Assessment for crisis intervention a triage assessment model

Assessment for Crisis Intervention �

Rick A. Myer Duquesne University

�

Christian Conte University of Nevada, Reno

This article describes the triage assessment system (TAS) for crisis interven- tion. The TAS assesses affective, behavioral, and cognitive reactions of indi- viduals to crisis events. This assessment model offers clinicians an understanding of the type of reactions clients are experiencing as well as the intensity of these reactions. The TAS provides a quick, accurate, and easy-to- use method that is directly usable in the intervention process. The system can also be used to monitor clients’ progress during the intervention pro- cess. Two case illustrations are presented to demonstrate the use of the model. In addition, the Triage Assessment Form: Crisis Intervention is included as an Appendix. © 2006 Wiley Periodicals, Inc. J Clin Psychol: In Session 62: 959–970, 2006.

Keywords: crisis intervention; psychotherapy; trauma; assessment

Effective crisis intervention is dependent on accurate assessment that directly translates into focusing treatment when it is needed. This assessment should give clinicians the information required to answer questions such as the following: What resources are needed for this client to resolve the crisis situation? What approach will be the most effective for the client at this time? Does the client need to be hospitalized? What support from family, friends, or community agencies is needed? Is the client contemplating committing suicide or harming someone else? Answering these questions requires that assessment of clients in crisis be ongoing, and that reactions be monitored in order to adjust the intervention as needed. Simple reliance on diagnostic models, standardized tests, or intake protocols can mislead clinicians in these situations (Hoff, 1995; Myer, 2001). A model specifically designed for crises is needed to guide the assessment process.

Correspondence concerning this article should be addressed to: Rick A. Myer, Ph.D., Associate Professor, Department of Counseling, Psychology, and Special Education, Duquesne University, 600 Forbes Avenue, Pittsburgh, PA 15282; e-mail: myerra@duq.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 62(8), 959–970 (2006) © 2006 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20282

Triage Assessment System

The triage assessment system (TAS) for crisis intervention (Myer, Williams, Ottens, & Schmidt, 1992a) provides a framework for understanding clients’ reactions during a cri- sis. This model integrates research from a variety of sources and presumes that reactions to crisis events are seen in three domains: (1) affective, (2) behavioral, and (3) cognitive. Clinicians assess clients’ reactions along all three domains. This point is critical because failure to assess each domain can result in a collapse in the resolution of the crisis and lead to additional problems (James & Gilliland, 2005). The TAS guides clinicians in the identification of the complex interaction among the three domains and helps prevent protracted mental health concerns.

The TAS uses Crow’s (1977) work on emotions associated with crises and research on primary emotions (National Advisory Health Council, 1995; Plutchick, 1980) as the foundation for identifying affective reactions clients experience when in crisis. These reactions are (1) anger/hostility, (2) anxiety/fear, and (3) sadness/melancholy. The expres- sion of these feelings can range from negligible to extremely severe; however, uncom- fortable levels of emotions are more characteristic reactions of people who are experiencing a crisis (Baldwin, 1979).

Assessing clients’emotional reactions is generally straightforward. It is relatively uncom- plicated to determine whether clients are angry, afraid, or sad. However, often clients express a combination of these feelings, bouncing from one to another and back again. We suggest that determining the emotion most frequently expressed identifies the primary affective reac- tion. If others are present, these are considered as secondary or tertiary.

Clients’ behavioral reactions can be assessed as (1) immobility, (2) avoidance, and (3) approach (Myer, Williams, Ottens, & Schimdt, 1992a). Immobility is defined as being stuck, or unable to sustain any consistent attempt to resolve the crisis. Avoidance is defined as an active attempt to escape or bypass problems associated with the crisis. In contrast, approach reactions are those that are active attempts to resolve problems result- ing from the crisis.

In the cognitive domains, reactions are (1) transgression, (2) threat, and (3) loss. Transgression is seen as a “demeaning offense against me and mine” (Lazarus, 1993, p. 26). The perception of the event is that it is happening primarily in the present. Threat, on the other hand, is viewed as potential, that is, something that will occur in the future. The perception is that an impending catastrophe is approaching. The perception of loss is that it occurred in the past and is irrevocable. Clients’ perceptions, whether accurate or not, are used in the assessment of cognitive reactions. The areas of clients’ lives that are perceived to be affected by the crisis include (1) physical, such as health, shelter, safety; (2) psychological/self-concept, such as identity and emotional well-being; (3) social rela- tionships, such as with family, friends, coworkers; and (4) moral/spiritual, such as per- sonal integrity, values, and belief system. Clients can perceive a transgression, threat, or loss in each of these life dimensions.

The TAS has been operationalized through the development of the Triage Assess- ment Form: Crisis Intervention (Myer, Williams, Ottens, & Schmidt, 1992b). The Appen- dix contains a copy of the form. This form adds a severity scale to each domain that allows crisis workers to rate the severity of clients’ reactions in each domain.

Reactions are rated on a scale of 1 to 10 with 10 the most severe reaction. A “rule out” process is the most efficient strategy to determine the severity of each reaction. We suggest beginning with 10 and going down the scale until finding a characteristic that meets the severity of reaction in that domain. This strategy of ruling out characteristics is the most rapid and accurate way to assess severity.

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Journal of Clinical Psychology: In Session DOI 10.1002/jclp

Initially, treatment should address the most severe reaction, permitting clinicians to address salient needs in a manner appropriate to the severity of the reactions. As the severity of the reaction varies throughout the crisis event and treatment, clinicians should adjust the treatment to meet clients’ needs. By totaling the severity scales, crisis workers can also judge how intense and directive the treatment should be: the higher the score, the more direct the intervention. Generally speaking, low scores (3–12) indicate a recom- mendation for no treatment or a nondirective approach. Clients whose total on the sever- ity scales is in this range may simply need a sounding board to resolve the crisis. Clients whose total on the severity scales is in the middle range (13–23) need clinicians to part- ner with them to help resolve the crisis. This approach is more collaborative, requiring clinicians to be more active. When clients’ total score on the severity scales is high (24–30), a direct approach is needed. Clients in this range are vulnerable and need a support system. Clinicians will be extremely active and engage in active problem solving with clients. If any severity scale score is 10, hospitalization is strongly recommended.

Case 1

The case of Ann involves a crisis in which she was coping with her apartment’s being burglarized. Ann was referred to the clinician by a friend, Gail, who was worried that she might need help in dealing with the burglary. Because our article concerns assessment, we report on the first 15 minutes of the interview. The setting is an urban agency that helps people who have been victims of a crime.

Client Description

Ann is a 26-year-old white female. With her was Gail, the friend who referred her to the agency. Ann insisted that Gail stay with her during the session. Ann continually looked around the room. On the intake form, Ann had indicated that she worked as a sales representative in a local business. She also reported that she was not on any medication and had not received any mental health services in the past. She identified having diffi- culty in concentrating and some trouble in sleeping. In addition, Ann reported being angry much of the time. She reported that these problems began the day after the bur- glary, which took place 8 days before.

During the first few minutes of the session, Gail blurted out that Ann was making statements that were crazy. Following up on this disclosure, the clinician discovered that Ann had been planning to get revenge on the person who burglarized her apart- ment. As Ann continued to talk she stated that she knew her former boyfriend had broken into the apartment. She repeatedly stated that she hated him for what he had done. As the session continued, the clinician discovered that Ann’s boyfriend had been verbally and psychologically abusive during their 9-month relationship and that Ann had broken up with him about 1 week before the burglary. Ann stated that although she did not have any proof, she “knew” he was the only one who would have broken into her apartment. When questioned about her thoughts of reprisal, Ann admitted she wanted to make his life the hell he had made hers but was not specific beyond that. Ann stated that she did not want to harm him physically, but just spread lies about him to his friends. Ann wanted to say things such as they broke up because he is gay and has acquired immunodeficiency syndrome or that he was unable to perform sexually. Add- ing to Ann’s anger was that when she reported the break-in to the police they said an investigation would be done but not to count on any conclusive resolution. At that time,

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Gail chimed in, stating that she had told Ann repeatedly to be cool, but that was becom- ing increasingly difficult.

Case Formulation

The crisis event in Ann’s case was the burglarizing of her apartment, allegedly by her former boyfriend; however, there was no proof for her belief. The crisis was complicated by the fact that Ann had lingering anger toward the boyfriend, who had apparently been abusive in the past. Sorting through the anger became the focus of treatment as the clinician worked to help Ann understand her feelings and not let them be the catalyst for taking action that would only result in more problems.