Terr (1983) examined the effects on children after 4 years. One child, dropped off before the other children riding on the bus were kidnapped, nevertheless showed significant symptoms of posttraurnatic stress disorder. It is important to keep in mind that individuals—adults and children— can suffer traumatic stress reactions even if they are not actually at the traumatic scene. A significant part of a comprehensive assessment includes the nature of the event, the individuals' locations (physical and temporal) relative to the event, and their relationships to others caught up in the event, The closer the relationship and the more threatening the circumstances, the more profound are the psychological consequences. The length of time one is given to conduct an assessment, and adapting one's assessment techniques to the phase of the traumatic event are additional challenges. Assessments carried out at the scene may have to be extremely brief, sometimes within 15 to 20 minutes. In these cases, it can be helpful to negotiate a longer period of time, meeting with a number of individuals in a group setting. In this way, the norm of the victim group can be established fairly quickly, with the professional then able to identify individuals who deviate from the norm in their emotions and behaviors. In a 1-hour, 20-person group debriefing following the sudden death of a young coworker at the workplace, one of us (E.B.) identified three workers at high risk for extreme reactions and five workers at low risk. An intervention plan utilizing the strengths of the low-risk workers and the needs of the high-risk workers was

108

Crisis Intervention and Trauma Response

then developed during the final debriefing stage and applied to the entire group. Phases of the traumatic event are part of an assessment continuum that begins prior to the event ("Where were you earlier that day?", "What were the things you noticed about your husbands health that made you feel he should see the doctor as soon as possible?") then extends through the event itself, its immediate postimpact stage, and finally, to the much lengthier postimpact period covering days or months, or in some cases, years. While the majority of assessments take place relatively soon after a crisis or trauma, it is not surprising to find clients who quite suddenly reveal traumas kept secret for years. These hidden traumas are most often those accompanied by greater degrees of shame and guilt than other traumas, for example, childhood sexual abuse; or, in adulthood, actions taken that are later regretted, or stigmatized by the community, for example, the killing of innocent civilians by soldiers during the Vietnam War. Another aspect of the initial assessment is an assessment for violence potential and suicidal potential. Both of these topics will be covered in the next chapter.

NORMATIVE RESPONSES AND BEHAVIOR The Dilation—Constriction Continuum Approach When a person is in crisis or in the midst of a trauma, the professional needs to have a general picture of the needs-resources balance outlined above, and, while not focused on the traditional psychological assessment for pathology, must also have some sense of whether the client has a potential for psychological vulnerability. The orientation of the crisis worker is recognition that it is not the client who is abnormal, but the situation itself. Nevertheless, there are some areas that need to be assessed for the helper to deliver an appropriate response. As well, because part of the crisis intervention work involves an identification of those involved who have the potential for more serious psychological complications (which may have been triggered by the crisis situation), the worker needs to be aware of this concept.

Assessment for Crisis and Trauma

109

In chapter 4, we outlined LJllibridge and KJukken's (1978) dilation-constriction continuum. We showed how reactions at each end of the continuum differ and are manifest at the cognitive, affective, and behavioral levels. This model is helpful because, as we have seen, different types of people require different approaches by the crisis worker. This continuum approach will also create an awareness of the need for knowledge of a broad spectrum of approaches and techniques, as we discussed in chapter 4. Remember that while the characteristics on the chart in chapter 4 are at either end of each continuum, it is the rare person who will present as a pure form of either extreme. You will probably find your client at some middle place along the line, but the extremes are emphasized for an easier understanding of the concept. As a brief review of the model, remember that at the dilated end of the continuum, the individuals* cognitive characteristics are disorganized thoughts and chaotic thinking and confusion. From the helper they need assistance to clarify thinking, be specific, and identify the problem. At the constricted end of the continuum, the persons' cognitions will be a preoccupation with the problem, ruminative and obsessive thinking. The helper will have to provide them with viable alternatives to their ruminations and a working solution to the problem. At the affective level, characteristics at the dilated end will be overemotional, with little or no attempt to control expression of feelings. The helper will have to provide an attempt to focus on specific feelings and to work with cognitive material for this person. At the constricted end, the client will be seen as holding feelings in, and the helper's goal will be to facilitate expression of feelings in any way. At the behavioral level, the dilated person will be seen as using excessive behavior, acting out, or manifesting behavior that is inappropriate. The helper will have to provide reality-oriented problem solving. At the constricted end of the continuum, the behavior can be expected to be paralyzed or immobilized and withdrawn, and the helpers goal will be to stimulate movement and help the client to do things. If we apply the dilation—constriction continuum to Van Gennep's (I960) stages (see chapter 3), what will emerge are two quite different pictures. The constricted individual may try to avoid acknowledging or revealing sadness. This client will distill it through complex intellectual concepts and probably deny it when you start to poke at it and

110

Crisis Intervention and Trauma Response

will no doubt have utterly fascinating rationalizations for confusion although may eventually admit that things feel utterly out of control. This admission of loss of control will further raise the anxiety level, and the client may request medication. There will be frequent reiterations of "why did that happen?" and repetitive reiterations of the circumstances, all presented In a very factual manner, with little or no affect. Body language will be tight and defensive. The dilated individual, however, may mourn openly and loudly for an unusual period of time. The client will not hesitate to let you know quite dramatically of the terrible pain of the loss and you will have difficulty cutting beyond the histrionics to the problem focus. Body language will be writ large and there will be a dramatic display of confusion and helplessness. Somewhere in between these two almost stereotypic descriptions is where you or your client will probably be in the experience of crisis. Remember, although the external behavior, affect, and cognition look different, the internal pain is the same. The product may look different, but the underlying process remains the same.

How Relate-Assess-Refer/Respond (R-A-R) Applies to This Model How we approach the individual will depend on the characteristics we see. In general the two basic approaches are problem focused and emotion focused. R-A-R, the basic model of this book, refers simply to relate-assessrefer/respond as the basis of good crisis intervention. If you keep this continuum model in mind in your work, you will be relating, assessing, and referring or responding differently depending on where on the continuum you judge the client to be. For example, if you are with a person who is pacing uncontrollably, alternately pulling hair out, sobbing, and screaming, you will recognize an extremely dilated person, and your relating will reflect that. Your approach will be be more structured, perhaps with a calming physical intervention (see chapter 7); a calm but authoritarian voice; and quiet, constant reassurance that once you and the client together can simply focus on the problem, it is solvable. This is a problem-focused approach. Your assessment of this

Assessment for Crisis and Trauma

111

person would have to take into consideration the dilated affect and behavior, and it would be important to understand how you would see this person if he or she were not in crisis. Your referral would be to a more structured helping situation if you cannot provide that yourself. If you are dealing with a constricted, withdrawn person, your relating will be emotion focused, and you will do everything you can to elicit feelings. This will probably involve nonverbal body work (see chapter 7), to which you will meet a certain resistance, but which will be very helpful. Before we presented the continuum, we alluded to the necessity of being comfortable in using a broad spectrum of approaches. A good example of this is people whose training is limited to Carl Rogers' (1959) client-centered approach. Rogers' basic concepts of empathy, unconditional positive regard, and nonjudgmental warmth should be basic to any work you do. However, when you are dealing with a dilated client, helping to delve further into feelings will be counterproductive. Let us look at this approach with a highly dilated client; Client (C):

(pacing up and down and wringing her hands), weeping, "I can't believe this is happening to me. I won't let it happen to me. I hate it! I'm furious. How can this be happening? How could my husband have run away with a tramp just like all those other horrible men? "

Helper (H)s

"You're really feeling angry, upset, and disbelieving that this is happening."

C;

"You bet you're sweet life I am, and not only that, if you don't do something to make this pain go away fast, I'll do something to you.too . . .!"

That clearly is not very effective. Let's take a more structured approach: H:

"I know you're really upset about this. But lets sit down and see what we can come up with to help make the pain go away."

C:

"Nothing can make the pain go away. Nothing ever will. Nothing will bring back my husband. I might just go out and shoot them both!"

112 H:

Crisis Intervention and Trauma Response "Perhaps nothing will bring him back, or it may be too early for either of us to know that. Shooting them would only make your life more miserable, but in the interim there are many things we can do to make your life more bearable right now. Let's look at some of them together,"

NONNORMATIVE RESPONSES AND BEHAVIOR Crisis-Prone Individuals Certain people repeatedly find themselves in a crisis situation. This is not a. normative response and needs to be screened for what Parad (1965) describes as crisis-prone individuals. Should you encounter individuals who fit this description, crisis intervention in itself will usually not suffice. These people require special treatment. Referral to a social service agency should be made directly. Parad (1976) says about this group, "typically the crisis-prone person lacks or is unable to utilize the personal, family, and social supports that help everyone to cope with stress while functioning in everyday roles." Often alienated from meaningful and lasting interpersonal relations, this person may exhibit some or all of the following interrelated problems: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Difficulty learning from experience A history of frequent crises, ineffectively resolved because of poor coping ability A history of mental disorder or other serious emotional disturbance Low self-esteem, which may be masked by provocative behavior A tendency toward impulsive acting-out behavior (doing without thinking) Marginal income Lack of regular, fulfilling work Unsatisfying marriage and family relations Heavy drinking or other substance abuse History of numerous accidents Frequent encounters with law

Assessment for Crisis and Trauma

113

Psychopathology Depending on all the variables we have discussed, that is, the person's past history and functional ability, internal and external resources, biological risk factors, personal and cultural environmental experience, mental health and personality, and so forth, psychopathology may be provoked by a serious crisis or trauma. The assessment criteria that we have listed previously all lead to sorting out that possibility. The list that follows is a quick, hands-on checklist for symptomatology. Warning Signs of Psyehopathology Weaver's (1995) list of the most common warning signs of psychopathology in a population that has been exposed to disaster follows. 1. 2. 3. 4.

Prolonged feelings of anxiety and despair Inability to concentrate/make decisions Changes in habits (e.g., eating, sleeping, or sexual activity) Changes in personality (e.g., a quiet, shy, cautious person, begins to live dangerously) 5. Loss of self-esteem (e.g., feelings of extreme guilt after an arrest or loss of one's job) 6. Withdrawal from others or social isolation 7. Symptoms of disordered thought processes: Undue suspiciousness of others Believes people are talking about, laughing at, or trying somehow to control the client Hears voices or sees things (auditory or visual hallucinations) Believes television, radio, or print media are addressing the client Extrasensory perception or telepathy Grandiosity Religious preoccupation 8. Misdirected anger or desire for revenge 9. Extreme dependency 10. Exaggerated fears

114

11. 12. 13. 14. 15.

Crisis Intervention and Trauma Response

Physical problems without any organic cause Mood swings Performances not up to par Compulsions or rituals (e.g., too frequent hand washing) Thoughts of harming self or others (includes overt statements or acts as well as covert moves, e.g., getting ones affairs in order as though preparing for death)

The last issue is discussed in great length in chapter 6. It is the quality, intensity, and frequency of experiencing these symptoms that determine whether to be concerned with psychopathology when assessing the client. The degree to which symptoms interfere with the persons ability to function and cope with the reality of the situation as well as the manifestation of several symptoms for a long period of time determine significance. An occasional manifestation of any of these responses does not signal abnormality. If the individual has had certain beliefs (such as extrasensory perception) for an ongoing time previous to the crisis or trauma, this symptom is not to be taken seriously. Suicidal ideation, however, which will be discussed in the next chapter, is never to be taken lightly. Individual Assessment A number of factors can be joined together to mask discovery of psychological suffering and impairment following a traumatic event. First, an individual may not feel like a true victim if he or she was not at the scene or did not suffer losses to the extent that others suffered. Second, the person may present physical rather than psychological symptoms. Low-back pain, headache, and sleep disturbances may remain at the center of attention. Third, there may be incongruence between aspects of a person's self-report ("I'm fine," "I feel terrible."). In summary, downward comparisons ("He had it much worse than me"), having a specific symptom or behavior to point out ("This is where I am hurting"), and confusion or misperceptions about one's own feelings and behavior and those of others ("She's okay." "She's not okay.") all tend to cover over the emotional impact of trauma and can cloud the assessment picture. If the helping professional is patient and reassuring, and

Assessment for Crisis and Trauma

115

points out to the client reasons for minimizing, avoiding, and/or confusing his or her perceptions, the individual may be more forthcoming. Underestimating traumatization is a natural human response. No one wants to feel helpless and powerless. Talking about what has happened initially runs counter to the impulse to hide one's experiences. The sensitive professional respects that impulse and allows the individual to alternately avoid and approach the unsettling experience. Posttraumatic Stress Disorder Although the term, posttraumatic stress disorder (PTSD) is used somewhat loosely and occasionally indiscriminately, it is meant to define a specific diagnostic category (American Psychiatric Association, 1994) of mental disorder. PTSD is a relatively new official diagnosis, first making its appearance in 1980 (American Psychiatric Association, 1980), as a subcategory of anxiety disorders. Understanding this diagnostic category is critical to the individual assessment process because it identifies those persons most in need of therapeutic intervention. It is also important because once a person is identified with PTSD, the individual can be further and better understood from a clinical standpoint when compared with a growing data base of information about men, women, and children in similar and different crisis situations. From a very practical standpoint, the presence or absence of PTSD in an individual can affect the outcome of litigation and whether mental health benefits and compensation may be received. Posttraumatic stress disorder can be diagnosed both in children and adults. On average, about 10% to 12% of those subjected to trauma or severe crisis actually develop PTSD. This percentage varies according to the nature of the trauma, the population sampled, and how the assessment is conducted. Lifetime prevalence for PTSD ranges from 1% to 14%, while prevalence rates for at-risk victims (e.g., those in combat or those criminally victimized) range from 3% to 58% (American Psychiatric Association, 1994). Many of the signs and symptoms of trauma we have been discussing throughout this book appear in diagnostic criteria listed for PTSD; however, individuals meeting the strict definition for PTSD form a relatively small group, or subgroup, of victims of crisis and trauma.

116

Crisis Intervention and Trauma Response

For assessment purposes, the diagnostic criteria for PTSD are as follows (American Psychiatric Association, 1994); A, The person has been exposed to a traumatic event in which both of the following were present: 1, the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2, the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior B. The traumatic event is persistently reexperienced in one (or more) of the following ways: 1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note; In young children, repetitive play may occur in which themes or aspects of the trauma are expressed 2. recurrent distressing dreams of the event. Notes In children, there may be frightening dreams without recognizable content 3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated), Note: In young children, trauma-specific reenactment may occur 4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Assessment for Crisis and Trauma

117

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. efforts to avoid activities, places, or people that arouse recollections of the trauma 3. inability to recall an important aspect of the trauma 4. markedly diminished interest or participation in significant activities 5. feeling of detachment or estrangement from others 6. restricted range of affect (e.g., unable to have loving feelings) 7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. 2. 3. 4. 5.

difficulty falling or staying asleep irritability or outbursts or anger difficulty concentrating hypervigilance exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than I month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. PTSD may be classified as: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Delayed onset: if onset of symptoms is at least 6 months after the stressor

118

Crisis Intervention and Trauma Response

Some victims experience PTSD symptoms for a short period of time; others for years. It is usually impossible to predict from initial responses who will suffer briefly, and who will become chronically impaired. The differentiation between PTSD and noe-PTSD is important not only for treatment considerations but also for legal considerations. PTSD is an individual diagnosis and thus difficult (although not impossible) to establish in class action lawsuits, PTSD may, however, be established in individual personal injury cases. Although a number of assessment instruments are available (e.g., Impact of Event Scale [Horowitz, Wilner, & Alvarez, 1979}; SCL-90 [Derogatis, 1977]; MMPI-2 [Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989]}, the best assessment instrument is the clinical interview, or selection of a standardized clinical interview format. The reason is that assessment measures in the form of questionnaires, surveys, and tests have been normed on a variety of populations, but not necessarily the population into which your individual case may fall. Most instruments have normative data on men, and particularly on combat veterans. Researchers are proceeding to gather data with instruments using varied populations in numerous traurnatic-event contexts. Thus far, there seems to be little differentiation in the research data regarding ethnic identity, religious affiliation, and additional grouprelated characteristics other than educational level.

COMMUNITY ASSESSMENT Community-level assessments are ordinarily carried out by relief agencies and governmental organizations, which assess the scope of the event, extent of damage, and available and emerging community resources. These agencies and organizations are assisted by private or public centers or groups with expertise in the social sciences (for example, sociology and economics). Research units may also become active at both assessment and intervention levels. Tierney (1989) identified four phases to describe disaster and postdisaster periods within the community;

Assessment for Crisis and Trauma

119

1. Mitigation 2. Preparedness 3. Response 4. Recovery Mitigation refers to prevention activities that may reduce the impact or scope of the catastrophic event. The most obvious mitigation technique is the evacuation of portions of the community prior to a hurricane. Preparedness refers to a variety of activities to educate the general public and specific organizational entities to respond in case of community emergencies, Response is the actual conduct of a variety of tasks involved in the rescue effort, emergency care, referral of high risk cases, and immediate social interventions to bring supplies and resources (including resource persons) to the stricken area. Recovery refers to the rebuilding efforts within the community, both the physical and the psychological. Mental health professionals may be active during all the phases, assessing which activities within the community would likely be accepted to reduce the possible magnitude of the catastrophic event, participating in public education efforts, responding to provide emergency mental health care, and providing longer-term treatment to individuals at high risk. Community-level assessments may be done through carefully designed sampling, through small-group assessments within neighborhoods and schools, and through assessing people's awareness and knowledge of resources available to them. Just as individuals vary in their response to trauma, so do communities. Some communities become very cohesive, others, more fragmented. Communities, like individuals, can be in shock. Honeymoon periods, when help is brought into a community, are often followed by periods of disillusionment when government and private agencies begin to leave and media coverage of the community event ceases. Mental health professionals need to be acutely aware of the stages communities go through in negotiating a traumatic event and perform their assessments—as much as is possible—with an eye toward a

120

Crisis Intervention and Trauma Response

longer time frame. This is why it is extremely important for helping professionals to be viewed by the community as a stable presence in the ongoing recovery process, and as a group that, unlike others, is unwilling to abandon the community once the outward signs of recovery have begun.

OTHER ASSESSMENT APPROACHES Korner Korner (1973), one of the earlier writers in this field, defines the need for a change of orientation for the client to "reduce the proportion of the crisis to the point where the individual is enabled to cope with it on his own" (p. 35). In the course of this process, he outlines a series of six questions for assessment. His first three touch on the usual functions (intellectual, emotional, and interpersonal). However, his last three present an interesting approach. These are; 1. What are the dimensions of the hope structure? "The sudden loss and/or destruction of something hoped for can produce crisis conditions. Any hope structure can be said to have two main components.The first is an affect-laden, belief-like component. The second is a rationale for considering that the desired occurrence has a high probability. . . . Hopes represent important coping mechanisms (and) can be reinstated, replaced, or compensated for, which concomitantly alleviates the crisis condition," 2. How much motivation does the individual have to help himself? Korner suggests a series of questions to probe this dimension. These include asking the client to recreate the experiences leading to the event, contacting others who may be of help, and going back into the situation to find out whether things are really the way the client has reported them. The latter also serves as a reality check. Asking clients whether they can take care of themselves now or when they think they will be able to take care of themselves also checks the motivation level.

Assessment for Crisis and Trauma

121

3. This last question is one that was previously discussed in the description of the crisis prone individual. It asks, "To what extent has the individual created or aggravated the crisis condition? At any point in the experience a helping professional may be able to ascertain some secondary gain that the client is deriving from the crisis situation; perhaps more attention and concern, a sense of importance, and so forth. Practitioners are aware that there are always people who somehow manage to create crisis situations throughout their lives, and these often emerge as traditional therapy begins to end. Awareness of this possibility, without losing one's stance of unconditional positive regard, can be a difficult balance for the helper, but one that needs to be kept in mind. Triage Model Myer, Williams, Ottens, and Schmidt (1991) offer a three-dimensional assessment model and rating scale that allow for a more quantifiable assessment. The three dimensions are affective, cognitive, and behavioral, and the ratings are from 1 to 10, where a rating of 1 means no impairment, and a rating of 10 means severe impairment. This is clearly a more quantitative model than those we have presented.

RESEARCH One of the greatest challenges in the assessment process is for the researcher-practitioner. Ideally, clinical theory and practice should evolve from, and in turn shape, the gathering of objective data. This kind of data gathering is rarely possible at any phase of the crisis except the longer postirnpact phase, that is, at least 1 or more days following the event. Most objective assessment instruments are paper-and-pencil tests that require some minimum amount of concentration and emotional perspective on the client s part—something very hard to come by in the immediate crisis impact phase. The assessment interview therefore remains the preferred method and can be more or less

122

Crisis Intervention and Trauma Response

structured depending on the nature of the crisis and the client's state of mind.

REFERENCES American Psychiatric Association, (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Press. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaernmer, B. (1989). Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Derogatis, L. R. (1977). SCL-90: Administration, scoring andprocedures manual-I for the revised version and other instruments of the fsychopathology rating scale series, Baltimore, MD: Johns Hopkins University Press. Horowitz, M., Wilner, N,, & Alvarez,W, (1979). Impact of event scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209—218. Korner, E. (1973). Crisis assessment and the psychological consultant. In G. A. Specter & W. L. Claiborn (Eds.), Crisis intervention. New York: Behavioral Publications. Lillibridge, E. M., & Klukken, P. G. (1978). Crisis intervention training, Tulsa, OK: Affective House. Myer, R. A., Williams, R. C, Ottens, A. J., & Schmidt, A. E. (1991). Threedimensional crisis assessment model. Unpublished manuscript, Northern Illinois University, De Kalb, IL, Myers, D. G. (1989). Mental health and disaster: Preventive approaches to intervention. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 190-228). New York: Wiley. Oxman, T. E. (1995). Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine, 57, 682-689. Parad, H. J. (1965). Crisis intervention: Selected readings, Milwaukee, WI: Family Service Association of America.

Assessment for Crisis and Trauma

123

Rogers, C, R. (1951). Client-centered therapy. Boston: Hougfaton-Mifflin. Rogers, C. R, (1959). A theory of therapy, personality and interpersonal relationships as developed in one client-centered framework. In S. Koch (Ed.), Psychology: A study of a science (Vol. 1, pp. 184-256). New York: McGraw-Hill. Terr, L. (1983). Chowchilla revisited; The effects of psychic trauma four years after a school-bus kidnapping. American Jmtrnal of Psychiatry, 140, 1543-1550. Tierney, K, J. (1989). The social and community contexts of disaster. In R. Gist & B. Lubin (Eds.), Psychmociai aspects of disaster (pp. 11-39). New York: Wiley. Van Gennep, A. (1960). Rita of passage. Chicago: University of Chicago Press. Weaver, J. D. (1995). Disasters: Mental health interventions, Sarasota, FL: Professional Resource Press.

This page intentionally left blank

Chapter

6

SUICIDE AND VIOLENCE: ASSESSMENT AND INTERVENTION This chapter covers; * Suicide • Violence

SUICIDE Introduction Suicide is a possibility following any crisis or trauma. The intensity of loss, the sense of being overwhelmed, and unfathomable grief can all combine to trigger the suicidal potential Understanding the loss—anger-violence continuum facilitates the understanding of the place of suicide in trauma work. If the violence engendered by loss cannot be expressed and is turned inward, suicide can easily be the end product. Workers continually exposed to trauma are often at high risk for suicide. Data on police indicate that death by suicide among this group is three times higher than killings of police by criminals (Rosenbaum, 1995). The cumulative impact of seeing traumatic events daily may be so overwhelming as a variable that suicide may be perceived as the only choice. Constant traumatization and the presence of access to a lethal weapon make the risk among this population extremely high. Suicide can also be triggered by any of the developmental or situational crises discussed in chapter 2. When the possibility of that triggering occurs, suicide itself becomes a crisis 125

126

Crisis Intervention and Trauma Response

situation. Should the suicide be successful, all of those around the subject will have to deal with intense, often life-long trauma. They, then, can also become trauma victims and patients. Because suicide is such a frightening topic, a whole weave of social myths have sprung up about the act itself, as well as how one can best respond to a potential suicide victim. Here are some of the most prevalent myths. Myths Myth #1: Talking about suicide can encourage suicide. Reality: Talking about suicide is essential. One can never plant the idea of suicide in someone's thinking. It is, however, necessary to talk about suicide to relieve the individual of the burden of thinking about it, and ascertain the degree to which the suicidal ideation is dangerous. Therefore crisis-trauma workers must work out their own feelings about death in general and suicide in particular to feel comfortable about discussing this important issue, asking the appropriate questions, and keeping an open dialogue. This dialogue may have to be repeated several times during the intervention relationship as the suicidal possibility may wax and wane, Myth #2: People who talk about suicide will not commit suicide. Reality: Eighty percent of those who have committed suicide have talked about it beforehand. For a. greater understanding of this, see Shneidman's work below. Myth #3: Once an attempt has been made and the patient starts to improve, the risk is over. Reality; In fact, the case is quite the opposite. When a person is severely depressed, that person may not have adequate psychic energy to activate a suicidal impulse. However, as the energy starts to resurface, and the reasons for the previous attempt are unchanged, the impulse can be reactivated. Some experts suggest that the first 90 days after an attempt are the riskiest. This can, however, continue longer. An additional factor is that, as in the case of any other crisis, social support will rally immediately after the event and then gradually slack off. As this happens, the individual is left in pain, nothing has changed, and, in the absence of social support, suicide makes more and more sense.

Suicide and Violence: Assessment and Intervention

127

Myth #4 : People who commit suicide are crazy. Reality: Only a small percentage of suicide victims are actually psychotic. Loneliness, alienation, hopelessness, helplessness, or unacceptable rage all contribute to the suicidal decision. This will become evident in our discussion of Shneidman's work later in this chapter. Myth #5: Suicidal behavior is inherited. Reality: Although suicide trends can sometimes be seen in families, there is no research to support this statement. Suicidal behavior in a parent can, of course, also provide a model for a solution to one's pain. But the general feeling of helplessness with which it leaves its living victims could also mitigate against this.

Demographics Profession Although suicide is often seen as highest among dentists and some mental health workers, it has recently been shown to be very high in young female veterinarians (Bloom, personal communication, July 17, 1996). Age

Suicide rates are high in adolescence, then become lower, and then increase with age. The risk for suicide tends to increase over the adult life cycle, with the decade from the mid-fifties to the mid-sixties constituting the age span of highest risk. Attempts by older people are much more likely to be lethal. The ratio of attempts to completed suicides for those up to age 65 is about 7:1 but is 2:1 for those over 65, Gender Women attempt suicide three times as often as men, but men are more successful. This is related to choice of medium: for women, drug overdose is most common. Lethality is lower in this medium, with the possibility of rescue greater. Men, however, chose a more lethal medium, often firearms or hanging, and the possibility of rescue is considerably lower.

128

Crisis Intervention and Trauma Response

Marital Status For both men and women, lethality is higher after separation and divorce. It is lower for married people and lowest for married people with children,

Other Sources of High Lethality If the client has a history of unsuccessful medical treatment or recent physical trauma, the lethality is high. With chronic illness, lethality increases, as it does with painful, life-threatening illness. Loss is always a factor in suicidal ideation. Loss can include loss of a loved one (person or pet), a job, status, and so forth. As we have discussed in previous chapters, loss must be seen from the clients subjective point of view. For example, if you have never had a pet, you may not understand the potential seriousness of the death of a pet. In addition, the client's loss history must be taken into consideration. As we have discussed previously, any new loss, whether human or pet, can reactivate painful memories of older losses, and the combination of these may strongly influence suicidal potential. Other Indicators

Many researchers have shown a link between parental bereavement, experienced either as an adult or as a child, and suicidal behavior. Pope (1986) reports that "Klerman and Clayton (1984, see also Beutler, 1985) found that suicide rates are higher among the widowed than the married (especially among elderly men), and that among women the suicide rate is not as high for widows as for the divorced or separated." Pope (1986) adds the following factors to our list of indicators: 1, 2.

Direct verbal warning, A direct statement of intention to commit suicide is one of the most useful single predictors. Take any such statement seriously. Past attempts. Perhaps up to 80% of completed suicides were preceded by a prior attempt. Shneidman (1985) found that

Suicide and Violence: Assessment and Intervention

3.

4. 5.

6. 7. 8. 9. 10. 11. 12.

13.

129

the patient groups with the greatest suicidal rates were those who had entered into treatment with a history of at least one attempt, Indirect statements and behavioral signs. People planning to end their lives may communicate their intent indirectly through their words (e.g., talking about going away, speculating on what it would be like to be dead) and actions (e.g., giving away their most valued possessions, acquiring lethal instruments). Depression. The suicide rate for those with clinical depression is about 20 times greater than that for the general population. Hopelessness. The sense of hopelessness appears to be more closely associated with suicidal intent than any other aspect of depression (Beck, Kovacs, & Weissman, 1975; Kazdin, 1983; Petrie & Chamberlain, 1983; Wetzel, 1976). Intoxication. Between one fourth and one third of all suicides are associated with alcohol as a contributing factor, Clinical syndromes. As mentioned above, people suffering from depression or alcoholism are at much higher risk for suicide. Religion. The suicide rates among Protestants tend to be higher than those among Jews and Catholics. Living alone. The risk of suicide tends to be reduced if someone is not living alone, reduced even more if he or she is living with a spouse, and reduced even further if there are children. Health status. Illness and somatic complaints are associated with increased suicidal risk, as are disturbances in patterns of sleeping and eating. Impulsivity. Those with poor impulse control are at increased risk for taking their lives (Patsiokas, Clum, & Luscomb, 1979) Rigid thinking. Suicidal individuals often display a rigid allor-none thought quality (Neuringer, 1974). A typical statement might be, "if I don't find work within the next week I'll commit suicide." Stressful life events. Excessive numbers of undesirable life events with negative outcomes have been associated with increased suicidal risks (Isherwood, Adam, & Hornblow, 1982; Cohen-Sandier, Berman, & King, 1982). Some types of

Crisis Intervention and Trauma Response

130

14.

recent life events may place clients at extremely high risk. For example, Ellis and her colleagues (1982) found that 52% of their sample of multiple-incident victims of sexual assault had attempted suicide. Release from hospitalization. Beck (1967) noted that "available figures clearly indicate that the suicidal risk is greatest during weekend leaves from the hospital and shortly after discharge" (Adapted from Pope, 1986, pp. 17-23).

Special Populations Although suicide is a possibility at any stage of life and in either gender group, some populations require specific attention. It is important to recognize the importance of age as well as gender differences in suicide assessment. Adolescents In the 15- to 24-year-old age group, suicide is the third leading cause of death (following accidents and homicides). Recent research by Lewinsohn, Rohde, and Seely (1996) showed that in a sample of 1,709 persons 14 to 18 years old, 10% of girls and 4% of boys had attempted suicide. Nineteen percent of the sample acknowledged suicidal ideation at some time in their lives. The rate of suicidal ideation was twice as high for persons diagnosed with depression. For Black male youths (ages 15 to 24) homicide is the leading cause of death (followed by accidents and suicide, respectively). Adolescent females attempt suicide more frequently in comparison to males. However, the ratio of successful male to female adolescent suicides ranges between 5:1 and 3:1 (varying by age). As we have seen, the risk of suicide in adolescents is high. An average of one young person commits suicide every 90 minutes (Hayes & Sloat, 1988). In an earlier chapter we dealt with the experience of life transition and the loss that must be acknowledged in that experience. Adolescence is a time of dramatic transitions, and the loss of the old self and development of a new one figures strongly as a background to all of adolescence. Yet, as Hetzel, Winn, and Tolstoshev (1991) remind us, adolescence is also a

Suicide and Violence: Assessment and Intervention

131

time of risk-taking, "The adolescent attempts to prove his transcendence over death and all its metaphors." This combination of the loss experience and the sense of invulnerability sets the adolescent up for an unusual proclivity for suicidal behavior. The rate of suicide in adolescents is 15 to 20 per 100,000. Adolescent suicide is undereported by 23% (Brent, 1995). The most common precipitants are interpersonal conflict, school problems, and legal or disciplinary problems. Capuzzi (1994) has developed a very interesting program for suicide prevention in the schools. He has identified the following factors, which he sees as contributing to adolescent suicide: 1. The adolescent transition itself, with the implications for choices about lifestyle (drug use, gangs, and so forth), and disillusion with adult figures. 2. Family dysfunctions: a number of patterns can be observed in dysfunctional families that can affect an adolescents vulnerability to depression and suicidal preoccupation. 3. Poor communication skills: "In most families of adolescents who have attempted or completed suicide, communication between parents and children (and usually both) has not been optimal," Research by Berman and Jobes (1991) and Brent (1995) has found that most adolescents who kill themselves feel misunderstood, are not communicating well with their families, or have experienced other external stressors. In our previous description of support systems, we emphasized understanding the client's sense of perceived support, rather than merely what may look like support to the interviewer. This concept is central here, too. Capuzzi also considers other factors, such as difficulties with single parenting, confusion in a blended family, midlife stressors that parents may be undergoing, pressure on adolescents for academic achievement, availability of drugs, and family mobility. All of these, no doubt, contribute to the status of adolescent suicide, and it is important to be aware of them as background material for assessment work. The combination of all of these factors as well as the availability of drugs, alcohol, and firearms sets the stage for potentially great lethality.

132

Crisis Intervention and Trauma Response

Because the suicidal ideation may wax and wane under circumstance, availability and accessibility of method, the method of choice may be provided by availability. In Brent's (1987) study of alcohol, firearms, and suicide among youth, he found that the combination of alcohol use and the availability of firearms increases the possibility of adolescent suicide dramatically. When firearms were available, as alcohol consumption rose, the likelihood of suicide by shooting increased. This generally occurred when the patient was corning down from the alcohol high. The increase in suicide rates is most significant in White males with access to firearms. Risk factors in this group increase with interaction of drinking and substance abuse. Adolescents must be taught not to keep the confidence of a suicidal communication from a friend. This can create a difficult conundrum. Peer groups are of primary importance to adolescents and they pride themselves on loyalty to friends (especially in opposition to parental influence). Yet they need to be made to understand that sharing a friend's suicidal plan is not a betrayal of confidence as much as a caring gesture to prolong the friend s life. In Shneidmans work we will see how important it is to expand the choices of anyone contemplating suicide. Adolescents must be reassured that it is not necessary for them to carry the burden of providing this expansion on their own. Telling a potentially helpful adult (not necessarily a parent) about a friend's suicidal plans is an act of love. Parents of suicidal victims showed higher incidence of depression, bipolar disorder, and alcohol and drug abuse than families of nonsuicidal adolescents. Parents had high rates of substance abuse, which conveys an environmental risk beyond the genetic liability. Availability of guns, regardless of how the guns are stored, was one of the most significant factors. A loaded gun in the house was a risk factor even for adolescents who are not depressed, suicidal, or substance-abusing. Suicides in nondepressed adolescents were 32 times more likely to occur when there was access to a loaded gun. Any psychiatric disorder in an adolescent—including major depression, mixed bipolar condition, substance abuse, or conduct disorder—created a 17 rimes greater incidence of suicide (Brent, 1995). The vast majority of young people who kill themselves have given verbal and nonverbal clues about their imminent suicidal behavior. .

Suicide and Violence; Assessment and Intervention

133

Brent (1995) found that 83% had made suicidal threats to others a week prior to their death. Berrnan and Jobes (1991) tell us further that "adolescents rarely initiate direct help seeking. The majority of suicidal youths receive help through the referrals of others, friends, family members, etc. Unfortunately, threats made to peers or siblings do not always lead to referrals, particularly in a subculture where confidentiality is important," (p. 124) Because suicide is a possibility in any life crisis, any person, adult or child, who feels overwhelmed by a crisis situation should be considered at risk. We have adapted the following checklist of adolescent danger signs from Berman and Jobes (1991): 1. Who is at specific risk? •

Depressed student

• » • • • •

Substance-abusing student Student with a history of rage, impulsivity, or instability Antisocial, acting out, disordered-conduct student Marginal, isolated loner Rigid, perfectionistic star Psychotic student

2. Other risk factors • Family history of suicide « Exposure to suicidal behavior of a peer or sibling • Hopelessness 3. Danger signs a.

Communication Suicidal content in school essays, poems, diaries, journals, art work. Preoccupation with themes of death, dying, afterlife, and so forth. Questions about suicide out of context b. Behavior warnings 1. Suicide threats 2. Poor impulse control 3. Rage

134

Crisis Intervention and Trauma Response

4. Availability of lethal method 5. Prior suicidal behavior, history of attempts 6. Termination behaviors, such as will writing, giving away prized possessions, making preparation for death 7. Acute behavioral change, such as acting out of character, mood swings, and so forth. Although the research of Lewinsohn, Rohde, and Seely (1996) also found that depression, low self-esteem, cognitive and interpersonal deficits, loss of a parent, suicidal behavior by a friend, early pubertal maturation (girls only), and access to firearms are serious risk factors for adolescent suicide, the strongest predictor of future attempts was a previous suicide attempt. They therefore recommend that all adolescent clients be assessed at intake for current or past suicidal ideation and previous attempts. These factors make programs such as Capuzzi's (1994) all the more valuable. Capuzzi's program of Suicide Prevention in the Schools insists that all school personnel, including administrators, teachers, counsellors, food service staff, janitorial staff, and so forth, be present at the training programs. One never knows when or to whom an adolescent will reveal, directly or indirectly, a suicidal ideation. The Elderly The elderly have the highest suicide rate of any age group. It has been estimated that each year (in the United States) as many as 10,000 deaths among the elderly may be the result of suicide. There are at least four major factors that have been shown to be related to elderly suicide: cumulative loss, alcohol and drug dependence, retirement with its financial and social concomitants, and social isolation resulting in loneliness (Stallion, McDowell, & May, 1989). Because losses are more frequent among the elderly, the term "cumulative loss" is used to describe the situation "in which elderly people must cope with a rapid succession of losses that do not allow sufficient time for the resolution of the grief inherent in each loss" (p. 172). As we know from our own clinical work, when many losses are experienced within a relatively short period of time, depression may become a chronic state. These

Suicide and Violence: Assessment and Intervention

135

losses refer to the loss of one's own abilities as well as the loss of one's relationships. Gender The Stone Center for the Study of Women makes a strong case for the fact that women develop and grow in a relational context. They feel that if a woman's movement toward emotional connection with others is met with disdain, ridicule, or punishment, it will constrict her relational world and her sense of strength and integrity. This experience can lead to suicidal behavior on her part. Although completed suicides are three times higher in men than women, 70% to 80% of attempts are by women. However, only 5% to 10% will complete the suicide. Rates of women's suicide have decreased with the increase in women's employment. Loss of hope to foster and maintain strength in emotional connection with others is at the core of women's suicidal action. The decision to kill herself and abandon all relatedness stands in direct opposition to the core of her identity. Women who attempt suicide are not of the same risk population as completers. The typical attempter is a young. White, unmarried woman who comes from a chaotic family with whom she is still living and has a history of chronic interpersonal conflicts and previous suicide attempts. The typical completer is an older, unemployed, married or widowed man living alone. This person may be alcoholic, may have legal problems, and may have sought help less often. The event preceding the man's suicide is often humiliation sustained in the realm of employment. Male attempters are also living alone, socially isolated, and link their suicide attempts to status loss in the realm of paid work, and the significant issue is injury to pride or self-esteem, whereas the significant issue preceding suicide in females is a breach in capacity for connection. Both may feel worthlessness, but the source is different. If, however, you reflect this to clients, you may aggravate their worst fears. It is important to reframe the suicidal attempt as a desperate effort to be heard and recognized in an increasingly relational world. This act is a

136

Crisis Intervention and Trauma Response

last grasp at a connection by the client. Help her to value and trust her relational capacities, hold on to the possibility of joining in a process of connection (Kaplan & Klein, 1991),

Assessment Techniques Putting together all that we have presented about suicide, your assessment plan should focus on: 1. 2. 3. 4. 5. 6.

Plan specificity—what it is, how detailed is the planning Means lethality—how dangerous is the chosen means Availability of the means to fulfill the plan Possibility for rescue in the plan Clients suicide history History of mental illness

There are essentially two approaches to doing a suicide assessment. Motto (1992) tells us that: Approaches to suicide risk assessment may be considered in two general categories: "clinical" and "empirical," Clinical assessment. , . is an , , , interview method that elicits detailed information about a person's life experience, character structure, and adaptive needs; when effectively carried out, it enables the examiner to recognize the circumstances under which a suicidal act is likely to occur in a given individual. An empirical approach, at the other extreme, consists of inquiring about a number of items previously observed in persons who have committed suicide, with the implied assumption that these observations should identify the person being assessed as similarly at risk. The clinical approach is relatively time-consuming; assumes that the person being assessed is cognitively clear, articulate, and willing to cooperate; requires a setting conducive to calm reflection; and, for optimal results, calls for a welltrained and experienced professional. An empirical assessment, on the other hand, can be done relatively quickly, usually in a matter of minutes; may use data from various sources; is compatible with the hectic atmosphere of an emergency department or a crisis line; and does not require years of training and experience to carry out efficiently, (p. 626) It is safe to say that very few persons with responsibility for estimating suicide risk use either of these approaches exclusively. The optimal

Suicide and Violence: Assessment and Intervention

137

approach, which is by far the most frequently used, is to utilize both methods of assessment to the extent that one can, mindful that what will work best is determined largely by the setting, the circumstances, the available time, the condition and cooperativeness of the person assessed, and—most importantly—ones own training, experience, and style. The usual pattern is to start with an abbreviated clinical inquiry along the lines, "What is happening in your life that is creating pain? What effect is it having on your thoughts, feelings, and behavior? And, finally, "Can you stand it?" This is generally followed by more empirically focused questions, such as whether suicide was attempted in the past or whether physical illness, drugs, or alcohol is involved. An empirical scale is used in many settings, especially psychiatric inpatient units and telephone crisis centers. When the brief clinical and empirical inquiries are combined with information available from third parties and with demographic observations of age, sex, and race, the clinician is ready to estimate the level of risk. (p. 627)

Specific Questions Practitioners, whether experienced or inexperienced, often feel they cannot discuss suicide because they do not have the appropriate questions to ask. If there is any question in your mind at all about an individuals possible suicidal intentions, you must ask "Have you thought of hurting yourself (or committing suicide, or dying)?" If the answer is yes, you must ask "How had you planned to do this?" If the answer is vague, the subject still needs further discussion, but lethality is lower. If, however, the patient replies with a specific means, pursue the issue further. Ask the client to describe the means and determine how specific the plan is, that is, when, how, where this could happen. Next determine if the client actually has access to the means of suicide. If the means is a gun, check for availability of firearms in clients milieu. Drugs are more complicated because a large enough dose of about anything in the common medicine cabinet can be lethal. If the plan is vague, but lethal means are available, such as a firearm, extreme caution is necessary. In our case, one of the authors (B.W.) insists that the firearm be relinquished to her. The other author (E.B.) insists on the client securing the firearm. In either case, this is seen as a high-risk situation. It is also important to ask about the client's past history with

138

Crisis Intervention and Trauma Response

suicide or suicidal gestures. To understand the significance of this information read the section based on Shneidman below. It is assumed that you are using, as effectively as possible, all of your listening skills. You are understanding and empathic, not judgmental. You can hear the client's pain but you need to use the paradigm mirror-pace-shift, hear the client, pace yourself to the client's pace, mirror and respond to his or her affect, and then gently move it in another direction. Any suggestion of suicidal ideation demands an active participation by the helper. The more lethal the means chosen and the more specific the plan, the more directive the helper must be. * First, make every effort to get the client to dispose of the means chosen. If possible, remove the means. Help the client dump the stash of pills, collect any firearms or assign someone close, such as a friend or relative, to do that. * If this is a. child or adolescent, confidentiality needs to be broken and family or close friends need to be informed. « At any age, establish a lifeline: get a list of persons (or at least one person) who want to see that client stay alive. Have the client inform them (from your office or wherever you are working) of the situation. If the client is unable to do this, you must do it for her, with her permission. The people on the list need to be in contact with the client during the difficult time, perhaps taking turns actually being with her. If this is not possible, and intentionality and lethality are high, the client must be taken to the emergency room of a hospital, * Set up a contract with the client. This should revolve around the fact that you will immediately start to work with him on those things that are causing the terrible pain, both immediate and underlying. For the period that you are working together, the client will postpone the decision to make a suicidal attempt. One of my colleagues calls this a living life contract Writing it down makes it more significant. * Immediately deal with the issue. If you are not skilled enough to do this, refer the patient to someone who can see him immediately. Even if you question your skill, it may be more important for you to work with the client if you now have his trust, In that case, get yourself supervision as soon as you can. If possible, mobilize the clients

Suicide and Violence: Assessment and Intervention

139

anger. If the anger can be mobilized and directed outwardly, then the suicidal possibility lessens. Nonverbal anger expressions (as described in chapter 7) can be very effective at this time. • Set up your next appointment as soon as possible. Remember that weekends are the worst time for anyone in pain. If you are seeing someone on a Friday, make sure that you have an appointment early on Monday. • Do behavioral planning. Go through the time between appointments with the client (particularly if this is over a weekend) and help the patient plan the time so that it is structured and leaves as little time as possible for solo rumination. • Be available by telephone whenever this is necessary. Motto (1992) tells us, "when all the questions have been asked and answered, the final decision regarding degree of suicide risk is a subjective one. It may or may not agree with the score on a risk scale . . . it may not even be explainable in terms of clear inference or reasoning. It is simply the , . . summation of all the information that has been gathered and processed at a level that is not entirely conscious. This can be called 'intuition'" (p. 628). Motto goes on to describe that we gather much information without our awareness and pick up verbal and nonverbal clues as we do so. He says "it is important to accept that when we have gathered all the information we can, this intuitive sense is our best guide to estimating suicide risk." Perhaps reading these words is frightening, particularly if you are just starting in this field. How can you trust your own intuition? Time, experience, reading, learning, listening, and watching are the best ways to get to this point. Many years ago one of the authors had a patient who had left a previous therapist abruptly, to become the author's client. The client was then a freshman in college. The author never accepts this situation until the client goes back and works through the reasons for leaving the former therapist. She agreed to this, had one last session with him, and spent the weekend in the hospital after a suicide attempt. When she came in to start therapy with the new therapist (B.W.) she was told, very clearly that the therapist had a very busy schedule and did not want to feel that the energy put into helping her was going to be wasted by some other suicidal gesture. She

140

Crisis Intervention and Trauma Response

agreed to that, made excellent progress in therapy, and eventually terminated her treatment. The next time the therapist heard from her was when she called to say she was applying to a doctoral program in psychology and wanted a reference. This is an extreme example of being very directive after a suicide attempt. Would this apply to any suicidal client? Certainly not. This is the function of intuition and experience. Eventually, one can trust it.

Understanding Suicide Suicide, or the possibility of suicide, is never easy to deal with. Your own feelings about the sanctity of life, combined with your sense that the challenge of preserving that life may seem overwhelming can complicate your reaction to the client. However, the greater your understanding of the clients inner torment, the better your chance to respond appropriately and empathically. Suicidologist Edwin Shneidman, in his 1985 book, Definition of Suicide, has given us a series of 10 insights into a better understanding of the suicidal person. We have drawn generously on Shneidman's own words because his many years of experience and research in this field give us a significant picture of the suicidal persons thinking. Many of his common characteristics of suicide are followed by a clinical rule. Shneidman's characteristics are: 1. "The common stimulus of suicide is unendurable psychological pain" (p. 124). The person is trying to escape the pain, and suicide must be seen as a movement away from an intolerable emotion, unendurable pain, and unacceptable anguish. Shneidman's clinical rule: Reduce the level of suffering, often just a little bit, and the individual will choose to live. The individual makes a qualitative judgment, "This far and no further" (p. 10). Each individual has a unique threshold. What this means to the worker is that the slightest movement you can facilitate, whether in a problemsolving mode or in an affective-expressive mode, can make the difference between the client carrying out his decision or reassessing it. Never underemphasize the importance of an appropriate intervention with a suicidal individual, even if that intervention seems small to you.

Suicide and Violence: Assessment and Intervention

141

It may just be the difference between what is tolerable and intolerable to the client. Students often fear intervening and responding to a suicidal person because they are inexperienced. But any intervention that indicates your interest in the person and a sincere effort to help him or her reassess these painful situations can be helpful. 2. "The common stressor in suicide is frustrated psychological needs. . . . Human acts are intended to satisfy a variety of human needs" (p. 126). Obviously, when a person approaches the level of suicidal behavior, that person has experienced a lack of satisfaction of significant psychological needs. Shneidrnans clinical rule: "Address the frustrated needs and the suicide will not occur. Focus on the thwarted needs" (p. 127). How does this translate into our clinical application? For example, often when a disaster strikes, individuals may regress to the core of their childlike belief systems. This system tells them that they deserve pain because they are essentially unlovable. There is no time in a crisis to engage in a lengthy exploration of the veracity of that belief system. Two fairly fast and effective approaches to this would be a cognitive approach that focuses on the underlying irrational thought and helps reframe it with a more rational one, as, for example, naming loving people. The affective approach encourages the individual to be a surrogate parent to this unlovable part of the child-self and break the power of the message of the original cast. The client can be encouraged to use pillows, a doll, or some other image to address that child part and give it some of the love that it has sought ineffectually; to treat it as he would treat his own child, reinforcing its sense of self and assuring it that it deserves to be loved and to live. This can be a very moving experience. Both of these approaches have been helpful, and the choice of technique depends on consideration of the constriction-dilation continuum as well the therapists ability in using the approach. 3, "The common purpose of suicide Is to seek a solution. . . . Suicide is not a random act. It is never done pointlessly or without purpose. It is a way out of a problem, dilemma, bind, challenge, difficulty, crisis, unbearable situation. . . . It is the seemingly only answer to 'how to get out of this'. . . . Each suicide seems to the person to be the best possible solution" (p. 129).

142

Crisis Intervention and Trauma Response

Shneidman's clinical rule: "Know the problem that is unable to be solved" (p. 129). To which we add, "Explore other solutions." This can be difficult in a trauma situation, and one must be prepared to be focused and directive in getting the necessary information. Be prepared also for much resistance and "yes . . . but" behavior. The client may have made his mind up rather assiduously and resent any solution you may offer. Don't let this deter you; it may well elicit irritation and anger by the client that is directed to you and your insistence on a solution. This anger can give you another entry into the client's process, One of the most effective ways of dealing with a suicide is to provoke the anger and externalize the self-destructive impulse. Work with the anger and redirect it. 4. "The common goal of suicide is cessation of consciousness. Suicide is a moving toward and a moving away. Moving toward the cessation—the complete stopping of one's consciousness and unendurable pain. The core ambivalence is between survival and unendurable stress" {page 129). Shneidman's clinical rule: "Take practical measures—talk to people, make arrangements, contact agencies, . . . this requires a benign person, an effective ombudsman" (p. 136). In all crisis work, the general orientation is, as Parad (1965, p. 36) says, "do only what they cannot do for themselves." Elsewhere we have discussed the important differentiation between being helpful and fostering dependency. We have seen how easy it is for a person to develop a dependency relationship with the helper in a time of trauma. However, when dealing with a suicidal individual, one will often find a kind of paralysis, in which the client seems frozen in pain, rigid thinking, and belief in a singular solution. It is here that even a small amount of the helper's direct involvement in making connections within the community or helping to develop a lifeline of friends and family for the client can go beyond any concern about dependency and can sometimes be lifesaving, 5. "The common emotion in suicide is helplessness . . . hopelessness" (p. 131). The suicidal person experiences an "impotence . . . a sense that there is 'nothing I can do and no one who will help me'. . . (there is) also a tendency to throw in the towel when suffering a setback .. . also closely related is an overpowering feeling of loneliness . . . We fear something worse than what we have . . . better dead than mad

Suicide and Violence: Assessment and Intervention

143

, . , this far and no further" (p. 132). Our clinical rule, from a cognitive viewpoint, is to help the client see that the fear of insanity can be reframed. From an existential viewpoint, the existential loneliness can be addressed, and your work on developing support contacts (chapter 4) needs to be activated. The helpers goal is to establish a sense of empowerment for the client, so that the client feels that there is much that can be done, 6. "The common internal attitude toward suicide is ambivalence— to feel that one has to do it and simultaneously to yearn and even to plan for rescue and intervention" (p. 135). Our clinical rule here is to listen very carefully at all times for this ambivalence; know that within each person no matter what else is being said, there is always a flicker of the flame of the life force. The work of the helper is to listen for any indication of that life force, to support it and magnify it, and help the client to focus on it. It is always there. 7. "The common cognitive state in suicide is constriction , . . this is . . . , not a psychosis, neurosis or character disorder . . . a transient psychological constriction of affect and intellect. . . . Tunneling, narrowing, focusing on the range of options usually available to that person's consciousness-—-either some specific . .. magical total solution or total cessation. . . . The range of choice is limited to two, , . . One of the most dangerous aspects of suicidal state is constriction . . . any attempt at remediation must deal with this pathological constriction . . . It takes a mind capable of scanning a range of options greater than two to make a decision as important as taking your life . . . or—never kill yourself when you are suicidal!" (p. 138). Shneidman's suggestions are to widen the mental blinder and increase the number of options. Our approach to this would be to help postpone the decision by contracting with the client not to act until a certain time has elapsed in our work together or until some other criterion has been reached. Another approach that is possible here may be some nonverbal expressions, such as anger release exercises (see chapter 7) that can help the client shift his/her thinking from narrow constrictedness to a wider range of feeling and a larger range of options. 8. "The common interpersonal act in suicide is communication of intentions. . . . A most interesting finding from a large number of retrospective psychological autopsies of suicides is that in the vast

144

Crisis Intervention and Trauma Response

majority there were clear clues to the impending lethal event. . . clues were present in approximately 80% of suicidal deaths , . . consciously or unconsciously (people) emit signals of distress, pleas as for response, opportunities for rescue in the usually dyadic interplay that is an integral part of the suicidal drama. The common interpersonal act of suicide is not hostility, rage or destruction, but communication of intention . , . not always a cry for help. First it is not always a cry—it can be a shout or a murmur or a communication of unspoken silences. And it is not always for help—it can be for autonomy in any number of areas . . . Statements tantamount to saying I'm going away, you won't be seeing me—I can't endure the pain any longer,' putting affairs in order, giving away prized possessions and generally behaving in ways that are different from usual behavior betoken a bubbling in a perturbed psyche" (p. 144). Our clinical rule is reflected in our directions for conducting a suicidal assessment. Remembering that suicide is always a possibility, the helper needs to be vigilant for any of the indicators that Shneidrnan has described. Also, whenever possible, helpers need to inform others in the client's life about the existence of these indicators. Clients need to be told that confidentiality, a basic concept in all helping work, is suspended whenever there is a possibility of injury to the client or to others in the clients milieu. 9. "The common action in suicide is egression—a person's departure or escape often from distress, to leave, exit or escape—a running away, a deserting" (p. 144). Our clinical rule: Explore other ways of reacting, and if escape is necessary, explore other areas of escape, such as from a relationship, job, and so forth. This can be done in reality or in fantasy and visual imagery. 10. "The common consistency in suicide is with life-long coping patterns—people dying do not go through any standard set of stages in the dying process through which all march to death. We see instead a display of emotions that are consistent with that individual's reactions to pain, threat, failure, powerlessness, impotence, and duress in previous episodes of that life" (p. 148). People who are dying have enormous consistency within themselves. So do suicidal people. ". . . yet it is an act with no precedent—it has never been done before. We must look to previous episodes of disturbance, to capacity

Suicide and Violence: Assessment and Intervention

145

to endure psychological pain . . . and dichotomous thinking for earlier paradigms of egression ..." (p. 148). Shneidman (1985) relates that in the Terman study (done from 1921 to 1970) 1,528 gifted men and women were followed at Stanford University. It was possible to predict at age 30 the five subjects who committed suicide at age 55 because of their characteristics or habitual patterns of reaction to threat, pain, pressure, and failure. We have said many times throughout this book that a time of trauma leaves no luxury for an extensive history taking, but an easy question such as "Have you had any previous experiences with difficulties, crisis, and so forth? If so, how did you react to them? Was this behavior effective?" can provide an important clue about lifetime behavior patterns. It is important to integrate and understand all of the material we have presented in assessing for and responding to the possibility of suicide.

VIOLENCE Sources of Violence A reaction we may not associate with crisis or trauma is violence. In our earlier discussion on the concept of loss we demonstrated the centrality of loss to every crisis and trauma. Loss can be internalized as sadness and mourning, as we have demonstrated, or it can be externalized as anger. When this anger is experienced by those who are either genetically or behaviorally programmed, violent behavior can result. Trauma is more visible today than ever before, and the media brings it into the sanctity of our homes on a daily basis. The media's invasion makes each of us a possible "secondary trauma victim." This exposure can give potentially violent individuals far more stimuli than formerly. It can also reactivate some of the earlier causes of their behavioral programming. Not only can trauma contribute to violence, but every violent outburst creates yet another traumatic experience for its victims and observers. Repetitive losses, such as those created by trauma, can create people who are "primed" for violent behavior. The structure of North

146

Crisis Intervention and Trauma Response

American society today creates a matrix of losses that contribute to the

crisis. With divorce rates hovering around 50%, our society is experiencing an ongoing breakdown in traditional family structures. This situation creates both the loss of a partner for the parent, as well as loss of predictable stability for the child. It also makes the traditional safety net of extended families—grandparents, aunts, uncles, cousins, and other traditional support systems—less available (Wainrib, 1976). With a decreasing availability of loved ones to cushion some of life's blows, the pool of both adults and children with a higher than usual "loss reservoir" increases. In addition, current economic pressures have increased the number of dual career families and the number of single-parent families has doubled in the past 20 years, according to Statistics Canada (Suicide in Canada, 1992). These economic pressures put the head of the household under added stress. When a parent is under this kind of stress, he or she may appear preoccupied and unavailable to a child. Children automatically assume that their parents will or can protect and save them from unthinkable experiences, such as those experienced in a traumatic situation. However, when that parent is experienced by the child as unavailable, the child is subjected to both the loss inherent in the crisis itself as well as a sense of secondary loss, and abandonment. This can make the child's loss reservoir approach the overflowing mark. This secondary loss can make the child more vulnerable. Increased mobility of the population implies increase in loss to each family member. With each move, every member of the family must recreate his or her personal community and support system. The loss of friends can affect adults and children alike. Adults, however, have a longer history of experience and may understand that they are capable of remaking connections. Children may not, and each loss due to moving also contributes to children's cumulative losses and may increase their vulnerability to trauma. In addition, research has shown that children from some of these backgrounds are at greater risk when trauma occurs. We saw this in chapter 3 when examining children's special needs. Pynoos et at (1987) and others have also reported that parental anxieties, fears, and tensions can create secondary trauma for children.

Suicide and Violence: Assessment and Intervention

147

If we see anger and violence as potential responses to loss, we can start to understand the increase in violent behavior in our society, Other sources can include gender role changes. These changes are seen by some men as a threat to their masculine identity, either through their work experience or through the change in balance in their marriages and personal relationships. The backlash this has created has been visible for a while, and the incidence of violence against women continues to increase. And, of course, modeling by the mass media has served to desensitize both children and adults to the reality of violent behavior. Daily the entire population is exposed to an attitude of "if someone hits you, strike back, only harder." Cartoon characters on television and computer games are examples of the glorification of violent behavior. Lethal weapons are readily available in most parts of the continent, and heroes model their use in any difficult or threatening situation. These may contribute to some frightening statistics. The homicide rate in the United States is 10 per 100,000. In 1987, 50% of homicides in the United States were committed within the family, and of these, two thirds are women killed by their male partners (Browne, 1987). In 1986 abuse of the elderly had risen to about 4% of the aging population in both Canada and the United States, with only 1 in 6 cases being reported. (Hudson, 1986). Ross and Hoff (1994) report that Canada has demonstrated extraordinary leadership in the issues of victimization of women, with several federally funded research centers as well as being the first country to pass a federal mandatory-arrest law for wife beaters. Nevertheless, in Canada, one half of all Canadian women have been the victims of personal violence (Statistics Canada, 1993). In the United States, Dr. Michael Mantell (1994), author of Ticking Bombs, reports that in a 1993 study, in one year (1992-1993), 2.2 million workers were victims of physical attack on the job, 6.3 million reported being threatened, 16,2 million reported being harassed. In addition, of those attacked in the workplace, 1 in 6 reported that the weapon with which they were attacked was lethal. Lalla (1995) reports that "twenty to fifty percent of medical residents will be assaulted by patients at least once" (p. 3). Violence in the workplace frequently moves beyond the workplace, and often, as in the case of Eric Huston, can leave the workplace and move into what might be

148

Crisis Intervention and Trauma Response

considered by some as a most unexpected venue. Eric Huston's employment was terminated in April 1992 from his job at Hewlett Packard. He then used a shotgun and a .22-caliber pistol to kill four innocent people, but not at Hewlett Packard. Instead, he went back to his high school in California and took his rage out on those whom he considered to have inadequately prepared him for doing his job, as well as the counsellors who advised him (Mantell, 1994). Throughout this book we have emphasized that as helping professionals we strive to create a safe place, a sanctuary in our professional environment. We try to create an environment of peace, trust, and protection. Yet violence can violate that sanctuary as well. Crisis workers must try to transport that sanctuary to any place where they may be called to work. Yet violence is a potential even in that place of peace, and for the sake of your clients as well as your own safety, you must understand violence and know how to assess for it.

Factors in Violence Assessment The following are important factors in assessing for violence: 1. Age: violent behavior is highest in adolescence and early adulthood and starts to decline by the fourth decade. 2. Gender: males are more likely than females to commit violent crimes. 3. Race: minorities account for a disproportionate number of violent crimes. Despite VandeCreek's (1989) statement about racial differences, Lalla (1995) says, "There is no racial group any more violent than another . . , when one adjusts for socioeconomic factors , .. the prime determinants in the social causation theory of violence are absolute poverty and marital disruption" (p. 5). 4. Intelligence: emotional lability and impulsive violence seem to correlate negatively with intelligence. 5. Academic performance: school achievement does not match ability level in violent young people. 6. Drug and alcohol abuse: these correlate positively with violent behavior.

Suicide and Violence: Assessment and Intervention

7. 8.

9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

149

Impulse control history: violent individuals exhibit a history of impulsive behavior such as walking off the job, quitting school, and so forth, Criminal history: there is frequently a history of violent behavior—such as assault and battery, homicide, property damage, being drunk and disorderly, reckless driving, arson, cruelty charges, domestic abuse, and so forth. History of personal victimization: persons who are victimized appear to be more likely to behave violently (see traumaviolence spiral). Intent: the client expresses an intent to harm someone, Plans: the client describes a plan of attack. Peer system: significant others encourage violence. Employment status: employment availability and job satisfaction correlate negatively with violence. Imminent loss of job and chronic unemployment are related to dramatic mood changes. Availability of means of violence: the client possesses lethal weapons and knows how to use them. Role of potential victims: the majority of violent crimes against people occurs between acquaintances. Focus: if there is a clear focus of aggression and an identifiable victim, the violence potential is very high. Family setting: the family incites violence. Repetition: Violence is often a repeat of past violent situations. (Adapted by VandeCreek, 1989.)

There are some basic things that the helper needs to know about violence, both to be able to assess for it, as well as to be protected from it. Some kinds of violence are precognitive processes. They are immediate, impulsive responses that take place quickly to provoking stimuli. If we can anchor the person in himself by getting him self-focused, you can defer some of this process. By using a simple Rogerian approach such as reflecting feeling, you have taken a step in deflecting that process. If you suspect violence, your first need is to get the perpetrator to focus on himself. Violent people have been shown to have a poor awareness of consequences, a deficit in consequential thinking, and thus generate fewer

150

Crisis Intervention and Trauma Response

solutions to problems. The helper needs, as quickly as possible, to suggest solutions, to move quickly into solution-focused work. For example, in our scenario (in chapter 4) of the construction worker who has been fired, the helper needs to have at hand and available immediately several resources for his use such as a place to get emergency money, unemployment insurance, a way to break the news to his family perhaps with the counselor's help, help for his family, and other similar issues. Research has also shown that aggressive people get less information than nonaggressive people before they act. Therefore, die more quickly one can provide information to a violent person, the more likely one is to calm him. Next, you need to know who can be violent. VandeCreek's list above suggests characteristics that can help make you aware of the potential for violent behavior. In addition, violent behavior can be a function of genetics or a learned function of life experience. With people who have either of these aspects in their background, the slightest stimulus—a sound, a look, an odor, a location—can trigger the entire memory chain of experience, including the associative aspects of the experience itself. For example, suppose you were repeatedly beaten as a child by an abusive, alcoholic parent who always beat you in a warm room with strong food odors. Now, as an adult, your boss has decided to fire you for reasons that make no sense to you. He chooses, however, to do so in what he considers a civilized fashion and takes you out to lunch. The restaurant he chooses is unusually crowded and warm and has strong food odors. Once you hear what the boss is up to, without any rational thought, your memory chain will connect you to the scenes of your helpless childhood and trigger your associative reaction. Feeling at the same time like both the helpless child and the strong, fully grown adult, you have both the painful memory as well as the strength and the impulse to do to your boss what has been done to you. Lalla (1995), however, feels that one need not have had this childhood experience for a reaction such as this to emerge. He says, "as a rule, anyone, under the appropriate circumstances, has a capacity for physically aggressive behavior," which is an even drearier prospect. Maxmen and Ward (1995) also warn us, "never assume that a mildmannered Clark Kent patient in front of you would never hurt a fly. . . . Violent tendencies tend to be expressed by two broad patterns:

Suicide and Violence: Assessment and Intervention

151

ongoing suppression or repression punctuated by sudden eruptions and routine, regular outbursts of anger and destructive behavior. Some are routinely violent only to a certain person—such as a spouse." (p. 25) Lalla (1995) gives us this checklist of behavior to watch for: Appearance: indications of use of alcohol or drugs. Physical behavior; sitting on the edge of the chair gripping the armrests, loud voice, pacing. These indicants may be of acute anxiety or drug or alcohol withdrawal. Poor hygiene: may indicate the client is potentially psychotic or not taking medications. Scars and tattoos: may suggest a violent lifestyle. While we try not to be prejudicial or stereotypic in our approach, research has shown that people who engage in these activities may be more violence prone (p. 14), Anxiety may not always be a good indicator because psychopathic personalities may not show any anxiety. Watch for coldness, icy looks, and a delight in giving you scary material as well as plans for particular attacks (Lalla, 1995). Some Stimulants That Can Be Controlled There are some things that you can control. Temperature and crowding have both been shown to be factors in stimulating violence. Moderately hot temperatures encourage violent actions. When the Montreal General Hospital expanded and improved the ventilation of their psychiatric acute care unit, physical attacks on the staff dropped by almost two thirds! Research has shown that the average temperature body buffer zone is four times larger with a violent person than with a nonviolent person. In addition, the rear body space comfort zone is significantly larger than the front one (Lalla, 1995). Penetrating this zone can create anxiety and autonomic arousal. Approaching a potentially violent person from the back can be dangerous. In chapter 7, we will talk about safe areas of the body and the issue of touching. The potential for violence will be factored into that discussion.

152

Crisis Intervention and Trauma Response

How to Protect Yourself from a Violent Client Protective strategies include: 1. Keep your environment safe. Avoid having potential lethal weapons such as letter openers, mugs of hot coffee, or breakable objects easily accessible or visible. 2. Keep your own chair near the door, and if possible, sit on a light chair that you can pick up and use as a shield. 3. Use the kinds of verbalization described above, both the empathy and the problem solving, which should help reduce the patient's anxiety. If these do not work, do not be ashamed to leave the room and call for help. Letting the client know that you are afraid is acceptable. It provides some reality testing and lets him know that he is not alone with his overwhelming feelings. One of the authors (B.W.) colleagues was accosted by a student with a history of violent behavior. As the student spoke to her he became more and more agitated and her fear leve! rose. Finally she said to him, "I am very uncomfortable being here alone with you because of the way you're speaking to me, and I am going to have to call security." The student was at once impressed that he had succeeded in frightening her and was appropriately concerned about the arrival of security. He apologized quickly and left. 4. Things you can do to protect yourself if you are trapped with an attacking client: * Stand sideways. This provides less vulnerable surface of body and allows your arms and legs to deflect blows. * Keep your arms in boxers position. This will guard your face and neck. * Keep your chin down, shield your carotid artery and trachea. * If you are grabbed, try to grab your assailants wrists and block breathing. * Use anything available in your orifice, such as pillows, or books that can provide protection against sharp weapons (Lalla, 1995).

Checklist Use the following checklist to assess a client in a potentially violent or suicidal condition.

Suicide and Violence: Assessment and Intervention L 2. 3. 4. 5. 6.

153

How urgent is the situation ? How severe is the situation? How appropriate are the clients responses? Where is the client on the dilation-constriction continuum? What is the client's level of functioning (cognitive, affective, behavioral)? What resources does the client have? internal external community spiritual

7. 8. 9. 10. 11.

What does client need ? How quickly? Is there potential for psychological pathology? What is violence potential? What is suicide potential? What follow-up is recommended?

REFERENCES Beck, A, T. (1967), Depression. Philadelphia: University of Pennsylvania Press. Beck, A. T., Kovacs, M., & Weissman, A. (1975). Hopelessness and suicidal behavior; An overview. Journal of the American Medical Association, 234, 1146-1149. Herman, A, L., & Jobes, D. A. (1991). Adolescent suicide assessment and intervention. Washington DC: American Psychological Association. Beutler, L. E. (1985), Loss and anticipated death: Risk factors in depression. In H. H. Goldman & S. E. Goldston (Eds.), Preventing stress related psychiatric disorders. Rockville, MD: National Institute of Mental Health. Brent, D, A. (1987). Alcohol, firearms and suicide among youth, temporal trends in Allegheny County, Pennsylvania, 1960-1983. Journal of the American Medical Association, 257, 3369-3372. Brent, D. A. (1995, April). Depression and suicide in youth: Antecedents and treatment. Paper presented to McGill University Meeting on Depression and Suicide in Youth, Montreal, Canada. Browne, A. (1987). When battered women kill. New York: Free Press.

154

Crisis Intervention and Trauma Response

Capuzzi, D. (1994). Suicide prevention in the schools: Guidelines for middle and high school settings. Alexandria, VA: American Counselling Association. Cohen-Sandier, R., Herman, A. L, & King, R. A. (1982). Life stress and symptomatology; Determinants of suicidal behavior in children. Journal of the American Academy of ChiU Psychiatry, 21, 178-186. Ellis, E. M., Atkeson, B. M,, & Calhoun, K. S. (1982). An examination of differences between multiple and single-incident victims of sexual assault. Journal of Abnormal Psychology, 91, 221-224. Hayes, M, L., & Sloat, R. S. (1988). Preventing suicide in learning disabled children and adolescents, Academic Therapy, 24(2) 221-230. Hetzel, S., Winn, V., &Tolstoshev, H. (1991). Loss and change :New directions in death education for adolescents. Journal of Adolescence, 14,323-334. Hudson, M. P. (1986). Elder mistreatment: Current research. In K. A. Pillemerand & R. S. Wolf (Eds.), Elder abuse: Conflict in the family (pp. 125-166). Dover, MA: Auburn House. Isherwood, J., Adam, K. S., & Hornblow, A. R. (1982). Life-event stress, psychosocial factors, suicide attempt and auto-accident proclivity. Journal of Psychosomatic Research, 26, 371—383. Kaplan, A.G., & Klein, R. (1991). Women and suicide—The cry for connection, Wellesley, MA: Stone Center for Research on Women. Kazdin, A. E. (1983). Hopelessness, depression and suicidal intent among psychiatrically disturbed inpatient children. Journal of Consulting and Clinical Psychology, 51, 504-510. Klerman, G. L., & Clayton, P. (1984). Epidemiologic perspectives on the health consequences of bereavement. In M. Osterweis, E Solomon, & M. Green (Eds.), Bereavement; Reactions, consequences and care, Washington, DC: National Academy Press. Lalla, E A. (1995). The violent patient, Montreal, Canada: McGill University. Lewinsohn, P. M, Rohde, P., & Seeiy, J. R. (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors and clinical implications. Clinical Psychology: Science and Practice, 3, 25-46. Mantell, M. (1994, August). Ticking bombs—Defining violence in the workplace. Paper presented at the annual meeting of the American Psychological Association, Los Angeles, CA. Maxmen, J. S., & Ward, G. (1995). Essential psychopatholagy and its treatment. New York: Norton. Motto, J, A, (1992). An integrated approach to estimating suicide risk. In R. W. Maris, A. L. Herman, J. T. Maksberger, & R. I. Yufit (Eds,), Assessment and prediction of suicide. New York: Guilford.

Suicide and Violence: Assessment and Intervention

155

Neuringer, C. (1974). Psychological assessment of suicidal risk. New York: Charles C Thomas, Patsiokas, A, T., Clum, G. A., & Luscomb, R, L. (1979), Cognitive characteristics of suicide attempters. Journal of Consulting and Clinical Psychology, 47, 478-484. Petrie, K.» & Chamberlain, K. (1983). Hopelessness and social desirability as moderator variables in predicting suicidal behavior. Journal of Consulting and Clinical Psychology, 51 485^187. Pope, K. S. (1986). Assessment and management of suicidal risk. Independent Practitioner, 6(2), 17-23. Pynoos, E, Nader, K., Arroyo, W., Steinberg, A,, Spencer, E., Nunez, R, & Fairbanks, L (1987). Life threat and post traumatic stress in school age children. Archives of General Psychiatry, 44, 1057-1063. Rosenbaum, S. (Executive Producer). (1995), Investigative reports: Cops on the edge. New York: Arts and Entertainment Network. Ross, M., & Hoff, L. A. (1994). Teaching nurses about abuse: A curriculum guide for clinical practice. Canadian Nurse, 90(6), 33—37. Shneidman, E. (1985). Definition of suicide. New York: Wiley, Stillion, J. M., McDowell. E. E., & May, J. H. (1989). Suicide across the life span. New York: Hemisphere. Suicide in Canada. (1992). Statistics Canada, Suicide Information and Education Centre, Calgary, Alta, Canada, VandeCreek, L. (1989). Assessment of dangerous behavior. Psychotherapy Bulletin, 24(2), 17-19. Wainrib, B. R. (1976). A tri-level model ofhuman support and its applications. Unpublished doctoral dissertation. Amherst, MA: University of Massachusetts. Wetzei, R. (1976). Hopelessness, depression, and suicidal intent. Archives of General Psychiatry, 33, 1069-1073.

This page intentionally left blank

Chapter

7

PUTTING IT ALL TOGETHER: THE PRAGMATICS This chapter covers: • Active listening: new or review • Body messages • See yourself through the client's eyes « Listening styles • To touch or not to touch? • Further active listening skills • Nonverbal techniques • Anxiety-lowering exercises • Positive reinforcers • Sleep exercises • Caregiver responses in trauma • Role playing » Working with the media • Building a. mental health response team • Documentation, debriefing, and critique • Concluding note

ACTIVE LISTENING: NEW OR REVIEW This chapter will cover many of the hands-on aspects of actually doing crisis and trauma work. For some readers, parts of this chapter will be a review. The section on active listening may be one of these. Anyone working in any helping profession may assume that active listening is a given, but our experience with training professional people at all

157

158

Crisis Intervention and Trauma Response

levels of experience has shown us that everyone can benefit from a review of this kind. Students, from newcomers to the field to seasoned professionals, will benefit from this basic material, whether it is being seen for the first time or a review. In addition, by practicing the role-play situations described in this chapter, the reader will have some experience of what actually dealing with crisis and trauma situations feels like. In a previous chapter, we quoted Carkhuff(I971), who taught us that the helper provides "the sanctuary of solitude, . . . a moment of respite from a world closing in . . ., assurance that, no matter what, she will attend to the client." How does this happen?

BODY MESSAGES Although it is a given that the worker's focus will be totally on the client, it is important to remember that fact when working in a crisis situation. Despite good intentions, when there is havoc all around you, it may be necessary to remember that you are there to hear one person at a time, and that person must get your full attention. How can you assure the client that you are fully present for her? In chapter 2 we discussed the importance of being at a physically equal level with the client. As well, your body messages are essential at a time of crisis. Remember to face the client fully, with your upper trunk leaning toward the client with your body inclined as close as is comfortable to both of you. Your posture needs to be simultaneously intense and relaxed. In chapter 4 we discussed self-scanning. Become aware of your own posture and monitor it throughout the work. A guarded posture, which may be manifested by arms or legs folded in front of you, bodily stiffness, or keeping very distant, may be an expression of a synchronistic response to what the client is telling you. Knowing this can be helpful in your interventions. It may, however, be a countertransferential response reflecting your own difficulty with the client s material. If this is the case, you need to assess whether or not you can work with this situation. If you feel this continually, it may be time to discuss this case with a supervisor or to transfer the client to someone else.

Putting It All Together: The Pragmatics

159

If you feel yourself getting fidgety, perhaps you are asking yourself "why am I here?" Even if you are not thinking that, the client may be getting that message. Your behavior needs to be consistent, yet appropriately responsive to the client's affect.

SEE YOURSELF THROUGH THE CLIENT'S EYES In every role play situation in this chapter take a moment to include this exercise. Take a moment to scan your body and your facial expressions and try to see yourself through the client s eyes. When you are in total synchronicity with your client you will suddenly observe that your posture mimics the client's. Clinicians often find themselves sitting in positions that feel strange to them, only to find that these are the same positions that the client is taking. This is what it feels like to be truly in synch with another. Eye contact, important at any time in establishing communication, is essential in this work. Remember that every crisis brings with it a possible crisis of trust. It creates questions about how much one can trust the world. At the moment that you are working with the client, you represent the world and you must create an atmosphere of trust. For clients who have been previously traumatized, this lack of trust is magnified many times over. Your eyes are the most visible parts of your communication, and they will be carefully watched by the client. Even if there will be times when the client's pain prevents her from maintaining eye contact, your eye contact must be available.

LISTENING STYLES During the course of real work in crisis and trauma, you may have to utilize a variety of styles of listening. Some, however, will be more effective than others. The following exercise and discussion will clarify

160

Crisis Intervention and Trauma Response

this. Each of these styles may have to be used in your crisis and trauma work. Each, however, comes with a caveat. As you will see in the following exercise, each demonstrates a potential for the negative impact of inappropriate listening.

Exercise 7.1: Listening Divide the group into subgroups of four people. Designate person A, B, C, and D in each group. The designated student is to attempt to tell a story—not necessarily emotionally laden—to the rest of the group. In each round the rest of the group will be instructed as to their response type. Each round should take 3 to 4 minutes. In round I , student A is the speaker. All other students in the quartet make irrelevant comments whenever a break occurs in student As story. In round 2, student B is the speaker and all other students in the quartet make tangential comments. A tangential comment is one in which the listener picks up on a word or concept of the speaker s and talks about it in the listener's own way, such as, "you come from . . . Kansas, my wife drove through Kansas once." In round 3» student C is the speaker and all other students in the quartet make interrogative responses (questions). In round 4, student D is the speaker and all other students make competitive statements (i.e., "You think that was bad, well let me tell you what happened to me," etc.). Some of the exercise experiences may feel very familiar to the participants, reflecting typical conversations with friends or at the dinner table. But they are not appropriate in any therapeutic situation, particularly in crisis intervention. Any of these response styles, whether interruptive, tangential, interrogative, or competitive, can cause the speaker to feel unheard and invisible. When this happens, the storyteller not only feels that his/her story is inappropriate or unworthy of being heard, but may feel that he/she is unworthy. Not being heard can create an erosion of the storytellers sense of self-esteem. This sense may already be shaken by the crisis or trauma and any additional blow is all the more significant. Because of the vulnerability inherent in the crisis experience, whatever we do in terms of our communication can effect the core self-esteem of the person in crisis. It is therefore a given

Putting It All Together: The Pragmatics

161

that all listeners must put all personal issues on hold and stay totally with the client. The following discussion will demonstrate specific ways in which this is manifest. Irrelevant Comments When this kind of response is made, the client has the experience of being made invisible, being totally nonpresent. While during the course of a class exercise some people may feel able to fight for attention and to be visible, it is very tiring to have to do this to feel truly heard, and in a crisis the client has no energy to fight for attention. When the speaker feels not heard, one response can be to internalize the feeling, "I'm not worthy of being heard. My pain is meaningless, or maybe I'm just stupid to think that my experience is important." This frustration can lead to an externalization of irritation such as the impulse to scream or yell, or perhaps, in some cases, to violent behavior. It can also create the internalization of the feelings, which leads to a sense of "frn not important" or "rny story is not important." Both of these reactions are diametrically opposite to the feelings of empowerment and healthy reinforcement that need to be engendered in the client at this time. In situations of trauma response, many things may be happening at once and there may be realistic reasons for interruptions. However, should this happen, you must be able to reassure the client that you are still with her story. Tangential Comments Tangential comments can often serve as a "pressure-reliever" for the counsellor, and may be used to lower the helper's anxiety level. As such, they may inadvertently be used when the client's conversation becomes difficult to deal with. Tangential comments often originate in the free association of the counsellor. They may be relevant to her/his own thoughts but have little meaning to the client. The helpers free associations must not be allowed to contaminate the client's words. Tangential comments also can serve to control the depth of the conversation. They send a signal that the helper is not willing to go very

162

Crisis Intervention and Trauma Response

deeply into what the client is saying. They interfere with what the client is thinking and feeling. The client adapts to the level of response and then gives back the message "no depth, please." Tangential comments, like the irrelevant comments discussed above, also reinforce the sense that "nobody really cares, I'm not valuable." Reactions can include becoming more dramatic to attempt a sense of being heard. A time of crisis or trauma also makes the client question her/his own mental function. She or he may not trust her/his memory or her/his perception of reality. When the response to her/his statement is tangential, this underlying fear can be reinforced. The client may wonder if she/he had in fact told you that part of the story or if she is merely imagining it. Crisis work may provoke necessary tangential comments by the helper. For example, the client may mention the disaster in a peripheral way but the helper may need more data about the experience to determine the objective severity. If this is the case, you have to handle it in a way that lets the client know that you are coming back to her/his story, but need to make a small detour to get necessary information. There are two possible agendas for the helper using a tangential response. One is the need to get more information, which can be handled effectively and is sometimes necessary, the other stems from the helpers personal "need to know," which may have little or no relevance to the client's needs. If you do something tangential you have to watch the clients response to see if she/he has been able to hold her/his own story line or if she/he has allowed your interruption to be a distraction. Has she/he lost her train of thought? If so, help her/him find the way back. Because pressures on you, as helper, may create a need to do some of this kind of communication, you must be able to pull the conversation back to the client's needs.

Questions Interference, particularly interrogative interference, can be very powerful. Yet there are questions that must be asked at a time of crisis. It is important to understand the role of the question and the questioner. If you observe conversations with questions, you will soon see that the questioner has the power to control an interaction. There are, however,

Putting It All Together: The Pragmatics

163

benign questions and malignant questions. Benign questions gently guide the client to wherever he seems to need to go. Malignant questions, like some tangential comments, serve only to fulfill the questioner's need to know and may often distract the client from what needs to be explored. Benign questions can make the client feel a true sense of atoneness with the questioner. They are attuned to the client and help her to move along toward what she is trying to get to. They come from really hearing and helping the client to move along. Good questioning should be like effective canoeing—moving together in synch moves the narrative along. It should also get you to the information that you need to have, particularly for assessment. If it does not, and if the client insists on straying, this is an indication to you that perhaps the information is too painful to touch, or that, in its most extreme sense, the client is in such extreme pain that she is starting to disassociate from the incident. Sometimes, even if the question is benign, the client may hear the message "Get on with it, cut to the chase" and may feel, "I'd better talk fast and get my story out while I have the chance." This suggests that the listener has not respected the client's pace. Learning to wait for a few seconds before jumping in with a question, as well as learning to sensitively read the client's facial expressions and eye movements can usually prevent this. Too many questions can also make the client feel under attack, which, again, is what the crisis does as well. Some questions also keep the client at the surface level and do not allow for the exploration of deeper feelings and reactions.

Competitive Responses Self-revelation in crisis intervention can sometimes be helpful in that it can help the survivor to feel hopeful. For example, sometimes revealing to the client that you had been in a similar situation and that you have been able to heal can be helpful. However, as we discussed in chapter 4, at other times, the client may respond with, "Yes, you were strong, you got better. But I'm too weak to even try." This reflects the client's feeling that your self-revelation has emerged as competitive, exacerbating the client's sense of being inadequate and the counsellor as omnipotent. In crisis, the client may be unsure about both her story

164

Crisis Intervention and Trauma Response

and herself and feel that anyone else could have dealt better with the situation. This sets the stage for a sense of feeling trivialized. Competitive responses would simply contribute additional indications that the client may be inadequate. If you are going to use self-revelation, do so with caution and reinforce the client's strengths and potential abilities at the same time. To demonstrate the acute sensitivity of some people in crisis, consider this example of a student who was talking to a client. The client said, "I'm recently widowed," and when the student said, "Yes, I've seen a lot of widows" (thinking this would reassure the client), the client responded, "Yes, I guess there are a lot of us," and the conversation ended there. Others report going inside when they sense competitiveness. In a debriefing group you may run into a situation when in the groups descriptive go-round some survivors may feel that "my experience wasn't really as horrible as yours." It is important to watch body language such as slumping down in chairs, recognize it as a going inside, and be responsive to it.

TO TOUCH OR NOT TO TOUCH? As Kertay and Reviere (1993) tell us, "Touch is one of the major forms of communication between individuals. From the simple handshake to a congratulatory hug to a sexual embrace, touch between humans is an ever-present aspect of human communication," However, the use of touch between therapist and client has always been at best problematic. In a situation of crisis or trauma it becomes an even more sensitive area. Some of the issues at stake in the use of touch are: 1. The personal and cultural background of the client 2. Safe and less safe areas 3. The impact of the crisis experience

Personal and Cultural Boundaries in Touching Every person has his or her own personal area or comfort zone concerning touching and being touched. If you question this, the class can

Putting It All Together: The Pragmatics

165

do the traditional comfort zone exercise: divide the class in half, with each half lining a wall of the room. At a given signal, the two halves approach each other, and each person stops when they reach their personal level of comfort vis-a-vis the person opposite them. In doing this, the class members can discuss the messages they got from their families and communities about what constitutes appropriate and inappropriate closeness. You will observe a wide range of differences, which need to be respected.

Safer and Less Safe Areas Desmond Morris (1971) tells us that if one is to touch another person there are general parameters of comfort. The least threatening area is the back, parts of the arms and perhaps the bottom of the legs, Anything on the front of the person becomes more sensitive and vulnerable and the nearer the sexual organs, of course, the greater the sensitivity. So, if you decide to try to use touch to comfort a client, remember to start at the back or in some relatively safe zone (hand, etc). The one exception to touching on the back is a case in which the helper suspects a potential for violence. In chapter 6 we discussed the acute sensitivity of the back region that has been found in violent people. In this case even greater caution is advised.

The Impact of the Crisis Experience The most important aspect of determining whether you will use touch, however, is the client's reaction. Should you decide to touch a client, do so extremely tentatively. Reach toward the person and be excruciatingly sensitive to the response. As you do, touch in a very safe zone, then wait for a minute or two to determine the response. If there is the slightest verbal or nonverbal sense of discomfort, withdraw your hand immediately. Touching during a time of crisis can be very comforting. However, it can also be very dangerous. The client is feeling very powerless and may not have the ability to tell you the touch feels inappropriate. As well, if the client has been previously traumatized by physical or sexual violation or molestation, your touch may set off a flashback to that previous invasion. This experience can be dangerous for the client.

166

Crisis Intervention and Trauma Response

FURTHER ACTIVE LISTENING SKILLS To continue in the development or review of active listening skills, we need to focus on several areas. These include developing a good sense of pacing, development of common themes, and deepening of affect. Students should start to become aware of the help or hindrance they can be by proper or improper responses or by improper pacing of responses. Particularly in crisis intervention, where individuals present themselves in an upset or distraught state, timing (or pacing) may be a difficulty for the helper. For one thing, the helper will feel pressured to make the client feel better. For another, the pressure of the client's anxiety and pain may raise the helper's own anxiety level. In addition, despite the warning in chapter 4, there may always be the temptation to show the client how brilliant you are and come up with a marvelous, insightful, magical comment that will immediately impress the client. In traditional therapy situations the latter is problem enough. In crisis intervention, where the helper may see the client only a few times, it becomes a crucial issue. It cannot be emphasized too strongly, however, how important the timing of a response can be. Responding too soon can cut off rather than open up further expression. Particularly when a person is in great pain, your silence may be the clients most valuable sanctuary. Beginning students in this field have the greatest difficulty in tolerating silences. Therefore one important exercise needs to be one that incorporates waiting 5 to 10 seconds before making an intervention.

Exercise 7.2: Tolerating Silence Try this exercise in dyads, Student A is the speaker, student B is the helper. Remember to practice nonverbal postures and eye contact and attempt to match your behavior to the client's mood. Focus on reflecting the content of what the speaker is saying while practicing delaying your response for as long a possible. Do this by trying to wait 5 seconds before responding. The client will then give you feedback. At the end of this section of the chapter you will find further exercises on this and related topics. When this role play is complete, switch

Putting It All Together: The Pragmatics

167

roles with your partner and try one of the situations at the end of the chapter. Try to do as many of them as you can, either in a dyad, on your own, or with a group or class.

NONVERBAL TECHNIQUES This part of the training involves exposure to, and experimentation with, nonverbal techniques that can be used in crisis intervention. If the helper is not comfortable with these techniques she will resist using them with clients. Students therefore need to participate in the demonstration of them in class. Some of these exercises come from the Bioenergetic orientation. Bioenergetics is an approach to therapy developed primarily by Alexander Lowen (1977) and John Pierrakos (personal communication, 1978). The primary thrust of their work is that many of the significant things that happened to us in our life were experienced preverbally, before we had language. In the context in which the exercises are used for crisis intervention, we do not necessarily apply the theoretical principles of Bioenergetics. We do, however, make use of some of their learnings about areas of affect that are best located within the body and are, consequently, best expressed nonverbally, through body work. Other exercises are an outgrowth of work done in relaxation and stress reduction. When using the exercises, the same principles of relevancy that we used in the approaches to verbal intervention should apply, that is, be aware of the differing needs of the constricted and the dilated client. The constricted client may be very resistant to affective expression (i.e., the anger exercises). Yet this is the person who may most benefit from them. The dilated client may be anxious to move into a more dramatic affective expression, but your role here is to direct the energies toward successful focusing on problem solving, and further dilating the client's affective field would not be in his or her best interests. Remember also how vulnerable an individual is in crisis. They may easily abdicate their power to you and allow you to lead them into exercises that would ordinarily be unacceptable to them. The helper

168

Crisis Intervention and Trauma Response

needs to use good judgment in deciding the relevant effectiveness of the exercise with any client. The clients own self-respect should never be compromised. One way to overcome this is to have the helper do the exercise along with the client. This helps to overcome the client's resistance and feelings of discomfort. This is especially true for highly defended, intellectualized clients. One such client once told one of the authors (B.W.) that she would have to question my qualifications as a therapist if I had to resort to nonverbal exercises. Much later, when she was terminating her therapy and reviewing what she had learned and what was effective, she confided that the work she had done in the nonverbal mode, after her initial resistance was overcome, was the most powerful and unforgettable of her therapy. These can be potentially powerful tools, but they must be used in an atmosphere of respect for the client. It cannot be overstressed that it is really important for the helper to be comfortable in doing these exercises. If the helper feels uncomfortable, that discomfort will be experienced by the client. In addition, the client has been through a difficult time and does not want to appear as a performing monkey to himself or the helper. It is therefore extremely important that you do these exercises together with the client (at least at the outset). If you feel that you cannot do that, then you may not be able to use these techniques. If, however, you are comfortable in doing them and sharing them with your client, you will have a very effective series of techniques available to you. An additional advantage is that the exercises give the client an actual technique that may be used on her own, after leaving your office. If you remember our discussion about the crisis client's need to feel that something immediate is being done for the situation, you will understand that these exercises can give the client an additional sense of mastery and the feeling that she has a tool to use immediately, to relieve discomfort. It is a token of security akin to taking a prescription along from a medical doctor.

ANXIETY-LOWERING EXERCISES Nonverbal exercises can be extremely effective during crisis for a number of reasons. One is that crisis evokes the preverbal experience of

Putting It All Together: The Pragmatics

169

helplessness, the memory of which may be locked in our bodies rather than our words. By allowing the body to speak, as it were, the helplessness can be converted to empowerment. Another is that by using these techniques we can also help clients to get in touch with their bodies and to learn that there may be a pattern to the body's stress response. This learning can help the clients identify their personal "stress centers" and use them as anticipatory guidance or preventive education. Once they can recognize that part of their bodies that responds most quickly to stress, they can become aware that their stress level is starting to build up to a problematic level and take appropriate steps to reduce it. This awareness would be an indication of a new crisis situation, and by using this early warning signal clients can then apply all of the coping systems that they have learned in the present context. These exercises are another way to fill the need for the client to have something to take home from the contact with you. In all nonverbal exercises, the helper must be aware that each individual has different areas of the body that respond to different feelings. One may experience anxiety in the neck, another in the stomach. One may harbor anger in the arms, and another may sense it in the legs. One of the authors (B.W.) clients was working on anger but seemed not to respond to some of the traditional anger-expressing exercises (see: "Off my back," below). However, whenever he seemed angered at something, his foot would kick out. Kicking exercises were designed for him, and his anger flowed easily. The helper needs, at all times, to be observant of how the client uses the body for self-expression,

Exercise 7.3: Breathing Essential to all attempts to help an individual be calm is the use of the most powerful tool within each of us; our breathing. If the person can become aware of how effective the use of breathing is, the ability to change the stress level is always available. Any of these exercises can be done standing up or lying down. Become aware of your breath. Breathe comfortably and easily and imagine your breath as a peaceful presence that enters your body to bring it peace. Direct your breath to a place below your navel, what the Yoga people call the Hara, Imagine your breath going down to that

170

Crisis Intervention and Trauma Response

place and calming all of the body as it does this. Then become aware of any part of your body that is tense. Bring your breath to that muscle or area and become aware of how much more relaxed it can become as your breath touches it. Now place your hand on the spot below your abdomen where you are directing your breath. Feel your arm becoming more and more relaxed as you do this. Continue for as long as you need to feel your body relaxing. Any client in crisis can benefit from the simple awareness of her or his breathing,

Exercise 7.4: Centering This is a Bioenergetic exercise. Stand with your feet about 10 inches apart, knees bent, and toes inward, in what skiers call the snowplow position. Keeping your knees bent, allow your upper body to fall forward and over, in a downward direction, until your head is hanging down as close as possible to your feet. Breathe deeply. Using your fingertips to maintain your balance and keeping your knees bent, slowly raise your heels off the ground. Experience the vibrations that go through your legs and into your body as you do this. Stay this way for as long as you can and then slowly return your heels to the ground, keeping your knees bent. Slowly raise your upper body to an upright position and then raise your arms above your head. Explore the space around you with your arms and become aware of die space you own in the world. As you do this, stay in touch with your own inner center, and say, out loud if possible, "I'm alive!". This exercise is almost as portable as the breathing. Many clients do this exercise in a variety of places, in their offices, in the cubicles of public toilets, almost anywhere. It is an excellent exercise for regaining a connection with your own center, for reducing the anxiety level, and for experiencing some revitalization of energy. It gives the participant a renewed sense of power and control over life—two of the most essential issues in crisis intervention.

Exercise 7.5; Progressive Relaxation Directions for a typical progressive relaxation exercise are as follows:

Putting It All Together: The Pragmatics

171

Lie down in a comfortable place. Breathe easily and regularly. Focus on your breathing. As you inhale, feel your breath bring peace and calm to every part of your body. Do this for a few minutes. At your next inhalation, point your toes and stretch the bottoms of your feet. Hold your breath, and as you do so, hold your feet in the outstretched position. Then gently exhale and relax your feet. Breathe comfortably for a few minutes. At your next inhalation, tighten your leg muscles and stretch your legs. Hold this position as you hold your breath, then gently exhale and relax your legs. Breathe comfortably for a few minutes. Feel your legs becoming warm, heavy, and relaxed. When you next inhale, tighten the muscles of your buttocks; hold this tightness as you hold your breath. Gently exhale and relax your buttocks. Breathe comfortably for a few minutes, then inhale and tighten your stomach muscles; hold this tightness as you hold your breath. Gently exhale and relax. Feel the whole lower half of your body becoming heavy, warm, and relaxed. Inhale and make your hands into two fists and pull your arms straight down, as if you were pulling them out of their sockets. Hold your breath and hold your hands and arms in this tight position, then gently exhale and relax your arms and hands. Breathe comfortably for a few minutes, then inhale and pull your head down and touch your chest with your chin. Hold this position as you hold your breath for as long as you can. Breathe comfortably for a few minutes, then exhale and relax your head and your chest muscles. Now your whole body is feeling warm, heavy, and relaxed. Breathe comfortably for a few minutes, and when you next inhale, raise your shoulders up to your ears and hold them there as you hold your breath for as long as you can. Then exhale and relax your head and neck. Breathe comfortably for a few minutes, then inhale and scrunch your face up and tighten all of your facial muscles. Become aware of how much tension you are carrying on your face and tighten all of those areas. Hold this position as you hold your breath for as long as you can, and as you exhale, relax your face muscles and feel all of the tightness dissolve.

Crisis Intervention and Trauma Response

172

Now breathe comfortably for a while. If there is any part of your body that still feels tense, visualize your breath as a ray of soft warmth that can be directed to that right place to relax it and heal it. Stay in this position for as long as you wish. Think of a code word, such as "peace" or calm" for the way you feel when you are relaxed, so that you can return to this position any time you need to. Practice saying your code word and feeling your whole body relaxed, warm, and heavy as it is now.

Visual Imagery Crisis and trauma make the client feel overpowered by some enormous, uncontrollable force. Regardless of the usual coping style the client uses, increasing his or her armamentarium of skills helps to change the balance of power between the trauma and his or her own self-perception. Visual imagery, or visualization, is a simple, easy to learn skill that the practitioner can teach the client. It is another skill that the client can take along after your session. Before you start to do imagery, it is important to have the client in a relaxed state. The progressive relaxation exercise, above, or any similar one will be helpful. Although there are many types of visual imagery, the most important thing to remember when you are using or teaching this technique is to listen to the client's language. Some people speak very graphically and use metaphor. If so, see how you can build on their own metaphor system. For example, if a client is talking about having lost his or her footing, build your imagery around grounding, strengthening solidity, and other such concepts. If your patient is talking about feeling closed in, limited, or imprisoned, try imagery around free activity in the outdoors. Before you start, it is often helpful to determine if the client has any phobias, dislikes, or physical limitations. For example, if your patient has a fear of skin cancer, avoid a sunny scene. If the client has a fear of height, stay away from high places. Example: Client (C): Helper (H);

I'm so jittery, I can't stand it in here. I feel as if the whole world is caving in on me, and there's no place to go to. It feels like you've lost your freedom, and that is really scary.

Putting It All Together: The Pragmatics

173

Ci

Yes, and I cherish that freedom and the ability to get out and feel safe.

Hs

Where do you feel most free and most safe?

C:

On a beach near my family's summer place,

HJ

Tell me about your experience of being at that place.

C:

Well, it's a place where I can really unwind, and where I can really feel protected.

HJ

Perhaps we can go there in our minds. Close your eyes and feel yourself breathing into relaxation. Imagine your whole body gently easing up and becoming more relaxed. As you breathe comfortably, take yourself to that beach near your parents' place. Visualize yourself doing whatever you most enjoy doing at that place, perhaps walking along the shore, or watching the water, or lying on a comfortable chair or blanket. Stay there for a while, and get a sense of how your body feels when you are there. Then think about what you are feeling and thinking. Get back in touch with who you are in that special place. See if you can take some of those feelings with you as you come back into this room.

Other Visual Imagery Some other examples of visual images that can be helpful in crisis include: 1. The swan: allow the client to imagine herself as a swan and watch the various pressures slowly roll off her back. 2. The skipping child: allow the client to remember being a carefree child and reconnect to those earlier, perhaps forgotten parts. 3. The caged lion/lioness: Allowing clients to visualize themselves as angry lions/lionesses in a cage may be easier for some clients than actually expressing their own anger directly. 4. "Visualizing oneself before this crisis" (mentioned previously in chapter 4) may help to reinstate personal empowerment. It can also function as a diagnostic tool in assessment, giving you a better image of the clients precrisis function. If this does in fact

Crisis Intervention and Trauma Response

174

connect to a former strength, it can then be followed by visualizing oneself out of this crisis, which creates both a solution focus as well as hope,

Safe Place The concept of safe place is key to all of our work on crisis and trauma. Loss of safety is key to the crisis-trauma experience. In reality, the very place that can help the individual feel safe may have been destroyed either concretely or emotionally. In a natural disaster, the very home the person lives in may have been destroyed. In an interpersonal breakdown, the person the client counted on for support, love, and emotional security may either be sick, injured, or dying, or may have decided to leave the relationship. Loss of safety is one of the most significant experiences of crisis and trauma. A safe place can be created in a number of different modalities. The most obvious safe place is, first and foremost, in the relationship with the therapist. This has to be seen as a sacred trust. Many traumatized people are so distrustful that even the slightest change in schedule can be a cause for their distrust to reemerge. Some practitioners will help the client visualize a safe place by actually describing one for them; as, for example, McCarthys (J. McCarthy, personal communication, January 15, 1997) image of a house surrounded by trees with a healing pool on protected grounds. Others, however, will prefer to allow the client to find and design the client's own concept of a safe place. The most important piece of this visualization, however, is the security of the client. The safe place must be one that allows no one else into it unless invited by the client. The client may chose to bring into the safe place any of the icons or objects of personal security, whether concrete or abstract. Exercise 7.6: Anger Releasing As we described at the beginning of this section, tailoring the angerreleasing exercise to the client's area of stress expression can be very helpful. If no such indication is given by the client, try the one that appears to be the most comfortable for both you and the client. The

Putting It All Together: The Pragmatics

175

only caveat here is that the helper cannot be hurt by the client. Here are some examples: Off my back: Have the client take the same position described in the centering exercise described above. Then have the client extend the jaw so that there is tension in the front of the neck. At the same time, have the client make two fists, raise the arms, bend the elbows horizontally so that the fists face each other in front of the chest. Instruct the client to say "off my back!" loudly and vigorously as, at the same time, he pulls his elbows behind him so that they try to meet behind his back. Do this as many times as necessary and process the exercise with the client, discussing whom he was speaking to and what unfinished business there may be that has to be addressed further, Other anger exercises: Having located the client's anger center, design an exercise around that. For example, giving the client permission to stand up and stamp the floor as a child in a tantrum can be very freeing. Having a large sturdy pillow around that the client can kick or punch is also very effective. In Bioenergetics, the client is encouraged to face a couch or bed, get down on his knees, and strike the pillow using an entire forearm from the elbow down to the fingers. This is a far more expressive means than the usual punching and is particularly effective for women, who tend to hold their anger back at the shoulder level and are socialized to express it only in small amounts, if at all (A. Welhaven, personal communication, December 20, 1978). Buckets of paint: This is a universally used exercise that is very simple and expressively gratifying. Stand up and put your arms down alongside your body. Make a fist of both hands and imagine that in each hand you are carrying a bucket of paint. Then imagine yourself vigorously swinging the two buckets of paint back and forth, and, at the same time, breathe deeply and let out a deep, guttural sound. Use your full arm, from the shoulder down, to swing the buckets.

POSITIVE REINFORCERS In chapter 4, we discussed the importance of a goody contract us a function of encouraging self-reliance. We enlarge on it here as a method of helping the client replenish during this trying experience.

176

Crisis Intervention and Trauma Response

People in crisis need now more than at any other time to take care of themselves, but, by the very nature of the experience, they may generally do very little self-care. It is therefore important for you to set up goody contracts with the client. These involve first letting clients tell you some of the things that they can do to feel good. These might include a long quiet tub bath, a candy bar, a quiet walk, a good meal, watching the clouds drift across the quiet sky, having a quiet cup of herbal tea, or any number of things clients suggest. Each of these suggestions may sound like an anathema to you if you are picturing people in the midst of a natural disaster, staying at a shelter. But that is exactly what makes them so precious and all the more important. Then set up a contract with them in which they agree to do (or try to do) at least one of these take-care-of-yourself things before your next meeting. If clients have a particularly difficult task to do, you can do a variation of the goody contract by helping them to chunk the task into small, doable pieces, and after each piece, reward themselves with one of the things on their goody contract list.

Exercise 7.7: Power Transfer This exercise essentially directs the client to relax and then asks him to recall a time or a situation when he felt most powerful. As your client develops this image, ask him to get in touch with how his body feels, what thoughts he hears in his mind, and what he is experiencing emotionally. Then ask him to name this experience with a cue word to later use to conjure up the physical, emotional, and cognitive reactions associated with feeling powerful. The client can then reproduce them by use of the cue word stimulus, thus transferring the power experience to a current experience. I often accompany the exercise with the use of a small stone that the client can keep, called a touchstone.

SLEEP EXERCISES A recent review of psychological treatments for insomnia (Murtagh & Greenwood, 1995) has shown that these techniques are effective treat-

Putting It All Together: The Pragmatics

177

ments for improving sleep patterns and subjective experience of sleep. Because crisis and trauma produce sleep deprivation, we report some of this work here. The treatments examined in the study were stimulus control, sleep restriction, paradoxical intent, and relaxation techniques. Stimulus control techniques focus on being in bed only when one is sleepy. "Clients are instructed to use the bedroom only for sleep and sex and not for reading, watching television, eating, or working." They are further instructed to "get out of bed when they are unable to sleep and to get out of bed at the same time every morning regardless of the amount of sleep" (Murtagh & Greenwood, 1995, p. 82). Paradoxical intent instructs the client to behave in an opposite manner from the desired outcome. The rationale for this Is to relieve the anxiety that insomniacs feel about not being able to sleep. The treatment gains for this technique generally did not compare favorably with other treatments. Relaxation techniques used included progressive muscle relaxation, meditation, systematic desensitization, imagery, autogenic training, and hypnosis. Our own work has found that the cognitive therapy concept of thought stoppage can be very helpful, particularly for constricted clients who ruminate about the situation and have difficulty in moving on. For those who have sleep difficulties related to the trauma, a simple method that this author (B.W.) has found effective is to have the client find a seven-syllable set of letters or numbers or phrase that she can repeat over and over again to herself to quiet her mind. The Canadian postal code system provides an excellent choice for this and it can be shared with anyone. The postal code seems to have the correct number of syllables and has been used effectively by many. An example of this is H3W2Y4, Another peace-inspiring, mantra-like phrase that has been found to be helpful is "the grass grows all by itself," or for winter lovers, "the snow falls all by itself."

CAREGIVER RESPONSES IN TRAUMA Young, cited in Roberts (1991), has suggested some helpful phrases for working with crisis and trauma clients. As you can see, they reflect our

178

Crisis Intervention and Trauma Response

warning against trivialization, mentioned in chapter 4. These phrases follow: Do say;

I am sorry this happened to you. You're safe now (if the person is indeed safe). I'm glad you're here with me now. I'm glad you're talking to me now. It wasn't your fault. Your reaction is a normal response to an abnormal event. It's understandable that you feel that way. It must have been upsetting/distressing to see/hear/feel/smell that. You're not going crazy. Things may never be the same, but they can get better, and you can get better. Your imagination can make a horrible reality worse than it is. Its okay to cry, to want revenge, to hate, and so forth. Don't say: I know how you feel. I understand. You're lucky that you're alive. You're lucky that you were able to save something. You're lucky that you have other children/siblings/and so forth. You are young and can go on with your life/find someone else. Your loved one didn't suffer when he/she died, She/he led a good and full life before she/he died. It was God's will. He/she is better off/in a better place/happier now. Out of tragedies good things happen. You'll get over it. Everything is going to be all right. You shouldn't feel that way. Time heals all wounds. You should get on with your life. (p. 95)

Putting It All Together: The Pragmatics

179

ROLE PLAYING In the following exercises, our students attempt to integrate all aspects of the crisis intervention material. They need to be aware of the implications of constriction or dilation in a client, cognitively, behaviorally, and affectively. As well, they need to be conscious of their own helping skills, both verbally and nonverbally. And they also need to be conscious of the possibilities of suicide and to be able to do a thorough suicide assessment if this is called for. Also it is of importance that students remember the difference between a traditional therapy approach and that of the Crisis Intervention model. Their job is to relate, assess, and either refer or take the client on, but working from an immediate, problem-solving approach rather than the more leisurely approach of traditional therapy. The following exercises are designed to be done in the role-play modality. If they are done in class, the recommended format is with one student as helper and the other as client, as previously described. At the end of the interaction the client gives feedback to the helper, the class discusses reactions and the roles are reversed. When time permits it is helpful if a demonstration dyad can demonstrate the technique to the entire class. If done without a class, the feedback, role switch and discussion should still be maintained. If these are done in a class setting, use the same format of feedback after the intervention and then switch roles.

Exercise 7.8; Role Playing 1. Chose dyads. Decide which dyad member will be the client and which will be the helper. Situation: Withdrawn (constricted) 65-year-old man whose wife has just died. His family members all live thousands of miles away. Has never lived alone. In this exercise, the helper will respond with nonverbals only, no language can be used. Continue this exercise for a minimum of 3 minutes. At the end of the 3 minutes, the client gives feedback to the helper. Whether you are doing this in class or with just one other person, it is important to process the experience. Areas to discuss could include:

180

Crisis Intervention and Trauma Response

How did it feel to abdicate all language? What does that set off in the helper? What felt helpful or not helpful to the client? Why? Did some people touch, others not? Why? Go back to our discussion of touch and the use of touch. See how it applies to this situation. Earlier in the chapter we discussed the importance of pacing of your response. We pointed out that in crisis, pacing of your response to the clients can be crucial. In the next exercise, continue to watch your timing as you move into practicing, listening for common themes. Listen for more than just what they are saying. In the next part, put together the nonverbals, the delayed response, the development of themes in the content, as well as the deepening of affect. Example: Helper; "There seems to be a series of things that have you upset, your work, your parents, and your marriage, and you also seem to be telling me that you are feeling very out of control because all of these things are happening to you at the same time." You can then start to deepen the affect and zero in on feelings. "Actually you seem to be feeling angry, hurt, and sad that all of this is happening to you at the same time." Each aspect of this can be done as a separate round, with partners changing roles. After each round, the client should give feedback to the helper, and time should be allowed to discuss how it felt to participate in the exercise both for the helper and for the client. Scenario for a second situation: A 50-year-old only child whose parent, in a distant city, has just been diagnosed as having Alzheimer's disease.

Exercise 7.9: Integrated Verbal and Nonverbal Exercise Further work with dilation and constriction: In chapter 4 we introduced the concepts of dilation and constriction and presented a sample exercise. Here are others that can be used in the same way.

Putting It All Together: The Pragmatics

181

1. Dealing with the dilated client: Situation #1. A young mother who has just discovered that her child has been sexually molested. Situation #2, An out-of-control child. Child is in classroom and loses control. Situation can either be taken from classroom or from office of helper or other school personnel. General discussion: Review the characteristics of the dilated person (cognitive, affective, behavioral). What special demands do these make on the helper? What approaches are effective (rational, cognitive, directive, etc.)? What approaches are not effective (deepening affect, etc.)? If time permits, do a demonstration dyad with a dilated case using the ineffective techniques to make this difference more obvious. 2. Dealing with the constricted client: Situation $1, A 32-year-old professional man who has become successful and has just been diagnosed as HIV positive. Situation #2. A withdrawn adolescent who has retreated to her room for several days following the suicide death of her best friend. Review the discussion of adolescent suicide in chapter 6.

Additional Scenarios That Can Be Played Either as Dilated or Constricted 1. An 86-year-old woman in her first day at a nursing home. 2. A 45-year-old woman whose husband has just left her after 25 years of marriage and who believed in "happily ever after." 3. A 26-year-old male medical student who has just been blinded. 4. A 45-year-old man, whose wife has left him, standing at the entrance to the bridge, 5. A 60-year-old woman whose home has been destroyed by a iash iood. 6. A teenager whose friend has just been shot in a drive-by shooting. 7. A teenage boy with an excellent driving record whose car swerved out of control and hit another car full of children, 8. A young woman who was date-raped.

182

Crisis Intervention and Trauma Response

9. A young man whose partner has just died of AIDS. 10. A 39-year-old woman who has just given birth to her first child and discovered it is stillborn. The following sections deal with hands-on skills that you will need in trauma work. They include working with the media and developing a mental health response team.

WORKING WITH THE MEDIA Because the media represent a constant presence at the scene of traumatic events, and because working collaboratively is essential for our public education efforts, a guide to working with the media is outlined below. Remember that media representatives—journalists, television and radio reporters, camerapersons, and staff—constitute a particular role that is critical to traumatic events. They both record and transform the event. Media representatives are also affected by the event, and some may become secondary or vicarious victims. While many regard the media as intrusive, it is nevertheless the case that it can be instructive, educational, and even therapeutic in its effects. It is wise to learn from its representatives and to work with them in cooperative ways. When asked to do an interview: * Establish a cordial relationship with the interviewer and determine the purpose in doing the story. No matter what the stated purpose of the interview, use it to get out to the public critical pieces of information. This takes practice, sensitivity, and skill at making seamless transitions from questions to answers. » Become a source of news. Let your media contacts and the public know that you have important information to share, on an immediate basis. • Whenever possible, give reporters written material they can read

Putting It All Together: The Pragmatics

* * « • • • • *

183

or quote from. Background information is always helpful to reporters. Try to focus the interview around one or two major points, which you can repeat and highlight with lively examples, Rely on sound data or evidence when giving your interview. In situations where such data are lacking, make that point very clearly. Confidentiality is critical. Disguise all individual examples used and never use names unless given permission to do so. Never give your name and phone number, but instead, your name as representative of a group or organization and its phone number, Review your professional association's ethical and professional guidelines before agreeing to be interviewed. Set parameters with the interviewer, as needed, based on these guidelines. Remember not to speak for the profession as a whole. Never imply or state that your remarks relate to all victims of this event or that you speak for them. Be yourself. Appear confident and competent, but also human. Don't let deadline panic push you into responding on a subject with which you are unfamiliar. Instead of saying, "no," to a reporter, suggest another angle to the story on which you can comment or refer the reporter to an appropriate colleague for this story.

Following the interview: * If there is time, debrief with interviewers. If you have been on the traumatic scene together, share some experiences and express empathy for the difficulties inherent in their job. « Write down the name and phone number of the reporter and the news organization the reporter represents. This serves as a personal record for you and allows you to reach the news organization later if there are errors in what is reported. On-air corrections can be made, » Tape any broadcast interviews and play them back to observe yourself. Ask others to watch the tape and comment about both your verbal and nonverbal behavior.

184

Crisis Intervention and Trauma Response

During interviews with victims: * Protect victims who have consented to interviews by advising them of their right to terminate these interviews at any time. If at all possible, remain on the sidelines (but clearly present and available) when victims or family members entrusted to your care are being interviewed. * Debrief with victims following their interviews. Some may be upset after recounting disturbing details. Others may experience relief and some renewed energy as a result of the interview experience. Many more elements go into the professionally conducted interview and the protection of victims who wish to be interviewed. Workshops and training sessions are valuable, as are mentors with experience in working in this area.

BUILDING A MENTAL HEALTH RESPONSE TEAM The consequences of personal and community tragedy can never be fully or adequately addressed by relief agencies, government organizations, or medical personnel. The public understands that there is more to getting back on one's feet than what these groups can provide. No agency can help prevent grief over loss, mitigate paralyzing fear, or treat sleepless nights and their unwelcome effects. Therefore, the mental health response team becomes an essential ingredient in the trauma response and recovery process. The response team, moreover, while it adopts certain guidelines and procedures, is not bound by particular bureaucratic structures that are inherent in certain large organizations like the Red Cross. One problem with these organizations may be their adherence to obsolete techniques (Brauman, 1992). It took the Red Cross 10 years to accept the Heirnlich Maneuver for choking victims, for example (H. Heirnlich, personal communication, October 14, 1987). Another problem has been the restrictions imposed by such organizations on those who work within their domain. The Frenchinitiated emergency medicine organization, Doctors without Borders,

Putting It All Together: The Pragmatics

185

was developed independently partly in response to International Red Cross Committee regulations forbidding its staff to speak openly about observed occurrences of ethnic genocide (Brauman, 1992). Although well-established organizations can offer a home to mental health professionals for certain distinctive areas of trauma work and for a training and experience background, ultimately it is only the independently functioning teams within the mental health community that will make a longterm difference in the kind of care the victims of a variety of traumas will receive (Bloch, 1993). While other organizations deal with the "hazard factor," mental health professionals are uniquely suited to also address die "outrage factor" (Hance, Chess, & Sandman, 1988), which lingers long after die hazard has ceased. This outrage factor is often apparent following criminal acts, rape, child abuse, toxic exposures, civil disturbance, acts of war, fatal accidents, and even corporate employee downsizing. The mental health team offers an unusual blend of resources to bring to the task. A large team may be formed within the community, with subgroups identified by professional experience, expertise, and talents. Thus, certain team members have expertise in dealing with specific populations (adults, children, special occupational groups, specific ethnic groups, disabled persons), with the problems to be addressed as a consequence of the traumatic event, and with methods of assessment and intervention. The team may also utilize the creativity, talents, and unique skills of a number of its members, including foreign language skills, writing and public speaking abilities, administrative or organizational skills, and contacts with outside groups that will facilitate the work of the team. The formation of the team should be on a pilot basis, with agreements made up front regarding recordkeeping, fees, and pro bono service arrangements. With continued, self-monitored experience, the team may establish itself within die community as a permanent presence. The work of the team involves several phases and performance of a variety of roles. These are described as: The Initial Evaluation; Mobilization I (for large-scale events); Mobilization II (for small-scale events); On-Site Team Activity; and Postintervention Functions and Activities. All possible roles have been considered in the model described below, however, only one or a few of them may be actualized in the team's response to a given event.

186

Crisis Intervention and Trauma Response

This material is a modified version of the protocol developed by Jon T. Perez, Ph.D. (1990), former director of the LifePlus Trauma Recovery Team, Los Angeles, California.

Initial Evaluation When taking the initial call, remember that the originator of this contact may be upset and distracted because of the event. Take a few minutes to rapidly establish a relationship and debrief this person, acknowledging feelings and the unusual stress the person may be experiencing. You may find it helpful to use the format of Figure 7.1 in recording information you receive at the time of the initial contact, whether this is done by telephone or in person.

Mobilization I Team members need to meet as soon as possible to prepare for their work on site. The site may be local or distant; in either case, the team needs to accomplish the following; 1. Have as much information about the event, persons involved, and available services to allow work on site to begin immediately 2. Have prior coordination with services and agencies on site, so that the team is integrated with these efforts 3. Assess current resources of the mobilized team (can the team meet the requests for services—all, or some of them; is the time frame reasonable; are the fees appropriate; is any pro bono portion of the work reasonable to accept). The following prearrival roles may vary depending on the event and size of the available team. In some cases, one-person-one-role will obtain; in others, one person will fill two or more roles simultaneously: Emergency Medical Services This person is responsible for contacting emergency medical services (EMS) and hospitals involved, especially if psychiatric services need to

FIGURE 7.1

Initial evaluation,

Original Contact: Name

Date of first contact:

Telephone ( )

Time

Fax

Recorder:

E-mail I. Nature of Event A. Classification Criminal Accidental Natural Discrete Ongoing

Single Multiple One community Several communities

Brief description

Date(s) and Time(s) of Event(s):

B. Persons Related Strangers

Number of known victims Age range of victims Gender predominant

Check off as many as apply, present at scene, (Time A) and/or post-impact (Time B) Eyewitness(es) Bystanderis) Paramedical personnel Medical personnel Rescue units Police Fire Specialized units

187

FIGURE 7.1 (Continued), Media Broadcast Print Camerapersons

Contact person and telephone:

Red Cross

Name and telephone of Contact person:

Mental Health Professionals Clergy Morgue personnel Funeral directors Government inspection team(s) Detectives Attorneys Employers/CEOs Government officials Insurance companies II. What Population® Is the Team Being Asked to Evaluate and/or Intervene with?

III. Ethnic/Cultural Milieu

IV, Estimated Number of Affected Individuals: 1. Estimated age range: ______ 2. Estimated geographical distribution: V. Media Presentation 1. Channels/Networks Providing Coverage Name{s) and Phone Number(s):

2. Print Media Available Name(s) and Phone Number(s):

188

FIGURE 7.1 (Continued). VI.

Relief Agencies/Personnel Involved EMS Servites Hospitals Government agencies Private agencies

What type of emergency command and control network/mechanism is already in place?

VII. Risk Factors Related to Event Lack of warning Abrupt contrast of scene "Innocence" of setting Degree of uncertainty and duration of threat Time of occurrence Scope of event Personal loss or injury Minimal Moderate Severe Covers entire range VIII. What Team Is Being Asked to Do Direct service to populations involved Coordination service Educational/training services Assistance to legal professionals Public education Debriefing of personnel Consultation services Other: IX.

Time Frame Team Expected to Work Within

X.

Estimate of Costs of Team Fees Breakdown of items:

189

190

Crisis Intervention and Trauma Response

FIGURE 7,1 (Continued).

XI. Evaluation of Initial Contact 1. Length of call or contact:_ 2. information received: Sufficient

Insufficient

Contact 2nd Team member to consult

Follow-up contact with other event sources

Contact Team and brief: mobilize/decline

[Contact Team and brief: Mobilize/decline]

Notify original contact of plan

be involved, Information gained in this role often includes number of injured, casualties, ages of victims, situation in waiting room areas of hospitals and close by the scene, and relative degrees of organization or chaos and disruption. If the team's services are requested days or even weeks following an event, it is wise to gather this information on a retrospective basis. It gives the team an idea of what the victims and families may have

Putting It All Together: The Pragmatics

191

experienced at the time of the event and provides an opportunity to offer the team's services to EMS and hospital personnel in posttrauma debriefing sessions, even though the original request for assistance was not from this particular source. Government Organizations This person is responsible for coordinating and contacting local, state, and national agencies and determining contact persons and lines of authority. This category includes police and fire departments. Private Organizations!'Agencies This person is responsible for locating key private agencies involved and determining in what ways the team might be of assistance. This subsection also includes any local group of mental health professionals. Media This person is responsible for maintaining contact with the media covering the event, not only for the purposes of public education efforts but also to determine the initial portrayal of the event, which has a psychological impact both on the victims and on their community. Advance Planner This person acts as the liaison between the team and those on site. The advance planner works in constructing brief data information sheets for the team's use and schedules the team's activities and airline and lodging accommodations, if needed. The advance planner may or may not be the initial evaluator. It is probably best if these prearrival roles, including that of the initial evaluator, are rotated. This gives everyone the opportunity to become familiar with each role and builds flexibility into the team's response. The team may decide, however, that it is efficient to learn a one-person-one-role format and become expert at it.

192

Crisis Intervention and Trauma Response

Mobilization II Many traumatic events are small-scale events from a community or national perspective. They do not require the services of emergency medical personnel and hospitals, government organizations, or larger private relief agencies. In some cases, the traumatic event is a personal family tragedy or a workplace situation where those affected need or request privacy. Roles played by the trauma team are therefore somewhat different than those described in the preceding section. Key Personnel/Spokespersons These persons are responsible for contacting the key people involved with the event. In some cases, these may be plant managers, bank managers or presidents, a school principal, head of a household, or government officials. In other cases, they may be key personnel associated with insurance companies, attorneys, or chief executive officers. Through these contacts it can be determined how the team might be of assistance and what is the chain of command. For example, in the case of a bank robbery, the bank manager may initiate contact but it will require a team person's contact with a bank vice-president before embarking on an intervention plan for traumatized workers. Community Resources This person is responsible for gathering information about community resources for those affected by the event. The team should keep a continuously updated file on such resources with contact names and phone numbers. Family Members In the case of personal family tragedy, this person is responsible for contacting key family members and identifying one or two members who will represent the family and its wishes.

Putting It All Together: The Pragmatics

193

Media This person is responsible for maintaining contact with the media covering the event. Public education efforts may be involved here (see Mobilization I); but sometimes the opposite is the case, that is, those traumatized request the team to shield them from the media. When businesses or companies are involved, the person filling this mobilization role should work closely with the team member whose role it is to contact and consult with key personnel/spokespersons. Advance Planner This person acts as the liaison between the team and those on site. Brief data information sheets should be constructed and distributed to the team. The team's activities need to be planned and scheduled and airline and lodging accommodations need to be made for out-of-town sites. The advance planner may or may not be the initial evaluator.

General Observations In mobilizing the team to respond to any traumatic event, the nature of the roles and who is to fill them should be kept as flexible as possible and dictated always by the circumstances of the event. Predefined roles, like those outlined in the two mobilization sections, are not exhaustive, but can be helpful both as a source of information for team planning and assisting the team's organized response to an event, which by definition is disorderly, emotion-laden, and unclear in its parameters. These two sections can serve as either a reference for the team to use or as its adopted model for any given event. Above all, an organized team response conveys to individuals, families, and communities a sense of calm and coherence that is therapeutic and vital to recovery,

On-Site Team Activity Depending on the nature and scope of the traumatic event, team members may play only a few or all of the following roles once they are

194

Crisis Intervention and Trauma Response

on-site. There is no way to preplan roles: the team adapts to the event, not the other way around. It is also important to remember that in a large-scale event, the team that mobilizes may have to call on the assistance of a second team. The second team can be briefed by the advance planner. That being said, keep in mind that a small team (two to four people) can perform well in a traumatic event by pyramiding their service. Four or five psychologists trained 400 professionals over the course of two days following the San Francisco earthquake; and five psychologists worked with a volunteer organization of several thousand in Cincinnati during the Gulf War. In single, isolated incidents, for example, a suicide at the workplace, two team members can probably do the major portion of their work at the management level. In this kind of event, direct linkage with the media may not be required, nor would contact with agencies or hospitals. Team Director The team director is responsible for overseeing the functioning of the team and sees to it that team members are provided the support they need in their activities. Professional Liaison This person is responsible for debriefing (when necessary) and training professional caregivers. Debriefer This person is responsible for doing debriefings with affected victims. Included here is a preliminary evaluation of those who may be referred for more extensive evaluation and treatment. It is probably the case that most of the intervention requirements posed by traumatic events can be met adequately through filling these roles. The team director can also fill the role of liaison to government and private organizations and consultant to top-level management when business and industry are involved.

Putting It Ail Together: The Pragmatics

195

Media Coordinator This person keeps the media informed of the mental health relief effort and provides education and reassurance to the general public. This person may also receive new information from the media regarding the crisis and alerts team members. In addition to these four roles, the following may also be useful, depending on the scope of the event, the time frame within which the team is operating, and the personnel and other resources of the team: EMS Liaison In those crises where emergency medical personnel are present, a team member may take charge of debriefing and, where necessary, referral for services. EMS personnel also may assist this team member in identifying and locating victims at psychological risk. Treatment Team This person's job is to coordinate a team that will do psychological evaluation, initial treatment, and referral of victims, family members, coworkers, EMS personnel. Treatment Supervisor In large-scale tragedies, this person is an invaluable resource to the team, providing clinical supervision to the treatment team and debriefers. The supervisor can work one-on-one or with the group as a whole, acting as their debriefer, identifying burnout, and recommending changes in care delivery that those close to the action are unable to recognize, Consultant/Assistant to Team Director In some crises, this role is a luxury; in others, an absolute necessity. Filling this role is necessary in situations that are extremely complex in terms of the team's activities, or situations in which the trauma extends over a long period of time.

196

Crisis Intervention and Trauma Response

Postintervention If the team orients itself to a primarily consultative anci education and training model, it can usually complete its work in 1 to 5 days. The key to this kind of work lies in providing interventions at several levels, a model proposed in the LifePlus protocol. Most trauma teams offer only direct service to victims themselves. Other trauma teams, modeled after emergency medicine teams, intervene for very brief periods of one to six hours (e.g., CISD teams) with focal groups. The latter approach can be very desirable, as in instances where school children can be "debriefed" in a period of several hours, following a traumatic event at school; however, a versatile team will go beyond this to reach parents, teachers, children in other schools, public education through the media, and so forth. Following its work, the team should appoint one of its members to conduct follow-up visits and telephone contacts with personnel at the site, at various intervals. A record should be kept of those contacts in order to determine the successes and failures of particular interventions. The initial contact person should be assured that the team—unlike the media—has not abandoned its interest in the outcome of the event and its effect on the victims. The team may wish to build a "foliow-up consulting fee" into its original estimate of costs and fees.

DOCUMENTATION, DEBRIEFING, AND CRITIQUE When the team returns, all written material used and gathered should be filed for use in the future by the team(s), for training, and for possible research and/or presentations. Debriefing and critiquing sessions should be held. The debriefer is ideally someone familiar with the team but who did not participate in this particular event. The critiquing session performs a different function: the team analyzes how it handled the demands of the event, what worked, what didn't work, and notes down for the files any recommendations for revising the protocol.

Putting It All Together; The Pragmatics

197

CONCLUDING NOTE Providing crisis intervention and trauma response as soon as possible is of critical significance. Chronic problems can be averted, if early and appropriate intervention is available. The reader will find that, with sufficient practice of the material we have presented and continued specialized training, he/she can make a valuable contribution both to the individual and to the community.

REFERENCES Bloch, E, (1993, August). Organizing responses to civil disturbances: New models for practitioner intervention. In B. Wainrib (Chair), Trauma responses: What practitioners can learn from recent disasters. Symposium conducted at the annual meeting of the American Psychological Association, Toronto, Canada. Brauman, R. (1992). The MMecins $ans Frontieres experience. Unpublished manuscript. Carkhuff, R. (1971). The art of helping. Amherst, MA: Human Resources Press. Hance, B. J., Chess, C., & Sandman, P. M. (1988). Improving dialogue with communities: A risk communication manual for government, Trenton, NJ: Department of Environmental Protection. Kertay, L,, & Reviere, S. (1993). The use of touch in psychotherapy: Theoretical and ethical considerations. Psychotherapy, 30, 32-40. Lowen, A., & Lowen, L, (1977). The way to vibrant health: A manual of bioenergetic exercise. New York: Harper Colophon. Morris, D. (1971). Intimate behavior. New York: Random House. Murtagh, D. R,, & Greenwood K .M. (1995). Identifying effective psychological treatments for insomnia: A metaanalysis. Journal of Consulting and Clinical Psychology, 63, 79-89. Perez, J. (1990). Responses to prolonged stress and trauma. Unpublished document adapted from "Operation Homefires." Los Angeles: LifePIus Foundation. Roberts, A. L, (1991). Contemporary perspectives on crisis intervention and prevention. Engiewood Cliffs, NJ: Prentice-Hall.

This page intentionally left blank

INDEX

Active listening, 157-158, 166-167 Adam, K. S., 129 Adolescents in crisis, needs of, 62 suicide in, 130-134 prevention programs for, 131 Advance planner, on mental health response team, 191 Age and response to crisis, 43 and suicide risk, 127 Alvarez, W., 118 Ambivalence, in suicidal client, 143 Ampy, L A., 95 Anger in life transition model, 55-58 release of, exercise for, 174-175 Anxiety reduction of, exercises for, 168-175 separation, 49-50 Armstrong, K., 94 Arroyo, W., 146 Art therapy, for children, 95 Assessment, 101—122

communication with referral source in, 102 in community, 118-120 dilation—constriction continuum in, 108-110 goals of, 103 Korner's model of, 120 of motivation, 120 for nonnormative responses, 112-118 for normative responses, 108-112 for posttraumatic stress disorder, 115-118 of psychopathology, 113-114 purpose of, 101-102 relate—assess—refer/respond model in,110-112 research on, 121—122 of resources, 105-106 of severity, 104 of suicide risk, 136-140 in trauma, 106-108 triage model of, 121 of urgency, 103-104 of violence, 148-151

199

200

Assessment (continued) in Wainrib's crisis intervention model, 74, 85 Assignments, designing, 83 Atkeson, B, M,, 130 Atutudinal relating, 73-79 avoidance of trivialization in, 78 creating safe place for, 75 cultural differences in, 77 dilation-constriction continuum in, 69/75-76 establishing initial relationship in, 75

hope in, 77-78

normalization in, 77 pace of, 76—77 power of suggestion in, 78-79 validation in, 77 workers reactions in, 76 Azarian, A., 95 Barath, A,, 36, 95 Bay Area Arts Relief Project, 95 Beck, A. T., 129-130 Behavioral planning with suicidal clients, 139 for weekends, 83 Bell, R. A,, 94 Herman, A. L, 129, 131, 133 Beutler, L E, 128 Bioenergetics, 167, 175 Bloch, E. L,, 25-26, 35,46, 66, 90-92, 185 Body language, 158-159 Bodywork, 167-175. See also Nonverbal exercises Boiin, R., 89-90 Boydston, J. A,, 28 Brauman, R., 184-185 Breathing exercises, 169—170 Brent, D. A., 131-132

Index Bridges, W., 51,53 Browne, A., 147 "Buckets of paint" exercise, 175 Butcher, J. R, 118 Bystanders, role of in crisis, 46—47 Calhoun, K, S., 130 Caplan, G., 4 Capuzzi, D,, 131, 134 Card, J. J,, 28 Carkhuff, R., 75, 158 Casual support, 84 Centering, exercise for, 170 Chamberlain, K., 129 Chess, C, 185 Childhood messages, and coping, 38-40 exercises for, 40-42 Children in crisis, needs of, 60-62 expressive art therapy for, 95 group work with, 94-96 loss in, and vulnerability to violence, 146 preparedness training for, 95—96 Choices, and coping, 38-40 Chronic illness, and suicide risk, 128 Chunking, 81-82 CISD (Critical Incident Stress Debriefing), 93-94 Clayton, R, 128 Clum, G. A., 129 Cognitive commitment, and coping, 37 Cognitive refraining, with suicidal client, 141 Cognitive techniques, for promotion of sleep, 177 Cohen-Sandier, R., 129 Comfort zone exercise, 165 Communities

Index

assessment in, 118-120 crisis intervention in, 89-92 Community resources, assessment of, 105 Competitive responses, 163-164 Confusion, in life transition model, 53-54 exercises for, 59—60 Constriction—dilation continuum, in suicidal client, 143 Consultants, on mental health response team, 195 Consultation, for communities, after trauma, 92 Contracting, with suicidal client, 138 Contracts, "goody," 80-81, 175-176 Cooperative Disaster Child Program, 95 Coping, 36-38 childhood messages and, 38-40 exercises for, 40-42 choices and, 38-40 Coping skills exploration of, 82 and response to crisis, 43 teaching of, 82-83 Creighton, J. L., 38 Crisis children's needs in, 60—62 definition of, 14-15 developmental, 15, 17 experience of, 11—12 life transition model of, 50-59. See also Life transition model response to, 19-20, 31-34 determinants of, 36 examples of, 31-32 historical view of, 32—33 initial, 12-14 nonnormative, 112—118

201

normative, 108—112 paradoxical, 26—27 physical, 13 risk factors in, 42-49. See also Risk factors situational, 15-16 themes in, 24-27 types of, 15-17 vs. trauma, 22t Crisis intervention assessment in, 74, 85, 101-122. See also Assessment attitudinal relating in, 73—79. See also Attitudinal relating in communities, 89—92 conceptual framework for, 67-69, 69/ definition of, 65—66 effectiveness of, workers life experience and, 71 empowerment in, 67 Gilliland and Jarnes' model of, 70-72 goals of, 66 group work for, 92-96. See also Group work mental health response team in, 184-196. See also Mental health response team philosophy of, 4 pitfalls to avoid in, 85—86 Puryear s model of, 72 referral in, 85 Roberts' model of, 70 role playing, exercises for, 179-182 self-concept in, 66-67 settings for, 5-6 technical relating in, 79-84. See also Technical relating Wainrib's model of, 72-74

202

Crisis-proneness, 112, 121 Crisis workers effectiveness of, life experience and, 71 reactions of, in attitudinal relating, 76 response of, to trauma, 177-178 role of, defining, 81 support for, 88-89 Critical Incident Stress Debriefing (CISD), 93-94 Culture and attitudinal relating, 77 and response to crisis, 43 and use of therapeutic touch, 164-165 Cumulative loss, in elderly persons, 134 Dahlstrom, W. G., 118 Dazzling, as pitfall in crisis intervention, 86 Debriefing in Critical Incident Stress Debriefing model, 93-94 by mental health response team, 194,196 Denial in community trauma, 90 as reaction to crisis, 12-13 Derogatis, L. R., 118 Developmental crisis, 15. 17 Developmental phase, and response to crisis, 43 Dilation—constriction continuum, 69/75-76 in assessment, 108-110 exercise for, 86-87, 180-181 Disability, and response to crisis, 43 Disaster, phases of, 119 Doctors without Borders, 184-185

Index Documentation, by mental health response team, 196 "Drama Triangle," 86 Earthquakes, preparedness training for, with children, 96 Economic pressures, and violence, 146 Education, for communities, after trauma, 91-92 Elderly persons, suicide in, 134-135 Ellis, E. M., 130 Embry, D., 90 Emergency medical services liaison with, 195 mobilization of, 186, 190 Empowerment of suicidal client, 142—143 of victims, 67 Erikson, E., 14 Evaluation, initial, by mental health response team, 186-190 Expectations, of self, and response to crisis, 43 Expressive arts therapy, for children, 95 External resources, assessment of, 105 Eye contact, 159 Fairbanks, L, 146 Family changing structure of, and violence, 146 contact with, by mental health response team, 192 Feldmann, T, R., 94 Firearms, access to, and suicide risk, 132 Fires, preparedness training for, with children, 96 Flexibility, and coping, 38—40

Index Follow-up, by mental health response team, 196 Formal debriefing, in Critical Incident Stress Debriefing model, 93-94 Framer, M., 34 Frieze, I. H., 67 Gender, and suicide risk, 127, 135-136 in adolescents, 130 General crisis response, 19-20 characteristics of, 20-21, 22t Gilliland, B. E,, 16-17, 70-72 Goodness of fit, between client and resources, 106 "Goody" contract, 80-81, 175-176 Government organizations, mobilization of, 191 Grace, M,, 47, 92 Graham,]. R,, 118 Green, B. L, 47 Greenwood, K. M., 176 Grieger, T. A., 28 Group work, 92-96 with adults, 93 with children, 94-96 Hance, B.J., 185 Harris, G., 90 Hayes, M, L, 130 Health, and response to crisis, 43 Heimlich, H., 184 Helplessness, victimization and, 35 Herman, J. L., 89 Heroes, role of in crisis, 46-^47 Hetzel, S., 130 Hiley-Young, B., 60 Hoff, L, A., 147 Holloway, H. C, 28

203

Hope in attitudinal relating, 77-78 components of, 120 Hopelessness, and suicide, 129 Hornblow, A. R., 129 Horowitz, M., 118 Hudson, M. E, 147 Human-induced trauma, 18-19 Identity, in life transition model, 58-59 Illness, chronic, and suicide risk, 128 Imagery, visual, 172-174 Information, for communities, after trauma, 90-91 Instrumental support, 84 Internal resources, assessment of, 105 Irrelevant comments, 161 Isherwood, J,, 129 James, R. K., 16-17, 70-72 Jobes, D.A., 131, 133 Jones, R. T., 95-96 Kaemmer, B., 118 Kaplan, A. G., 136 Kazanis, B., 95 Kzzdin, A, E., 129 Kertay, L., 164 King, R, A., 129 Klein, R., 136 Klerman, G. L., 128 Klukken, P. G., 14, 68, 70, 109 Korner, E., 120 Kovacs, M., 129 Kramer, T., 92 Lalla, F. A., 148, 150 Lane, P. S., 94

204

Langer, E., 36 Lazarus, R., 36-37, 78 Lewinsohn, P, M., 130, 134 Lewis, J,, 33 Life crisis, universal, 21-24 Life experience, and crisis worker's effectiveness, 71 Life transition model, 50-59 anger in, 55—58 confusion in, 53-54 exercises for, 59-60 identity in, 58-59 loss in, 56—57 mourning in, 51—53 exercises for, 59-60 Lillibridge, E. M., 14, 68, 70, 109 Lindemann, E., 3 Lindy, J., 25, 47 Lin ton, J, C, 93 Listening active, 157-158, 166-167 exercise for, 160—161 styles of, 159-164 irrelevant comments and, 161 questions and, 162—163 tangential comments and, 161-162 Listen to the Children, 95 Loss, 49-50 cumulative, in elderly persons, 134 in life transition model, 56-57 and suicide risk, 128 and vulnerability to violence, 146 Lowen, A., 167 Luscomb, R. L., 129 Magers, H., 90 Mantcll, M., 147-148 Marital status, and suicide risk, 128 Marmar, C. R., 94

Index Mastery, after trauma, 59 Matul, D., 95 Maxmen, J, S., 151 May.J. H., 134 McCarroll, J. E., 28 McCarthy, J., 174 McDowell, E. E,, 134 McFarlane, A., 93 McLain, S. L, 94 Mclaughlin, K, J., 95 Media violence in, 147 working with, 182-184, 191, 193, 195 Meldrum, L, 93 Mental health response team, 184-196 advance planning by, 191 advantages of, 184 consultants on, 195 contact with family by, 192 contact with media by, 191, 193, 195 debriefing by, 194, 196 director of, 194 documentation by, 196 and emergency medical services, 186, 190 initial evaluation by, 186-190 mobilization of resources by, 186, 190-193 on-site activity of, 193—195 postintervention work by, 196 resources of, 185 roles of, 185-186 spokespersons on, 192 supervision on, 195 Mental illness, assessment for, 113-116 Mitchell, J, T., 93 Mitigation, of disaster, 119

Index Motivation, assessment of, 120 Motto,]. A., 136, 139 Mourning, in life transition model,

51-53

exercises for, 59-60 Murtagh, D, R., 176 Myer, R. A., 121

Myers, D.G., 34, 42, 44, 49, 91, 106

Nader, K., 146 Natural disasters, 18 Needs, unmet, and suicide risk, 141 Neuringer, C., 129 Nolan, V. E., 25 Nonverbal exercises, 167—175, 179-180 for anger release, 174-175

breathing, 169-170 centering, 170

power transfer, 176 progressive relaxation, 170—172 safe place, 174 visual imagery, 172-174 Normalization, in attitudinal relating, 77 Nunez, E, 146 O'Callahan, W., 94 Occupation, and response to crisis,

47

Ochberg, E M., 77 "Off my back" exercise, 175 Ollendick, T. H., 95 Ottens, A.J., 121 "Outrage factor," 185 Oxrnan, T. E,, 106 Pacing in active listening, 166 in attitudinal relating, 76—77

205

Pain, psychological, and suicide risk, 140 Parad, H. J., 65, 80, 112, 142 Paradoxical intent, for promotion of sleep, 177 Patsiokas, A. T., 129 Pearlman, L. A., 89 Perez, J,, 60, 90, 186 Persian Gulf War, emotional reactions

to, 89-90

Personal revelation. See Self-disclosure Petrie, K., 129 Phoenix phenomenon, 27-28 Pierrakos, J., 167 Pitfalls in assessment, 103 in crisis intervention, avoidance of, 85-86 Plussing, exercise for, 88 Pope, K. S., 128 Positive reinforcers, 175-176 Posttraumatic stress disorder (PTSD), 115-118 Power of suggestion, in attitudinal relating, 78-79 Power transfer exercise, 176 Preadolescents, in crisis, needs of, 61-62 Preparedness, for disaster, 119 Preparedness training, for children, 95-96 Preschoolers, in crisis, needs of, 61 Problems, defining, in technical relating, 81-82 Problem-solving expansion of, 81-82 resistance to, by suicidal client, 142 with violent client, 150 Profession, and suicide risk, 127 Progressive relaxation, 170-172 Proximity, as risk factor in crisis, 48

Index

206 Psychological needs, unmet, and suicide risk, 141 Psychopathology, assessment for, 113-116 Public service announcements, for communities, after trauma, 91 Puryear, D. A., 70-71, 75, 77, 80 Pynoos, E, 146 Questioning, 162—163 in assessment of suicide risk, 137-140

Rahe, A. ]., 28 Raphael, B., 93 Recovery, from disaster, 119 Referral, 85 source of, communication with, 102 "Rehearsal plus," 96 Reinforcers, positive, 175—176 Relate—assess—refer/respond, in Wainrib's crisis intervention model, 73-74 during assessment, 110—112 Relating attitudinal, 73—79. See also Attitudinal relating technical, 79-84. See also Technical relating Relationship, initial, in attitudinal relating, 75 Relaxation, progressive, 170-172 Reporters. See Media Rescuing, as pitfall in crisis intervention, 86 Research, on assessment, 121—122 Resources access to, after trauma, 106-197 assessment of, 105—106

Responses competitive, 163-164 tangential, 161-162 Revelation, personal, as pitfall in crisis intervention, 86 Reviere, S.» 164 Risk factors, 42-49 individual, 42-44 related to event, 47-49 role-related, 44-47, 107 for suicide, 128-130. See also Suicide, risk factors for Rituals, for adolescents in crisis, 62 Roberts

A. L,177 A. R., 70 Rogers, C, 75, 111 Rohde, P., 130, 134 Role, as risk factor in crisis, 44-47, 107

Role playing, exercises for, 179-182 Ross, M,» 147 Saakvitne, K., 89 Sablijak, L., 95 Sadness, acceptance of, 52 Safe place exercise, 174 Safety in attitudinal relating, 75 and use of therapeutic touch, 165 "Safe zone," after trauma, 25—26 Sandman, R M., 185 Schmidt, A. E., 121 Schneidman, E,, 128, 138, 140 School-age children, in crisis, needs of, 61-62 Seely, J. R., 130, 134 Self, expectations of, and response to crisis, 43 Self-concept, in crisis intervention, 66-67

Index Self-disclosure, 163—164 as pitfall in crisis intervention, 86 Self-esteem, raising, 79—80 Self-reliance, encouraging, 80—81 Self-scanning, for body language, 158-159 Separation anxiety, 49-50 Severity, assessment of, 104 SewellJ. D., 94 Shilo-Cohen, R, 95 Shinske, F, K., 95 Silence, tolerating, 166—167 Simons, S., 79 Simonton, O, C., 38 Simonton-Matthews, S. T,, 38 Situational crisis, 15—16 Skriptchenko-Gregorian, V., 95 Sledge, W, H., 28 Sleep, exercises for, 176—177 Sloat, R. S., 130 Small groups, for trauma victims, 92—96. See also Group work Spencer, E., 146 Spiritual resources, assessment of, 106 Spitz, L, 57 Spokespersons, on mental health response team, 192 Steinberg, A,, 146 StillionJ. M., 134 Stimulus control, for promotion of sleep, 177 Strengths, reinforcement of, 79—80 Stressors, and suicide, 129-130 Suicidal clients ambivalence in, 143 behavioral planning with, 139 cognitive reframing with, 141 communication of intention by, 143-144 constriction—dilation continuum in, 143

207

contacting support system for, 138 contracting with, 138 empowerment of, 142—143 problem-solving with, resistance to, 142 Suicide, 125-145 in adolescents, 130-134 prevention programs for, 131 demographic factors in, 127—128 in elderly, 134-135 myths about, 126-127 risk factors for, 128-130 access to firearms as, 132 assessment of, 136—140 gender as, 135-136 psychological pain as, 140 unmet needs as, 141 understanding, model for, 140-145 Supervision, on mental health response team, 195 Support casual, 84 during confusion, 54 for crisis worker, 88—89 instrumental, 84 Support systems assessment of, 105 contacting, for suicidal client, 138 identification of, 83—84 and response to crisis, 43 Tangential comments, 161-162 Technical relating, 73-74, 79-84 assignments in, 83 chunking in, 81-82 defining problem in, 81-82 defining worker s role in, 81 encouraging self-reliance in, 80—81

208

Technical relating (continued) exploration of past coping strengths in, 82 identification of support systems

in, 83-84

raising self-esteem in, 79-80 reinforcing strengths in, 79-80 teaching new skills in, 82-83 Tellegen.A., 118 Temperature, as stimulus to violence, 151 "Ten things" exercise, 88 Terr, L, 107 Therapeutic relationship, 73—84 attitudinal aspects of, 73-79. See also Attitudinal relating technical aspects of, 79—84. See aba Technical relating Therapists, See Crisis workers Tierney, K. JL, 118 Titchener, J., 47 Toistoshev, H, 130 Touch, therapeutic use of, 164-165 Training, for communities, after trauma, 91-92 Trauma. See also Crisis assessment in, 106—108 classification of, 18 in communities, crisis intervention for, 89-92 experience of, 11-12 history of, and response to current crisis, 43 mastery after, 59 posttraumatic stress disorder from, 115-118 response to, 31—34 by crisis worker, 177—178 determinants of, 36 paradoxical, 26-27

Index risk factors in, 42-49. See aba Risk factors "safe zone" after, 25-26 scope of, 17-19 themes in, 24-27 vs. crisis, 22t Traumatic countertransference, 89 Triage model, of assessment, 121 Trivialization, avoidance of, in attitudinal relating, 78 Uncertainty, duration of, as risk factor in crisis, 48 Undoing, as reaction to crisis, 13 Universal life crisis, 21—24 Urgency, assessment of, 103-104 Ursano, R. J., 28 Ursin, E., 25 Validation, in attitudinal relating, 77 VandeCreek, L, 150 Van Gennep, A., 51, 53, 109 Vera, E., 32, 33 Victimization concept of, 34—36 and helplessness, 35 Victims, empowerment of, 67 Violence, 145-153 assessment of, 148-151 incidence of, 147 loss and, 146 in media, 147 risk factors for, 148-149, 151 scope of, 19 sources of, 145-148 stimuli for, control of, 151—152 in workplace, 147-148 Violent clients problem-solving with, 150 protection from, 152 Visual imagery, 172-174

Index Wainrib, B., 84, 146 Ward, G., 151 Weaver, J. D., 113 Weissman, A,, 129 Wetzel, R., 129 Wilkinson, C, B., 32, 33 Williams C, E, 95 R. C., 121

209 Wilner, N.» 118 Wilson, ]., 93 Winn, V., 130 Women, violence against, 147 Workplace, violence in, 147-148 Yeh, E,, 46 Zimmerman, A. C., 90