READINGS CSS 3060 Crisis Intervention Theory-Practice PDF

+\-\-\-\-\-\--cursor parking lot\-\-\-\-\-\--+ I I I I +\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--+ +-----------------------+-----------------------+-----------------------+ | **Week** | **Reading Topics** | **Gym Leader | | | | Assigned** | +-----------------------+-----------------------+-----------------------+ | **1** | Chapter 1 | Leann | | | | | | Jan 6 | | | +-----------------------+-----------------------+-----------------------+ | **2** | Chapter 2 & 3 | Tyanna and Sabrina | | | | | | Jan 13 | | | +-----------------------+-----------------------+-----------------------+ | **3** | Chapter 4 & 5 | Leann and Ginuel | | | | | | Jan 20 | | | +-----------------------+-----------------------+-----------------------+ | **4** | BLOCK WEEK YIPPEE | N/A | | | | | | Jan 27 | | | +-----------------------+-----------------------+-----------------------+ | **5** | Chapter 6 & 7 | Tyanna and Sabrina | | | | | | Feb 3 | | | +-----------------------+-----------------------+-----------------------+ | **6** | Midterm Test | N/A | | | (Chapters 1-7) | | | Feb 10 | | | +-----------------------+-----------------------+-----------------------+ | **7** | Chapter 8 | Ginuel | | | | | | Feb 24 | | | +-----------------------+-----------------------+-----------------------+ | **8** | Chapter 11 | Tyanna | | | | | | Mar 3 | | | +-----------------------+-----------------------+-----------------------+ | **9** | Chapter 9 & 10 | Leann and Sabrina | | | | | | Mar 10 | | | +-----------------------+-----------------------+-----------------------+ | **10** | Chapter 13 & 14 | Ginuel and Tyanna | | | | | | Mar 17 | | | +-----------------------+-----------------------+-----------------------+ | **11** | Chapter 15 | Sabrina | | | | | | Mar 24 | | | +-----------------------+-----------------------+-----------------------+ | **12** | Case Studies, | N/A | | | Discussion, Exam | | | Mar 31 | Review | | +-----------------------+-----------------------+-----------------------+ ### **Week 1 - Leann** #### Chapter 1: Approaching Crisis Intervention The Case Against Too Much "Helping - Trauma Tourism - commercialization of crises, travelling to disaster scenes to provide unrequested assistance - Assumption that people are incapable of managing post-crisis situations and require external help COVID-19 and the Rise of Telebehavioural Health - Significantly shifted mental health services to telebehavioural formats (video conferencing, mobile apps, other remote tech for crisis intervention) - People have become more positive in accepting outreach strategies following crisis (less victim blaming, cost effective Definitions of Crisis - No fixed or absolute definition, individual definitions include: - In a clinical context → An acute emotional upset arising from situational, Summary definition → perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person's current resources and coping mechanisms - Behavioural Emergency - when a crisis escalates to the point that the situation requires immediate interventions to avoid injury or death to oneself or others - Indirect/Noncommissioned - occur when people place themselves in potentially lethal situations with no directed purpose or intention to harm themselves or others (e.g. drunk driving) - Parasuicide behaviour - accidentally going into a situation and getting themselves killed - Systemic crisis - when response systems are unable to contain and control a traumatic event in regard to both physical and psychological reactions - Mega Crisis - crises that affect entire countries or the world (directly or vicariously) - Metastasizing Crisis - when a small, isolated incident is not contained and begins to spread (e.g. school failure to deal with isolated cases of bullying → bullying outside of school spaces) - Primary prevention - stopping a problem before it starts - Secondary prevention - minimizing harmful effects Characteristics of Crisis (PSNTURPC) - **Presence of danger and opportunity** - danger because it can overwhelm the individual, opportunity because it encourages the person to seek help - **Seeds of growth and change** - anxiety and discomfort provides an impetus for change - **No Panaceas or Quick Fixes** - may not be applicable to many crisis situations - **The Necessity of Choice** - not choosing is a choice (usually turns out to be negative), choosing to do something allows a person the chance to set goals and formulate a plan to overcome the dilemma - **Universality** - Disequilibrium or disorganization accompanies every crisis - **Resiliency** - key jobs of crisis intervention is finding the right combination of support systems and coping mechanisms and forming them into plans that foster resilience - **Perception** - how people interpret events and what the worker can do to reframe them - **Complicated Symptomolog**y - complex, defies cause-and effect, many compounding problems Transcrisis States - A continuous state of low grade crisis which has not been resolved, and given the right conditions may become a full blown crisis (previous traumatic feelings resurface) - Transcrisis vs. PTSD: - PTSD caused by extremely traumatic event and very specific criteria must be present for PTSD diagnosis - Individuals with PTSD can be in transcrisis state, but not all in transcrisis have PTSD - Transcrisis points - Occur frequently in transcrisis states within the therapeutic intervention. These points are generally marked by the client's coming to grips with new developmental stages or other dimensions of the problem. Transcrisis points do not occur in regular, predictable, linear progression Theories of Crisis and Crisis Intervention Basic Crisis Intervention - Basic Crisis Theory - focuses on helping people in crisis recognize and correct temporary affective, behavioural, and cognitive distortions brought on by traumatic events - Brief Therapy Theory - attempts to remediate ongoing emotional problems Expanded Crisis Theory - **Psychoanalytic theory** - crisis can be understood by accessing unconscious thoughts and past emotional experiences (e.g. early childhood fixations) - **Systems Theory** - looks at the environment that the person lives in and the dynamic interactions the person has within it - **Ecosystems Theory** - micro, mezzo, macro, I hope you guys remember that shit - **Adaptational Theory** - person's crisis will recede when maladaptive coping behaviours are changed to adaptive behaviours - **Interpersonal Theory** - enhance personal self-esteem in order to build the confidence to overcome crisis - **Relational Cultural Theory** - developing empathic relationship interwoven within the client's culture - **Chaos Theory** - crises are chaotic systems that can evolve to become self-organizing as people adapt - **Developmental Theory** - developmental tasks that are not accomplished during life stages accumulate and cause problems (Erik Erikson) Applied Crisis Theory - **Developmental Crisis** - dramatic change/shift occurs → abnormal responses (life transitions) - **Situational Crisis** - uncommon/extraordinary events that can't be foreseen (car accident) - **Existential Crisis** - inner conflicts associated with human issues of purpose, responsibility, independence, freedom, and commitment (I SHOULD'VE BEEN BORN IN A FICTIONAL WORLD WITH FIYERO RAHHH) - **Ecosystemic Crisis** - when natural or human caused disaster overtakes a person/group (COVID) Crisis Intervention Models - **Equilibrium Model** - people in crisis are in states of psychological or emotional disequilibrium where their usual coping mechanisms and problem-solving methods fail - Goal → restore equilibrium - **Cognitive Model** - crises are rooted in faulty thinking about events that surround the crisis - Goal → help people become aware and change their views/beliefs about the crisis events - **Psychosocial Transition Model** - crises may be related to internal (emotional, psychological) or external difficulties (social, environmental) - Goal → assess internal and external difficulties contributing to crisis and help choose workable alternatives to current behaviour, attitudes, and environments - **Developmental-Ecological Model** - integrates developmental stages and environmental issues - Goal → assess interrelationship between individual and environment - **Contextual-Ecological Model** - focuses on contextual elements of crisis - Three Premises→ Proximity to the event, reaction, amount of change caused, divided by the amount of time passed - **Psychological First Aid** - address the immediate crisis and provide immediate relief - Crisis therapy - second order intervention that seeks to resolve the crisis, generally provided by human services professionals **Eight Core Actions** (CSSIPCIL) 1\. Contact and Engagement 2\. Safety and Comfort 3\. Stabilization (if needed) 4\. Information Gathering: Current Needs and Concerns 5\. Practical Assistance 6\. Connection with Social Supports 7\. Information on Coping 8\. Linkage with Collaborative Services - **ACT Model** - **Assessment** of presenting problem, **Connecting** clients to support systems, **Traumatic** reactions and posttraumatic stress disorders - Crisis assessment → establishing rapport → identifying major problems → dealing with feelings → generating and exploring alternatives → developing plans → providing follow up - **Playbook/Game Plan Model** - tailored to diffuse and de-escalate angry, distraught, out-of-control, potentially lethal individuals who are in the middle of crisis - Usually used by the police, trains first line responders by teaching them how to assess individual's behaviour and develop a game plan of verbal de escalation techniques - **Eclectic/Integrated** - all people and crises are unique and distinctive (e.g. perception of the event), all people and all crises are similar (e.g. bereavement) Characteristics of Effective Crisis Workers - Life experiences - Problems may overlap with clients → burnout - Personal characteristics - Poise, creativity and flexibility, energy, resiliency, quick mental reflexes, assertiveness, spirituality, - Other Attributes - tenacity, ability to delay gratification, courage, optimism, reality orientation, calmness under duress, objectivity, positive self-concept, appropriate sense of humour, abiding faith that humans are strong, resilient, and capable of overcoming difficulty ### ### ### ### ### **Week 2 - Sabrina and Tyanna** #### Chapter 2: Culturally Effective Helping in Crisis (Sabrina) Multicultural Counseling and Therapy (MCT) - Understanding how culture and identity influence a client's mental health, stability, etc. - How they react to counseling itself Aspects of MCT: - Culture-specific, culture-universal, culturally adaptive, culturally responsive Relational Cultural Therapy (RCT) - Culture-centered theory used to help counselor and client explore intersection of intrapersonal, interpersonal, social-embedded experiences Uncertainty Avoidance - Degree to which cultures feel threatened by uncertainty and ambiguous situations, - Resulting in rules, procedures, rituals and laws formulated to buffer uncertainties of individual judgement **Core Multicultural Attributes** (SKSA) 1. Self-knowledge; awareness of one's own cultural bias 2. Knowledge about status and cultures of different groups 3. Skills to effect culturally appropriate interventions 4. Actual experience in counseling and crisis intervention with culturally different clients **Culturally Biased Assumptions** 1. People all share a common measure of "normal" behaviour 2. Definition of problems can be limited by academic disciplines boundaries 3. Western culture depends on abstract conceptualizations and designations for crisis workers 4. Formal counseling is more important than client's natural support systems 5. Everyone depends on linear thinking 6. Individuals need to fit into system 7. Client's past has little relevance to contemporary events 8. Belief that knowledge should not be based on logic, facts, empirical evidence alone 9. Belief that all humans seek pleasure and happiness over pain and sorrow, negative feelings should be avoided 10. Independence is valuable and dependencies are undesirable 11. Individuals are the basic building blocks of all societies 12. Psychological homeostasis and balance must be maintained so people sail through life on even keel 13. Human services workers already know all their assumption **Relational Cultural Counseling (RTC)** - We grow through relationships and are inevitably interdependent, connected - Highly interactive conceptualization of growth and relationships **Individualism** - Worldview that centralizes the personal -- personal goals, personal uniqueness, personal control and treats the social group or social context the individual operates in as insignificant **Collectivism** - Based on the assumption that groups bind and mutually obligate individuals, that the personal is simply a component of the larger social group or context and subordinate to it **Low Context Culture** - Self-esteem and self-worth are defined in personal, individual terms - Information is generally transmitted explicitly and concretely through language **High Context Culture** - Stories, proverbs, fables, metaphors, similes, analogies - Facial expressions, gestures, tone of voice are as important as meaning of words being said - Self-esteem and self-worth are tied to group High Uncertainty Avoidance (e.g. Japan): - Develops broad range of rules, regulations, procedures to cover many contingencies **Emic Model** - Subject view of who they are, not just their individual parts but them in entirety (unique traits) **Etic Model** - Traits and factors common to all within the group that can be objectively identified by outside observers (common traits) **SAFETY Model** **S**tability **A**ffect **F**riction **E**nvironment **T**emperament **Y**earning **Broaching** Crisis worker's consistent display of openness to invite client to explore issues of diversity and recognition that race, ethnicity or universal trait may be contributing to the crisis ![](media/image2.png) #### Chapter 3: Intervention and Assessment Models (Tyanna) **Introduction** **Equilibrium:** A state of mental or emotional stability, balance, or poise **Disequilibrium:** Lack or destruction of emotional stability, balance, or poise **Mobility:** A state in which the person can change or cope in response to different moods, feelings, emotions, needs, conditions, and influences; being flexible or adaptable **Immobility:** A state in which the person is not able to change or cope in response to different moods, feelings, emotions, needs, conditions, and influences; being inflexible or unadaptable **A Hybrid Model to Crisis Intervention** (PESAPCF) **Four Stages** (EFBB) 1. Exposure to stressor(s) and attempts to restore equilibrium and mobility 2. Failure to restore equilibrium and mobility 3. Behavioural emergency occurs 4. Breakdown of physical health and psychosocial functioning - Crisis isn't always linear; issues may arise that prevent stages **Task 1. Predispositioning/Engaging/Initiating Contact** - Predisposing individuals to be receptive to interventions during a crisis - Empathy and authentic - Let individual know what to expect - (1)Establish a psychological connection and create a line of communication (2) clarify intentions **Task 2. Problem Exploration: Defining the Crisis** - Understand the problem from the client's POV; core listening skills **Task 3. Providing Support** (PLSI-) - Psychological support - Empathy and understanding - Logistical support - Instrumental and informational - Social support - Client's primary support systems - Informational support - Next steps and alternatives \*Safety is the primary concern; keeping you, others, and the client safe\* **Task 4. Examining Alternatives** (SCP) - Situational supports: People the client knows who care about them - Coping mechanism: actions, behaviours, or resources that may help the client - Positive and constructive thinking patterns: Ways of reframing the problem that may lessen the client's stress and anxiety **Task 5. Planning in Order to Reestablish Control** - Helping create a plan to guide clients to a resolution - Mobilizing the client - A plan should (1) identify additional people and resources that can provide immediate support, and (2) provide coping mechanism for the client during the crisis - Focus on problem-solving and the client's capability - Collaboration with client; control and autonomy Psychoeducation: Providing information to victims and survivors about what is happening and what is going to happen to them psychologically after a traumatic event **Task 6. Obtaining Commitment** - Clear, concise, and behaviour-specific **Task 7. Follow Up** - Keeping track of client's success **Assessment in Crisis Intervention** - Continuous throughout crisis; making judgments on the actions that the client needs and assessing the situational crisis - Assessment enables the worker to determine (1) the **severity** of the crisis (2) the client's current emotional, behavioural, and cognitive **status** and mobility or immobility (3) the alternatives, coping mechanisms, support systems, and other **resources** available to the client; (4) the client's level of **danger** to self and others and (5) and **worker's ability** in deescalating and defusing the situation **Assessing the Severity of a Crisis** - Triage assessment system - Quick and effective **The ABCs of Assessing Crisis** - A: Affective (Emotional) state - Atypical or impaired affect is often the first sign that the client is in a state of disequilibrium - Help client express feelings appropriately - B: Behavioural functioning - Facilitate positive actions that the client can take at once - C: Cognitive functioning - Assess the client's thinking patterns **The Triage Assessment Form (PAGE 67 - Ginuel)** - Says how the client is doing and how the worker is going to defuse the situation *The Affective Severity Scale* - Emotional qualities found in a crisis: Anxiety, anger, depression, frustration - Secondary emotions may lie within these emotions - May manifest verbally and non-verbally - Emotions may be singular or combined *The Behaviour Severity Scale* - Behaviourally immobile - Once the crisis goes beyond the client's capacity to cope in a meaningful manner, the client is immobilized *The Cognitive Severity Scale* - In a crisis, the client typically perceives the event in terms of transgression, threat, loss, or any combination of the three - Four areas of cognitive functioning that are involved in a crisis: Physical, psychological, social relationships, and moral/spiritual beliefs *Comparison with Precrisis Functioning* - Use TAF as a guide - Gauge deviation from client's typical ABC levels *Rating Clients* - 3--10: **Minimal impairment** - These clients are self-directing and able to function effectively on their own - 11--19: **More impaired** - May have difficulty functioning on their own and need help and direction - Low teen scores (11--15) call for some guidance and directiveness - High teen scores (16--19) clients are losing control of their ability to function effectively and need more than passive and palliative responses (find immediate support systems for the future during this range) - 20 or above: **Deeper into harm's way** - Need a great deal of direction and a secure and safe environment - Scores in the high 20s: **Some degree of lethality is involved** - Either premeditated or client is so out of control they cannot stay out of harm's way *Severity* - Intensity, duration of feelings/thoughts/actions, and how well clients can control themselves **Default Drug Assessment** - Assess prior trauma, psychopathology, and use, misuse, or abuse of drugs in an effort to determine whether they correlate with the current problem **Assessing the Client's Current Emotional Functioning** - Four factors in assessing emotional stability: (1) the **duration** of the crisis (2) the **degree** of emotional stamina or coping at the moment, (3) the **ecosystem** within which the client resides, and (4) the **developmental stage** of the client *The Client's Current Acute or Chronic State* - The one time crisis client requires direct intervention to help get over the specific event or situation that caused the crisis - After reaching pre-crisis equilibrium, the client can form coping mechanisms and rely on social supports - The chronic client requires more time in counselling - They need help with coping mechanisms, supports, strategies, and gaining affirmation **Assessing Alternatives, Coping Mechanisms, and Support Systems** - Keep in mind, mobility, the client's viewpoint, and the capability of using alternatives **Assessing for Legal and Ethic Issues** - Five Moral Principles of ethical decision-making (ABFJN): **autonomy**, **beneficence**, **fidelity**, **justice** and **nonmaleficence** (Veracity added in 2014 idk) - Friction in crisis intervention occurs when autonomy clashes with any of the principles - Use naturalistic decision-making models - Allows you to make decisions under pressure and time constraints - Use basic philosophical principles on which ethical standards are developed, but employed in a hierarchical manner - LASER model - **Legal:** Legal responsibilities - **Assessment:** TAF - **Setting:** Setting and context (procedures, policies, and politics) - **Ethical Principles:** Selecting the most important ethical principles during a crisis - **Resolution:** Not formulaic; think on your feet ### ### **Week 3 - Leann and Ginuel** #### Chapter 4: The Tools of the Trade (Leann) **Listening in Crisis Intervention** *Guidelines for Open-Ended Q's* - Request descriptions - Focus on plans - Expansion ("tell me more") - Assessment - Avoid "why" questions (clients can get defensive) *Guidelines for Close-Ended Q's* - Request specific info - Obtain a commitment - Increasing focus - Avoid negative interrogatives (Don't, doesn't, isn't, aren't, and wouldn't seek or imply agreement *Restatement and Summary Clarification* - Restatement - generally has to do with the content of the crisis rather than underlying feelings or thoughts - Summary clarification - packages preceding dialogue and lets the client and crisis worker are on the same wavelength (client may also be asked to summarize what the plan is and how they are going to go about it) *Owning Feelings* - **Collaborative Owning Statements** - avoid "we" statements (only the interventionist and the person in crisis matter at the moment, we implies the presence of others' thoughts) - "We" should be reserved for cooperation between worker and client - Relational Markers - shorten the psychological distance between client and worker through the use of words as "this," "these," "we," "our," "here," and "now" as opposed to "that," "those," "mine," "there," and "then." - **Disowned Statements** - many of us disown may human qualities that indicate that we are less than perfect - E.g. confusion → being willing to express confusion can be a trust reinforcing event (reduce the need to pretend, client can begin to become actively involved with the worker to work together) - **Conveying Understanding** -"I understand" clearly conveys to the client that you understand what is happening right now is causing the client distress (TERESA WOULD DISAGREE RAHHHH) - **Value Judgements** - owning statements speak specifically to the worker's judgement about the situation and what they'll do about it (not judgements about character) - **Positive Reinforcement** - always used regarding a behaviour, often to approximate a client towards a mini goal or moving towards alternate behaviours - WARNING may cause client to become dependent on praise - **Personal Integrity and Limit Setting** (Boundaries) - important to set clear limits with clients starting to get out of control or are trying to manipulate the worker - **Assertion Statements** - clearly and specifically ask for a specific action from the client - KISS protocol (Keep It Simple Stupendous) *Facilitative Listening* - Give full attention to the client by: 1. Focus total mental power on client's world 2. Attend to client's verbal and nonverbal messages 3. Pick up on client's current readiness to enter into emotional and/or physical contact with others, especially with the worker 4. Display attending behaviours to strengthen relationship and build trust - Predispositioning statements - make initial owning statements that express exactly what they're going to do - Listening to respond in ways that let the client know that the worker is hearing the facts and emotions from the client's message (restatement, summarizing, paraphrasing) - Facilitative responses enable clients to feel hopeful and to sense an inclination to move forward, away from the crisis - Helping clients understand the full impact of their crisis to allow clients to become more objective and rational **Basic Strategies of Crisis Intervention** (ACSEFGMOP) - **Creating Awareness** - worker attempts to bring conscious awareness to repressed feelings, thoughts, and behaviours that freeze client's ability to respond to crisis - **Allowing Catharsis** - letting clients talk, cry, or anything that allows them to vent their feelings and thoughts (take caution with allowing anger to build up) - **Providing Support** - attempt to validate that the client's responses are as reasonable as can be expected given the situation (avoid using "normal" → "common" to have these feelings not "normal") - Useful when the client is attempting to move into action - **Promoting Expansion** - worker engages in expansion activities to open up clients' tunnel vision of the crisis - Helps clients step back, reframe the problem, and gain new perspectives - **Emphasizing Focus** - worker attempts to partition clients' catastrophic interpretations and perceptions of the crisis to more specific, realistic, manageable components and options - **Providing Guidance** - worker provides info, referral, and direction for clients' obtaining assistance from external resources and support systems - **Promoting Mobilization** - worker attempts to activate and marshal clients' internal resources and use external support systems to help generate coping skills and problem-solving abilities so they become mobilized and don't remain stuck in crisis - **Implementing Order** - worker provides order and helps clients classify and categorize problems to prioritize and sequentially defuse the crisis in a logical and linear manner - **Providing Protection** - worker safeguards clients from engaging in harmful behaviours, feelings, and thoughts that may be psychologically or physically injurious or lethal to themselves or others **Climate of Client Growth** - According to Rogers, the most effective helper is one can provide these three conditions for client growth - **Empathy** - worker senses feelings and meanings the client is experiencing and communicates to client that the worker understands how it feels - **Genuineness** - being completely open in the relationship; nothing hidden no facades, no professional fronts (client is encouraged to reciprocate) - **Acceptance** - worker feels unconditional positive regard for the client *Communicating Empathy* - Sympathy vs. Empathy - I bet you guys have watched that video enough to know by now - Distancing - crisis workers may become overwhelmed and distance themselves from the overwhelming effect → own our inability to find the right words to indicate that you do feel for the client - Five Important Techniques: - **Attending** - focusing fully on the client, here and now (conveying this is a skill) - **Verbally Communicating** - understanding client's emotions and accurately communicating that understanding to the client - **Reflecting Feelings** - focus on client's expressed affective and cognitive messages, worker deal **directly** with clients' concerns and do not veer off into talking **about** them - **Non-Verbally Communicating** - accurately picking up and reflecting all unspoken cues, messages, and behaviours clients emit - Also be aware of worker's own body messages - **Silence** - clients need time to think - Critical that workers aren't rushed and that client has time to understand what's going on *Communicating Genuineness* 1. **Being role free** - worker is genuine in life and the therapeutic relationship 2. **Being spontaneous** - communicates freely, with tact, and without constantly gauging what to say (behaviour is based on a feeling of self-confidence) 3. **Being non defensive** - be open to negative client expressions without feeling attacked 4. **Being consistent** - few discrepancies between what they think, feel, and say and their actual behaviour 5. **Being a sharer of self** - when appropriate, people who are genuine engage in self-disclosure *Communicating Acceptance* - Worker is able to put aside personal needs, values, and desires and does not require clients to make specific responses as a condition of full acceptance *In the Field* - **Simple, initial steps** - Introduce yourself in a way that says "I am here for you and I am no threat" - Obtain person's name and personalize it if possible - Express what you're seeing across affective, behavioural, and cognitive dimensions (use "I" statements) - Summarize the info and feed it back so both parties are on the same page - **Safety** - setting limits, involves determining the degree of threat a person is feeling and how they intend to protect themselves from it - **Assessing for Medical Problems** - Finding medical staff who have worked with clients is often critical in de-escalating a crisis (many clients are well known as repeaters by police, EMTs, and 911 operators) - After making initial contact, medical issues, physical and psychological, need to be checked out - **Drugs** - gathering info on drug use and misuse is critical in planning action steps - Difficult to de-escalate a person who has misused drugs or stopped taking psychotropic meds - **Support -** find out what human support systems are available, what systems have ceased to exist, and what the client had done to access these systems - **Meeting Basic Needs** - if basic needs aren\'t met, then little resolution to the crisis will occur (help client get some of these needs met to build trust) **Acting in Crisis Intervention** *Directive Intervention* - Providing specific info and guidance clients need to make decisions, setting limits on behaviours that range from inappropriate to lethal, and apprising them of the consequences of their affective, cognitive, and behavioural responses to the crisis - Types of immobile clients: - need immediate hospitalization because of chemical use or organic dysfunction - suffering from severe depression and cannot function - experiencing a severe psychotic episode - suffering from severe shock, bereavement, or loss - anxiety level is temporarily so high that they can't function until the anxiety subsides - are out of touch with reality - currently a danger to themselves or others *Collaborative Counselling* - Collaborative client is a full partner in identifying the precipitating problem, examining alternatives, planning action steps, and making a commitment to carrying out a plan - Not as self-reliant as a fully mobile client - When triage assessment indicates client can't function successfully in a nondirective mode but has enough mobility to be a partner in the process *Nondirective Counselling* - Desirable whenever clients are able to initiate and carry out their own action steps - Worker is a support person (assists clients in mobilizing what is already inside them) **Action Strategies for Crisis Workers** - Recognize individual differences → every situation is unique, be multiculturally sensitive - Assess yourself → be aware of your own values, limitations, physical and emotional status, and readiness to deal objectively with the client and their crisis - Show regard for client safety - Provide client support → be available as a support person - Define the problem clearly → make sure each problem is clearly and accurately defined from a practical, problem solving POV - Consider alternatives → use open-ended questions and leads to elicit a number of choices that the client may have been unaware of - Plan action steps → assist client in developing short-term plans to get through the immediate crisis and make transitions to long-term coping - Use the client's coping strengths - Use referral resources - Develop and use networks → closely allied referrals - Get a commitment → from the client to follow through on the action plan #### Chapter 5: Crisis Case Handling (Ginuel) MEOW Handling Crisis Cases VS Long-Term Cases (Differences) - **Principles** ----------------------- ----------------------------------------------------- -------------------------------------------------------------------- **Long-Term Therapy Mode** **Crisis Case-Handling Mode** Diagnosis Complete diagnostic evaluation Rapid assessment Treatment Focus on underlying causes and whole person Solution-focused on immediate trauma/crisis Plan Personalized comprehensive plan, evidence-based Individual problem-specific plan, best-guess (based on precedence) Methods Knowledge of variety of techniques Knowledge of time-limited brief therapy techniques Evaluation of Results Systematic processing of client's total funcitoning Target crisis (client return to precrisis functioning) ----------------------- ----------------------------------------------------- -------------------------------------------------------------------- - **Objectives** -------------------------------------------- ------------------------------- **Long-Term Therapy Mode** **Crisis Case-Handling Mode** Prevent problems Ensure client safety Correct etiological (psychosocial) factors Predisposition Provide systematic support Define problem Facilitate growth Provide support Reeducate Examine alternatives Express and clarify emotional attitudes Develop a plan Resolve conflict and inconsistencies Obtain commitment Accept reality Follow-up Reorganize attitudes Maximize intellectual resources -------------------------------------------- ------------------------------- - **Client Functioning** ----------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------- **Long-Term Therapy Mode** **Crisis Case-Handling Mode** Affect Sufficient, some basis for experiencing and understanding emotional state Insufficient, impaired understanding of emotional state Cognition Some ability to understand connection between behaviour and consequences, rational vs irrational Inability to think logically, is irrational Behaviour Some control of self Client is out of control and poses danger to self or others ----------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------- - **Assessment** ----------------- ------------------------------------------------------------ ------------------------------------------------------------------ **Long-Term Therapy Mode** **Crisis Case-Handling Mode** Intake Data Client is able to provide info Client may not be able to provide info Safety Not primary focus Primary focus Time Therapist has enough time Crisis worker doesn't have enough time Reality testing Therapist assumes client is in touch with reality Crisis worker determines whether client is in touch with reality Referrals Implications for long-term development Implications of immediacy for client safety Consultation Available as needed Crisis worker mostly on their own Drug use Therapist relies on data from intake Crisis worker relies on verbal and visual responses Disposition Client starts and finishes with same therapist over months Client starts and stops with same worker over hours or days ----------------- ------------------------------------------------------------ ------------------------------------------------------------------ Case Handling at Walk-In Crisis Facilities - Chronic Crisis - Treatment of chronic mental illness falls on community mental health centres - Legal and political problems impact the mental health of marginalized people, leaving them to fend for themselves - Social/Environmental Crises - Treatment falls on mental health clinics, emergency rooms, agencies, centres, and police stations - E.g. abuse, substance misuse, unemployed, disabilities etc. - Combination of Types - Handling multiple crises with same client = rule rather than exception - E.g. Treating trauma survivor with addiction problems Case Handling at Community Mental Health Clinic - Entry - Client comes on their own, relatives, or agencies; assessment begins - Involuntary holds - IF client is chronically delulu and refuses to be sent to facility, involuntary hold order is issued (officer transports them) - Intake Interview - Occurs IF client is coherent enough to provide verbal and written info - Two critical components - Degree of client lethality - Drug use - Prescriber's Digital Reference (PDR) -- Physician's Desk References - Disposition - Proposed diagnosis and treatment recommendations - Short-term -- basic needs of living (short-term provisions) - Long-term -- comprehensive review of needs - Anchoring -- client not left alone - Psychological anchor -- real person who acts as advocate, support, and contact - 24 Hour Service -- Telephone connections - Mobile Crisis Teams (MCTs) -- Emergency psychiatric services - Two reasons - Home visits or provide services to older clients/clients with disabilities - Client out of control and unwilling/unable to go to clinic (workers go to client) - Crisis Resolution Team -- Specialized mental health team that provides rapid assessment and intensive treatment to individuals with severe mental illness in crisis Police and Crisis Intervention - Changing Role of Police - Instrumental crimes -- theft, robbery, assault - Expressive crimes -- individuals pose threat to themselves or others because of anger, fear, etc. - Police and People with Mental Health Crises - People with mental health issues first interact with police officer rather than crisis worker -- meaning JAIL RAHHHH - Crisis Intervention Team (CIT) -- trains patrol officers to deal with mentally ill and emotionally disturbed - The Concept -- collaborative efforts among police, mental health community, and consumer advocates to provide help to the mentally ill - CIT Training Using Mental Health Experts and Providers (topics covered): - Topics such as cultural awareness, substance misuse, legal stuff - Verbal defusing and de-escalation techniques - Open-ended and closed-ended questions - Owning statements - Client security - Officer and client safety - Crowd control - Reflection of feelings and thinking - Summary recapping rechniques - Fishbowl discussion with mental health patients - Patients state what they need during interviews - Success -- CIT concept is now international - Increased calls, reduced use of force - Co-respondent Teams -- police officer and mental health professional team up to handle crisis calls (e.g. COAST in Hamilton) - Advantages -- worker safety and consultation - Sequential Intercept Model (SIM) - Integration between criminal justice systems and mental health systems - Decriminalize mental illness contacts with police - 6 Justice Decision Points (Intercepts) - 0 - 0-point contact with emotionally disturbed - 1 - Co-responders make contact and de-escalate crisis - 2 - Court hearing occurs - 3 -- Adjudication to specialized courts - 4 -- Pre-release transition - 5 -- Follow-up by specialized community case managers - Suicide by Cop - People who want to kill themselves but don't have the courage gain attention of police 🡪 act in threatening manner 🡪 get themselves shot - Police are trained to recognize this through many indicators (I AINT LISTING ALL THEM TF) - Basically if they undergone any big life changes personally or socially OR if body language and/or communication is sus Transcrisis Handling in Long-Term Therapy - Anxiety reactions - When clients achieve something great but are impacted by a task that doesn't seem difficult 🡪 irrational fear of failure personally/socially 🡪 severe anxiety and flight response - Regression - Risk of taking next step in therapy = too overwhelming 🡪 Regress in behaviour - Problems of Termination - When clients reach therapy goals 🡪 may suddenly regress and produce problems for therapist - Help approximate client to termination - Crisis in Therapy Session - Be cool-headed and take a firm and directive stance as therapist - Psychotic Breaks - Stay calm and help client stay in contact with reality - People with Borderline Personality Disorder (BPD) - Might manipulate therapists for various reasons (e.g. avoiding engagement, testing therapist's credibility, etc.) - Mentalization -- field of therapy that targets childhood trauma and lack of attachment 🡪 contributing to BPD - BPD may be co-occurring with PTSD/C-PTSD - BPD Criteria -- **IMPULSIVE** - **I**mpulsiveness in two damaging areas - **M**ood instability with excessive mood swings - **P**aranoia or dissociation when under real or imagined stress - **U**nstable self-image - **L**abile, intense relationships ("I hate you, don't leave me") - **S**uicidal thinking, gestures and self-injury - **I**nappropriate anger beyond acceptable social boundaries - **V**ulnerability to abandonment - **E**mptiness and hopelessness - Presenting problems -- people with BPD have problems like no other client has (e.g. unusual combination of symptoms) - Therapeutic Relationship -- people with BPD attempt to turn therapeutic relationship upside down (e.g. misinterpretations of client's statements) to test therapist, but also crave attention - Important to set limits and boundaries as therapists Counselling Difficult Clients - Ground Rules for Counselling Difficult Clients - Therapists set ground rules at initial session (e.g. no violence + consequences) - Confronting Difficult Clients - Confrontation, assertion, and directive tactics Confidentiality in Crisis Case Handling - Confidentiality may not be possible when crisis occurs because: - Individual not comprehending informed consent, needing to tell their "story" without interruption, changing content, and environment of crisis (other people see) ### **Week 5 - Tyanna and Sabrina** #### Chapter 6: Telephone and Online Crisis Counselling **Case Handling on Telephone Crisis Lines** - Convenience - Client anonymity - Emotions can make face-to-face encounters with a stranger difficult - The ability to hide one's face can facilitate openness and freedom from inhibition - Control - The client decides when and if they want assistance - The client can terminate the conversation without fear - Immediacy of access - Cost effectiveness - Therapeutic effectiveness - Access to support systems - Avoidance of dependency issues - Worker anonymity - Availability of others for consultation - Availability of an array of services - Service to large and isolated geographic areas **Telephone Counselling Strategies** - The crisis worker is entirely dependent on the content, voice tone, pitch, speed, and emotional content of the client - Crisis workers depend on their verbal ability to stabilize clients and have little physical control over the crisis *Making Psychological Contact* - Making psychological contact is different than establishing rapport - Psychological contact: Creating a non-judgemental, caring, and empathetic relationship with the client asap; this creates credibility and gains the client's trust - Providing support comes first - Must be able to react in a calm and collected manner - The worker's response should not be deprecating, cynical, cajoling, or demeaning - Making initial contact means getting a name from the caller and and attempting to get one back *Defining the Problem* - Gain an understanding of the events that led to the crisis and by assess the client's coping mechanisms - Reflect the client's feelings because there is no way to garner visual cues - Open-ended questions *Ensuring Safety and Providing Support* - If the crisis worker detects the potential for physical injury, the strategy of Providing Protection may be used - Close-ended questions to gain information - "Do, have, and are" *Considering Alternatives and Making Plans* - Alternatives need to be explored in a slow, step-wise manner while assessing the client's capability *Obtaining Consent* - Simple, specific, and time-limited *Errors and Facilicies* - You are not there to be an expert - Talking about "it" will not cause "it" to happen - If you feel you're being manipulated, you probably are - Not all callers are good people - Delusion of fixed alternatives "If I can't find a solution there is no solution" "If I found a solution, this is the only solution" **Regular, Extremely Distressed, and Abusive Callers** - Chronic callers can devour the time and energy of staff, which legitimate callers may desperately need - They do not improve - All behaviour is purposive - Calls become part of their lifestyle and their methods of coping - "Regluar" is better to say than "chronic" - Set time limits for these callers *Understanding the Client's Regular Caller's Agenda* - Regular callers want affirmation that their problems are unsolveable; this causes them to dependent on the crisis line - Worker should not support this when it blocks process - They seem receptive of plans the crisis worker makes but does not follow through with them Chronic Callers and Mental Disorders: - Paranoid - Guarded, secretive, and jealous - Difficult to shake their persecutory beliefs - Focus is to stress their safety needs - Schizoid - Restricted emotional expression and experience - Feels self-conscious, anxious, and shy in social settings - Focus is to build a good sense of self-esteem - Schizotypical - Feelings of inadequcy and insecurity - Stange ideas, behaviours, and appearances - Foucs is to give them reality checks and promote self-awareness and more acceptable behaviour - Narsisstic - Grandoise, self centered, and believe that the have completely unique problems that no one understands - Always needs to be right - Focus on getting to see how their behaviour affects others while not engaging in "no-win" arguments - Histrionic - Move from crisis to crisis - Shallow depth of character and deeply ego-involved - Crave excitement then become quickly bored - Self-destructive, demanding, and manipulative - Focus is to rely on helpful sources from the past - Obessessive-Compulsive - Fixtated on tasks - Waste time and energy on said tasks - Focus is to build trust in others and the use of thought stopping behaviours and modification - Bipolar I - Extreme mood swings - May be aggressive to those who stop their plans or may be at risk for suicide when in a depressive state - Focus is to put a psychological governor or safety valve on their runaway behavior in a manic episode. However, confrontation about grand plans only alienates them - Suicide intervention is a primary priority - Bipolar II - Only hypomanic and major depressive episodes - Focus is to figure out a way to slow down hypomanic behaviour. During depressive episodes, attention should be given to suicidal ideations and behaviours - Dependent - Have trouble making decisions and seek other people to do so - Worthlessness, insecurity, fear of abandonment - Focus is to reinforce strengths and to act as a support without accepting responsibility of their lives - Self-Defeating - Usually choose people and situations that lead to disappointment, failure, and mistreatment by others - They reject attempts to help them - Focus is to highlight talents and consequences of sabotaging themselves - Avoidant - Little ability to maintain or establish social relationships - Fear of rejection - Focus is encouragement of successive approximations to relationships through social skills and assertion training - Passive-Aggressive - Cannot risk rejection by displaying anger - They believe control is more important than self-improvement - Focus is to promote more open and assertive behaviour - Borderline - May display any of the above mental disorders - "Borderline" of being functional and dysfunctional - One of the most challenging **Handling the Extremely Distressed Caller** (SRDKMAA) - They represent a variety of mental illnesses - Not uncommon for behaviours to be fueled by drugs - These people are distanced from reality and threatening 1\. Behavior is always **purposeful** and serves motives that may be either conscious or unconscious 2\. Behavior is **comprehensible** and has meaning even though the language used may not 3\. Behavior is **characteristic** and consistent with personality even though it is exaggerated 4\. Behavior is used to keep a person **safe** and free of anxiety *Slow Emotions Down* - Don't uncover these feelings - They may besieged by too many feelings and need to get them under control - Focus on here and now issues - Don't bring up more feelings with open ended questions - They may become more out of control and it may be hard to manage - Use calm interventions that allow a person to order their thinking - Slow emotions down and reestablish control - Feelings are not the focus of attention - Closed questions are encouraged *Refuse to Share Hallucinations and Delusions* - Never side with psychotic ideation - Grandoise thinking should never be denied - I.e. "It's pretty clear you really believe the CIA is listening to you. When did this start?" - The worker affirms the delusion is real without agreeing to its veracity - Ask "when" questions to elicit information and gain a scope and extent of paranoia. Do not ask "why" questions for it may result in defensiveness *Determine Medicine Usage* - Obtain information about the use of any medication, the amount and time of dosage, and the stopping of medication without consultation - Ask about medication being added recently - This provides a better idea of the mental disturbance being treated - The worker should try to get them to their physician *Keep Expectations Realistic* - Confronting the problem directly will generally determine whether the caller is lonely or needs immediate assistance *Maintain Professional Distance* - When difficult feelings emerge, it is important for workers to make owning statements about these feelings and get supervision or pass the line to another worker - Countertransference is not uncommon, and disturbed callers can sometimes unearth the worker's own hidden agendas and insecurities *Avoid Placating* - Placating and sympathizing do little to bolster the caller's confidence or to help move the client toward action - I.e (inappropriately sympathetic) "From all you've told me, you've had a really rocky road. Nobody should have to suffer what you have, but things can only look up" (the way I would say something similar LMAO I SUCK) - Empathetically respond, explore past feelings, and coping skills *Asses Lethality* - Default area of inquiry - Regular callers in particular should be assessed for sucidal and homicidal ideation because they may feel the need to "prove" that they need help - Assessing lethality is a preventative measure - Puts distance between their thoughts and the actions that might result from lethal thoughts - Don't ever give out your full name, personal information, or agree to meet with a caller **Other Problem Callers** *Rappers (1 2 3 Disequilibrium Division REPRESENT IMMOBILITY homies* *we are in crisis)* - Talk with no pressing issues - Allow some leeway to approach issues but also confront their loneliness *Third Party Callers* - Calls on the behalf of someone - \(1) gather enough information to gauge the **safety** and risk of the suicidal person, (2) obtain contact and **identification**, if possible, (3) **coach** the caller on helping the person, (4) attempt to **reach out** to the person, and (5) contact **911 if the risk is imminent** or other solutions are not possible *Covert Callers* - Some callers who call for help for an individual may be referring to themselves - Assume the call is about the caller but never try to prove so - Other reactions: - "Oh, I thought this was a recording." -Affirm that it is not - -"You must be really crazy to work there. I'll bet there are some real nuts who call up." - Avoid the "test" and respond empathically: "I wonder if you're concerned that calls are handled seriously here?" - Intellectual types tend to be know-it-alls. They always "win" but are very insecure and unsure of themselves. Immediately let them defeat you. "You're right. I am a volunteer here, and I don't know as much as you do about bipolar disorder. What I do know is you sound pretty concerned about it and seem to be looking for some help." - Other callers may call and be silent or say they have the wrong number. There are no wrong numbers. "May I help you?" or "What number were you calling?" are default responses to "wrong numbers" *Pranksters or Nuisance Callers* - If the prank is treated seriously they will probably not call back or they will hang up. If you hang up, they will call back - Don't see it as a prank *Silent Callers* - Ambivalent - Don't hang up, demonstrate acceptance, and remove any barrier from communication - If there is still no response, after a minute or so you could say, "I guess it is difficult to talk about this right now. I'll stay on the line for another minute, and then I'll have to go to another call. Call back when you feel ready to talk." *Manipulators* - Questioning the worker's ability, role reversal in which the worker is tricked into sharing details of their personal life, and harassment. - Redirect manipulation and focus on unmet needs to uncover reasons for their manipulative behaviour *Sexually Explicit Callers* - Their primary purpose is to masturbate while talking to someone (freaky ass) - Switch the caller to someone of the opposite sex and reframe the call to put a damper on their mood *Callers with Legitimate Sexual Problems* - Must have education about sexual concerns and training on what to do with legal/ethical issues - In most cases the worker should not use their opinion to sway the caller, but sometimes the caller needs information that the worker can provide - Fine line between a worker's own biases and needed information **Handling Problem Callers** (OTTSCA) *Pose Open-ended Questions* - Can help defuse the problems generated by frustrated callers *Set Time Limits* - If attempts to refocus the problem are futile, then set a time limit *Terminate Abuse* - When behaviour of the caller escalates to abuse, the call should be terminated in a clear and firm manner *Switch Workers* - Switching the call to another worker not the same gender - If another worker is not available, transfer it to a supervisor - Sexually explicit callers often externalize their fantasies by reporting some hypothetical significant other's problem in florid detail - The worker should interpret the behaviour as the caller's own and make the switch *Use Covert Modelling* - The client is asked to use mental imagery to picture either reinforcing or extinguishing a particular behavior *Formulate Administrative Rules* **Hotlines** - Telephone is the most used method of suicide intervention *Time-limited Hotlines* - It is typically used to deal with a specific problem or to engage a special client population *Specialized Hotlines* - Deals with specific topics - Provides crisis intervention by volunteers or professionals with an understanding and knowledge of the topic **Tele-behavioural Health Growing Role in Crisis Intervention** *Video Conferencing* - Major concern is **confidentiality** regarding the platform and physical location the crisis worker uses - Second issue with **making contact** and observing an individual's reactions - Limitations of the camera - Third issue is **assessing** a person in crisis-more or other questions may be needed *Texting* - Boundaries *Mobile Apps* - Provide support, provide guidance, and encourage mobilization *Chat Rooms (I JUST GOT YOUR MESSAGES)* - Used for different types of crises - Helping individuals access chat rooms provides support, guidance, and mobilization *Email* - Asynchronous and may not be the best method for someone in crisis *Social Media* - Researchers found that when messages suggesting suicidal ideations were responded to by trained volunteers, a decrease in the ideation was experienced *Artifical Intelligence* - AI has many advantages, such as being more attentive and being available 24/7, which is an advantage in crisis intervention - Needs more research *Virtual Reality* - Many computer programs perform assessment and self-help psychoeducational/ therapeutic functions - Reduce negative behaviour or promote positive behaviour change - High level of acceptance by clients and outcomes are comparable to face-to-face therapy **Appeal of Online Counselling** *Feedback* - Periodic texting through mobile apps can serve this function. Once emotional control has been reestablished, asynchronous emails can be sent to check on the client *Disinhibition* - Disinhibition effect: People tend to open up more in e-therapy in comparison to in-person therapy - May due to the absence of visual cues or not needing to look the therapist in the eye - Depersonalization and distance seem to make it safer to share intimate information **Problems of Legal and Ethical Issues in Tele-behavioural Health** *Legal and Ethical Issues* - Using techology can put confidentiality at risk as well as duty to warn - No guarantees when using public internet - Hackers *Charlatans* - High fees and questionable claims - May put themselves at risk of secondary traumatization by using sketchy services *Technology Failure* - Always a concern - Have alternative plans to reestablish communication *Licensing and Insurance* - Have to consider ethical standards of your organization *Technological Competence* - Competent at identifying misleading websites, phishing emails, etc *Learning the Language* - Helps avoid misunderstandings and miscommunication - Netiquette: Civil and appropriate rules of discourse when operating on the internet **Netiquette** - Conflict occurs more online than in-person **Predispositioning/ Making Contact** - Miscommunication can occur due to the inability to see body language, voice intonation, or rate of speech through text and email; Chatrooms have all expect body language; Video conferencing has limited body language - Important to let the client know how crisis intervention works on each type of technology - Cultural awareness: Includes your culture and the client's culture and the culture of communicating via technology #### #### Chapter 7: Telephone and Online Crisis Counselling **Mobile Crisis Response** - Mobile Crisis Rapid Response - COAST - Situation Tables - Toronto Community Crisis Service (TCCS) - Dispatches trained teams of crisis workers to response to people experience a MH crisis **Telephone Counselling and Online Counselling** - Convenience - Client Anonymity - Control - Immediacy of Access - Cost Effectiveness - Therapeutic Effectiveness - Access to Support Systems - Avoidance of Dependency Issues - Worker Anonymity - Availability of Others for Consultation - Availability of Array of Services - Service to Large and Isolated Areas and Population [Appeal of Online Counselling] - Beneficial for people from all locations ex. Cannot travel for services, convenience - Regular feedback given - Disinhibition - Orientation towards immediate gratification → impulsive behaviour driven by current thoughts, feelings, external stimuli without regard for past learning, consideration or future consequences [Strategies:] - Making Psychological Contact - Defining the Problem - Ensuring Safety and Providing Support - Considering Alternatives and Making Plans - Obtaining Commitment [Hotlines] - First established in 1906 by National Save-a-Life (998) - Often deal with distress calls, fueled by either anger, frustration, crisis, other - Rules: - Slow emotions down - Refuse to share hallucinations and delusions - Determine Medication usage - Keep expectations realistic - Maintain professional distance - Avoid placating - Assess lethality - "Problem Callers" - Pose open-ended questions - Set time limits - Terminate abuse - Switch workers - Use covert modeling [Legal and Ethical Issues] ![](media/image4.png) **PTSD (Post Traumatic Stress Disorder)** "Mental health condition triggered by experiencing or witnessing a terrifying event, characterized by flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event" - Can be catalyst for other crisis - Suicide, partner violence, substance misuse - Sexual assault & partner violence can lead to PTSD - Can co-exist with other comorbid problems - Early PTSD-like symptoms in late 19th-20th cen. linked to railway accidents → *railway spine* - Synonymous term "compensation neurosis" - Frontline workers in Healthcare experience PTSD due to pandemic [Diagnostic Criteria] - Exposure - Intrusive Thoughts - Avoidance - Mood Alteration - Hyperarousal **Complex PTSD** - Recognized in the ICD 11 BUT NOT in DSM5-TR - Results from repeated exposure to traumatic situations, usually involving personal victimization during key developmental stages - Somatization → physical problems, associated pain, functional limitations - Dissociation → personality division into functioning & trauma regressed components - Affect Dysregulation → changes in impulse, awareness, self-view, and relational perceptions [Key Psychological Response and Challenges in PTSD] - Intrusive-Repetitive Ideation - Denial/Numbing - Increased Nervous Symptom Arousal - Dissociation - Social Support **PTSD and Crisis Intervention** - Emergency Outcry phase - Emotional Numbing and Denial Phase - Intrusive-Repetitive Phase - Reflection-Transition Phase - Integration Phase **Maladaptive Patterns Characteristic of PTSD** - Death Imprint - Survivors Guilt - Desensitization - Estrangement - Emotional Enmeshment **Assessment** 1. Are symptoms of PTSD present? 2. Assess for prior trauma when presenting problem is substance abuse 3. Consider the ability to control affect 4. Physical, temporary and political climates may have great deal to do with how event is interpreted **ASD (Acute Stress Disorder)** "Condition characterized by severe stress symptoms that occur immediately after a traumatic event, called peritraumatic symptoms, can be a precursor to PTSD" - Diagnosed when traumatic stress symptoms persist for 3-30 days post-event → dissociative symptoms - Immediate intervention crucial - Higher rates in severe trauma ex. rape **Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)** - Phase-based therapy effective for various trauma - Designed for children 3-18, adaptable - Short term → PRACTICE: - Psychoeducation - Relaxation - Affective expression - Cognitive coping - Trauma narration - In vivo mastery - Conjoint sessions - Enhancing safety **Group Treatment** - Preventative Groups - Structured Therapy Groups - Long-term Support Groups **Family Treatment** - Involves addressing stress disorder in the individual and related family dysfunctions - Assesses willingness to change, resolve pre-existing or trauma-induced dysfunctions **Childhood Trauma** +-----------------------------------+-----------------------------------+ | **Type I Trauma** | **Type II Trauma** | | | | | - Fully detailed, etched-in | - Results in developing | | memories | defensive and coping | | | strategies to ward off the | | - Retrospective rumination | repeated assaults on | | | integrity | | - Cognitive reappraisals | | | | - Exhibit massive denial, | | - Mistiming of event | psychic numbing, avoidance of | | | psychological intimacy | | - Foreshortened future | | | | - Deep-seated rage | | - Reenactment | | | | - Aggression | | - Physical responses | | | | - Emotional distancing in | | - Displacement | adulthood | | | | | - Transposition | | +-----------------------------------+-----------------------------------+ ###

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