Crisis intervention strategies 8th edition pdf

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Crisis Intervention Strategies Eighth Edition

Richard K. James University of Memphis

Burl E. Gilliland Professor Emeritus, University of Memphis

Australia Brazil Mexico Singapore United Kingdom United States

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Printed in the United States of America Print Number: 01 Print Year: 2016

© 2017, 2013, Cengage Learning

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WCN: 02-200-203

In the spring of 2015, I was honored by my undergraduate and master’s degree alma mater,

Eastern Illinois University, with a lifetime achievement award. In my acceptance speech, I spoke

to the writing, research, and service paths that led to that award. But I also spoke to something

much more important than those “things” I did. Indeed, it is what I believe has been my greatest

achievement in 50 years of doing counseling and teaching and is best represented by two people

who attended that ceremony. I would like to introduce them to you now and say why this book is

dedicated to them.

First is Steve Allen, Ed.S., who was an intern of mine in 1973–74 in the Title III ESEA

Intensive Care Unit innovative education program for socially and emotionally maladjusted

children in Mattoon, Illinois. Of the roughly hundred interns I have supervised, Steve was the

best. Steve went on to become a world class K–12 school counselor in rural east-central Newman,

Illinois. He garnered enough well deserved honors and recognition over the course of his career to

also be recognized by Eastern Illinois University as a lifetime achievement recipient for the work

he has done in innovative teaching, counseling, and educational practices.

The second person is Kay Dorner, Ph.D., who was a junior high school student I counseled in

Mattoon, Illinois, in 1968. Kay has had a distinguished career as a psychologist in private prac-

tice and as an administrator in high schools in California and Oregon. Among her noteworthy

achievements has been the principalship of a Bill and Melinda Gates small school grant to estab-

lish Technology High School in Rohnert Park, California. She is presently working as a school

psychologist in Central Point, Oregon.

But those are not the reasons this eighth edition is dedicated to these two outstanding therapists

and educators. The real reason is that both of these individuals have fought through many of the

crises’ snares and traps in this book that could have easily defeated them. Put in life’s furnace and

fired, they came out tempered steel. Many in their place would have turned to cinders and burned

up. Neither Steve nor Kay did and, in fact, they grew stronger from the adversity they have faced.

I am honored and humbled that both of these fine people believe that I have had some influ-

ence on their lives by counseling and teaching them. Both of them have felt indebted to me, but it is

really I who am indebted to them for what they have become and I have become with them. They

have repaid the debt they felt they owned me for that counseling and teaching back in the 1960s and

1970s over and over with the many lives they have touched and changed for the better. They are my

legacy and best epitaph. They have, indeed, paid it forward.

My fervent hope for any of you neophytes starting out in this business is that you can also mani-

fest the sterling character, strength, compassion, skills, resiliency, and empathy that these two pro-

fessional human services workers possess and continue to pay forward in 2015. If this book helps

you in some way to do that, then I have done my job.

Dick James

Professor of Counselor Education

University of Memphis

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Brief Contents

1 Basic Training: Crisis Intervention Theory and Application 01 1 Approaching Crisis Intervention 03 2 Culturally Effective Helping in Crisis 27 3 The Intervention and Assessment Models 48 4 The Tools of the Trade 73 5 Crisis Case Handling 96 6 Telephone and Online Crisis Counseling 116

2 Handling Specific Crises: Going Into the Trenches 143 7 Posttraumatic Stress Disorder 145 8 Crisis of Lethality 203 9 Sexual Assault 240

10 Partner Violence 286 11 Family Crisis Intervention 331 12 Personal Loss: Bereavement and Grief 373 13 Crises in Schools 429

3 On the Home Front: Crisis in the Human Services Workplace 481 14 Violent Behavior in Institutions 483 15 Legal and Ethical Issues on Crisis of Trauma 518 16 Human Services Workers in Crisis: Burnout, Vicarious Traumatization,

and Compassion Fatigue 546

4 No Man’s Land: Facing Disaster 577 17 Disaster Response 579

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v

Contents

CHAPTER 1 Approaching Crisis Intervention 3 A Brief History of Crisis Intervention 3

Grassroots Movements 5 The Importance of Volunteerism 6 The Need for Institutionalism 6 The Media and the Societal Impetus

for Crisis Intervention 7 The Case Against Too Much “Helping” 8

Definitions of Crisis 8 Individual Crisis Definitions 9 Behavioral Emergencies 9 Systemic Crisis Definitions 10 Metastasizing Crisis 11

Characteristics of Crisis 11 Transcrisis States 12

Transcrisis Differentiated From Posttraumatic Stress Disorder 13

Transcrisis Points 13 Theories of Crisis and Crisis

Intervention 14 Basic Crisis Intervention Theory 14 Expanded Crisis Theory 15 Applied Crisis Theory 18

Crisis Intervention Models 19 The Equilibrium Model 19 The Cognitive Model 19 The Psychosocial Transition Model 19 The Developmental-Ecological Model 20 The Contextual-Ecological Model 20 Psychological First Aid 20 The ACT Model 22 Playbook/Game Plan Model 22 Eclectic/Integrated Crisis

Intervention Theory 22

Characteristics of Effective Crisis Workers 23 Life Experiences 23 Personal Characteristics 24

Rewards 25 Summary 25

CHAPTER 2 Culturally Effective Helping in Crisis 27 Multicultural Perspectives in Crisis

Intervention 27 Core Multicultural Attributes 28 Culturally Biased Assumptions 29 Universal Versus Focused Views 30 Working on the Individualist/Collectivist–High/

Low-Context Continuum 30 Emic Versus Etic Models

of Multiculturalism 33 Awareness of Both Ecology and Multicultural

Competencies 36 Shortcomings of a Multiculturalist

Approach to Crisis Intervention 38 Culturally Effective Helping During a Crisis 39

Positive Aspects of an Effective Multicultural Counselor 40

When in Rome, Italy . . . or Georgia 41 Language Barriers 42 Religion and Spirituality 42 Support Systems 43 Occupation as a Cultural Barrier 44 Geographic Locale as a Cultural Barrier 45 The Dilemma of Local Consultation 45 The Necessity of Acting 46 Training 46 Where It Stands Now . . . Sorta 47

Summary 47

1 Basic Training: Crisis Intervention Theory and Application 01

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CHAPTER 3 The Intervention and Assessment Models 48 Introduction 48 A Hybrid Model of Crisis Intervention 49

Task 1. Predispositioning/Engaging/Initiating Contact 50

Task 2. Problem Exploration: Defining the Crisis 51

Task 3. Providing Support 52 Default Task: Safety 53 Task 4. Examining Alternatives 54 Task 5. Planning in Order to Reestablish

Control 55 Task 6. Obtaining Commitment 56 Task 7. Follow-up 56

Assessment in Crisis Intervention 58 Assessing the Severity of Crisis 58 The ABCs of Assessing in Crisis

Intervention 58 The Triage Assessment System 59 The Triage Assessment Form 59 Alternate Forms of the TAF 67 Psychobiological Assessment 68 Assessing the Client’s Current Emotional

Functioning 69 Assessing Alternatives, Coping Mechanisms,

and Support Systems 71 Assessing for Suicide/Homicide Potential 71

Summary 71

CHAPTER 4 The Tools of the Trade 73 Introduction 73 Listening in Crisis Intervention 73

Open-Ended Questions 73 Closed-Ended Questions 74 Restatement and Summary

Clarification 74 Owning Feelings 75 Facilitative Listening 78

Basic Strategies of Crisis Intervention 79 Climate of Client Growth 82

Communicating Empathy 82 Communicating Genuineness 85 Communicating Acceptance 86 In the Field 87

Acting in Crisis Intervention 88 Directive Intervention 89 Collaborative Counseling 90 Nondirective Counseling 90

Action Strategies for Crisis Workers 91 Summary 95

CHAPTER 5 Crisis Case Handling 96 Handling Crisis Cases Versus Long-Term

Cases 96 Case Handling at Walk-In Crisis Facilities 97

Types of Presenting Crises 97 Case Handling at a Community Mental Health

Clinic 100 Police and Crisis Intervention 102

Changing Role of the Police 102 Police and the Mentally Ill/

Mentally Disturbed 102 The Crisis Intervention Team (CIT) Program 103

Transcrisis Handling in Long-Term Therapy 107 Anxiety Reactions 107 Regression 108 Problems of Termination 108 Crisis in the Therapy Session 109 Psychotic Breaks 109 People With Borderline Personality

Disorder 110 Counseling Difficult Clients 113

Ground Rules for Counseling Difficult Clients 113

Confronting Difficult Clients 114 Confidentiality in Case Handling 114 Summary 114

CHAPTER 6 Telephone and Online Crisis Counseling 116 Introduction 116 Case Handling on Telephone

Crisis Lines 117 Telephone Counseling

Strategies 119 Making Psychological Contact 119 Defining the Problem 120 Ensuring Safety and Providing Support 121 Looking at Alternatives and Making Plans 121 Obtaining Commitment 122 Errors and Fallacies 122

Regular, Severely Disturbed, and Abusive Callers 123 Understanding the Regular Caller’s Agenda 124 Handling the Severely

Disturbed Caller 126

vi ■ CONTENTS

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2 Handling Specific Crises: Going Into the Trenches 143

Other Problem Callers 129 Handling the Problem Callers 131

Hotlines 132 The Internet’s Growing Role

in Crisis Intervention 134 Behavioral Telehealth 134

The Appeal of Online Counseling 135 Problems of Online Counseling 136 Netiquette 137

Predispositioning 137 Texting 140 Virtual Reality 140 Need for Training 141

Legal, Ethical, and Moral Issues of Telephone and Internet Counseling 141

Does It Work? 141 Summary 142

CHAPTER 7 Posttraumatic Stress Disorder 145 Introduction 145 Background 146 Dynamics of PTSD 148

Diagnostic Categorization 148 Complex PTSD 150 Conflicting Diagnoses 151 The Question of Preexisting

Psychopathology 151 Neurophysiological Responses 152 Affective-State-Dependent Retention 153 Children and Neuropathology 153

Incidence, Impact, and Trauma Type 153 Incidence 153 Residual Impact 154 Importance of Trauma Type 154 Vietnam: The Archetype 155 Intrusive-Repetitive Ideation 159 Denial/Numbing 159 Increased Nervous Symptom Arousal 160 Dissociation 160 Social Supports 161

Maladaptive Patterns Characteristic of PTSD 162

The Traumatic Wake of Iraq and Afghanistan 163 The Comprehensive Solider Fitness Program 164

Components of Treatment for Adults 165 Assessment 165 Phases of Recovery 170 Importance of Acceptance 171 Risks of Treatment 172 Multiphasic/Multimodal Treatment 173

Psychotropic Medication 176 Individual Intervention Stages 176

Emergency/Outcry 176 Extinguishing Intrusive Images 177 Numbing/Denial 177 Reflection and Transition 179 Integration 181

Group Treatment 181 Support Groups 181 The Life Adjustment Group 187 Family Treatment 188

Eye Movement Desensitization and Reprocessing (EMDR) 189 The Controversy Over EMDR 189 EMDR Therapy 190

Children and PTSD 192 Diagnostic Criteria for Children 192 Support Systems 194 Types of Trauma 194 Etched Memories 195 Developmental Issues 195 Other Responses to Type I Trauma 196 Type II Traumas 197 Intervention Strategies 197 Therapy 198

Moving Beyond the Trauma 200 Summary 201

CHAPTER 8 Crisis of Lethality 203 Background 203

The Scope of the Suicide Crisis 203 Suicide and the Moral Dilemma 204

The Dynamics of Suicide 206 Psychological Theories 206 Sociological Theory 207

CONTENTS ■ vii

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Interpersonal Theory 207 Existential-Constructivist Framework 207 Other Explanations 208 Characteristics of People Who Commit

Suicide 209 Similarities Between Suicide and Homicide 210 Analyzing Suicide/Homicide Notes/Videos 210

Myths About Suicide 211 Assessment 213

Suicide Clues 213 Assessment Instruments 214 Clinical Interview 215 Using the Triage Assessment Form

in Addressing Lethality 216 Intervention Strategies 218

The Three I’s 218 Older Adults 229 Guidelines for Family, Friends,

and Associates 232 The Psychological Autopsy 234 Postvention 235

Losing a Client to Suicide 238 Summary 239

CHAPTER 9 Sexual Assault 240 The Scope of the Problem 240

Underreporting 241 Defining Rape: The Unique Situation

of Sexual Abuse/Rape Survivors 241 The Dynamics of Rape 242

Social/Cultural Factors 242 Personal and Psychological Factors 242 Myths About Rape 243

Date and Acquaintance Rape 246 Date Rape Risk 246 Preventing Date, Acquaintance, and Other

Forms of Rape 247 Intervention Strategies for Rape and

Battery: The Case of Melody 248 Immediate Aftermath 248 The Following Three Months 253

Adult Survivors of Childhood Sexual Abuse 255 Psychological Trauma and Sequelae 255 False Memories 256

Intervention Strategies for Adult Survivors: The Case of Heather 257 Assessment 257

Treatment of Adults 259 Discovery and Admission 259 Grounding 260 Validation 262 Extinguishing Trauma 262 Prolonged Exposure/Cognitive

Restructuring 263 Grief Resolution 264 Support Groups for Adult Survivors 266

Sexual Abuse in Childhood 266 Dynamics of Sexual Abuse in Childhood 267 Dynamics of Sexual Abuse in Families 268 Phases of Child Sexual Abuse 270

Intervention Strategies With Children 271 Assessment 271 Therapeutic Options 272 Need for Affirmation and Safety 273 Regaining a Sense of Control 273 Education 274 Assertiveness Training 274

Intervention Strategies for Child Sexual Abuse: The Case of Elizabeth 274 Disclosure 275 Immediate Aftermath 275

Prosecuting the Perpetrator 277 Interviewing the Child 277 Preparing the Child for Testimony 278 Aftermath 279

Counseling 279 Group Counseling 279 Boundary Issues 280 Group Support Work With Nonoffending

Parents 280 Preventing Revictimization 281 Individual Counseling 281

Summary 284

CHAPTER 10 Partner Violence 286 Introduction 286 The Incidence of Partner Violence 287 Emerging Approaches to Partner

Violence 288 Dynamics of Partner Violence 290

Psychosocial and Cultural Dynamics 290 Psychological Factors 293 Stressors 294 Myths About Battering 295 Profiling the Batterer 296

viii ■ CONTENTS

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The Cycle of Violence 297 Realities for Abused Women 297

Intervention Strategies 298 Assessment 298 Components of Intervention 301

Shelters 308 Counseling Women at Shelters 308 Follow-Up 312

Intervention With Children 312 Courtship Violence 314

Stalking 315 Gay and Lesbian Violence 317

Prevalence of Violence 317 Complicating Factors 317 Crisis Intervention Involving Gay

and Lesbian Violence 318 Treating Batterers 319

Intervention Models 320 Hybrid Models 321 Treatment Goals 321 Assessment 322 The Intake Interview 322 Motivation 323 A Typical 24-Session Domestic Violence

Reduction Group 323 Program Success 328

Summary 329

CHAPTER 11 Family Crisis Intervention 331 Introduction 331 Definition of Family Crisis 332 Transcrisis 334 Research on Family Crisis 335

Medical Crises 335 Disaster Recovery 335

Family Crisis Models 336 Types of Crisis Families Encounter 338 Dynamics of Family Intervention 340 Case Vignette 344 Hybrid Model Applied to Families 345 Stages of Family Resolution of Crises 362 Cultural Issues 371 Summary 371

CHAPTER 12 Personal Loss: Bereavement and Grief 373 Introduction 373

Terms Critical to Understanding Loss 375 Dynamics of Bereavement 377

Cultural Dynamics 377 Sociocultural Mores 378 Spirituality and Religion 379

Conceptual Approaches to Bereavement 380 Stage/Phase Models 380 A Counterpoint to Traditional Models 381 Assessment Tools 382

Types of Loss 383 Death of a Spouse 383 Loss Due to Caregiving 384 Death of a Child 385 Bereavement in Childhood 385 Bereavement in Adolescence 388 Bereavement in Elderly People 389 HIV/AIDS 390 Job Loss 391 Separation and Divorce 393 Death of a Pet 393 Complicated/Prolonged Grief, Bereavement,

and Mourning Reaction 393 Intervention Strategies 396

Being There for Grievers: A Worker Imperative 397

Fitting Technique to Style of Grief 398 Cognitive-Behavioral Approaches 399 Narrative Therapy 400 Attachment Theory and Therapy 400

Dealing With Loss 400 Sudden Death of a Spouse 400 Traumatic Death of a Child 403 Bereavement in Childhood 409 Separation and Divorce 412 Death of a Pet 416 Bereavement in Elderly People 417 Bereavement in an HIV-Infected Client 419 Complicated Grief: Death of a Mother 421 The Crisis Worker’s Own Grief 425

Is There Any Lemonade in All These Sour Lemons? 426

Summary 427

CHAPTER 13 Crises in Schools 429 The New-Millennium, Violence-Proof School

Building 429 Conflicting Statistics 431 Violence and Youth 433

CONTENTS ■ ix

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x ■ CONTENTS

Gangs 435 Types of Gangs 435 Emergence of Suburban and Rural Gangs 435 Gang Intervention/Prevention Programs 436

Bullying 441 Cyberbullying 442

The Estranged Violent Juvenile Offender 445 A Comparison of Traits, Characteristics, and

Behaviors of SVJOs and EVJOs 445 Case Study: Seung-hui Cho 449 Screening the EVJO 450 Interviewing the Potential EVJO 451 Acting 455

School-Based Suicide Prevention and Intervention 456 Risk Factors/Predictors/Cues 457 Preadolescent Suicide 458

Child and Adolescent Cases of Suicidal Ideation 458

Postvention 460 Planning for a Crisis 464

The Crisis Response Planning Committee 466 The School Crisis Response Team (SCRT) 466

Implementing the Crisis Plan 469 Physical Requirements 469 Logistics 469 Responding to the Crisis 470

Bereavement in Schools 472 Group Work 473 Defining the Boundaries 475

Transcrisis Intervention with Individuals and Total School Systems 475 The Case of Josh 476

Epilogue 478 Summary 479

CHAPTER 14 Violent Behavior in Institutions 483 Introduction 483 Precipitating Factors 484 Institutional Culpability 486

Universities and Their Counseling Centers 486

Denial 487 Staff Culpability 487 Legal Liability 488 Dynamics of Violence in Human Services

Settings 488 Violence Potential Assessment Instruments 489 Structured Professional Judgment 489 Bases for Violence 490

Intervention Strategies 493 Security Planning 493 Threat Assessment Teams 494 Training 496 Record Keeping and Program Evaluation 499 Stages of Intervention 499

The Violent Geriatric Client 509 Mild Disorientation: The Case of Cliff 509 Distinguishing Between Illusions

and Hallucinations 512

Severe Disorientation: The Case of Grace 514 Follow-up with Staff Victims 515 Summary 517

CHAPTER 15 Legal and Ethical Issues on Crisis of Trauma 518 Introduction 518 Ethical and Legal Interface

with Crisis Intervention 519 Misconceptions Regarding Ethical

Decision Making 520 The Five Moral Principles of Ethical

Decision Making 527 Limitations of Implementing EDMs

in the Context of Crisis 530 Discernment and Heuristics 530

Case Studies 532 Mental Health Center 532 Commentary 533 Disaster Center: Potential Sexual Abuse 535 Commentary 535 Community College Suicide 537 Commentary 539 Crisis Hotline: Potential Elder Abuse 540 Commentary 541 Schools: A Potential Runaway 542

3 On the Home Front: Crisis in the Human Services Workplace 481

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Commentary 543 Summary and Implications for Practice 545

CHAPTER 16 Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue 546 Helping Professionals:

Prime Candidates 547 Dynamics of Burnout 548

Cornerstones of Burnout 549 Research on Burnout Dynamics 550 Myths That Engender Burnout 551 Symptoms of Burnout 551 Levels of Burnout 551 Stages of Burnout 553

Worker–Client Relationships 553 Countertransference 554

Secondary Traumatic Stress/Vicarious Traumatization/Compassion Fatigue 555

Compassion Satisfaction 556 The Culpability

of Organizations 556 Self-Recognition of Burnout 557 Intervention Strategies 557

Assessment 558 Intervention Through Training 559 Intervention with the Organization 559 Self-Care 564

Private Practitioners and Burnout 564 Intervention with the Individual: A Case

Study 565 Epilogue: Cross-Cultural Comparisons 574 Summary 575

CHAPTER 17 Disaster Response 579 A Brief History of Disaster Mental Health

Provision 579 Where the World Is 582 International Terrorism and Human-Made

Disasters 582 New Directions and New Visions 584 System Overview 586

Microsystem 586 Mesosystem 586 Exosystem 589 Macrosystem 590 Chronosystem 590

Defining Principles of a Crisis Intervention Ecosystem 594 National Crisis Response Teams 596 Vertically and Horizontally Integrated Local

Emergency Management Systems 598

Mental Health Components of Local EMAs 603 What Happened with Katrina? 604 Psychological First Aid and Psychosocial Support

as Applied to Disaster Survivors 606 When More Than PFA Is Needed 607 The Current State of Affairs 607

The People of Disasters: Responders and Survivors 609 Crisis Workers at the Disaster 609 Thoughts of a Mental Health Worker

on Katrina One Year Later 609 Lessons I Learned From Katrina 612

Case Study of the Benefield Family 613 Focus on the Worker 629

Debriefing Models 629 Debriefing Emergency Workers 631 Debriefing Crisis Workers 632

Final Thoughts 635 Summary 636

4 No Man’s Land: Facing Disaster 577

REFERENCES 637

GLOSSARY 718

INDEX 729

CONTENTS ■ xi

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xiii

Preface

Rationale for the Book The Primacy of Crisis Intervention The Chinese characters embedded in the front of the book and the beginning of each chapter symbolize both “danger” and “opportunity!” That is the essence of crisis—the human dilemma that is common to all cultures. We believe that practically all counseling is initiated as crisis intervention. As much as the help- ing professions would prefer otherwise, people tend either to avoid presenting their problems to a helper until those problems have grown to crisis propor- tions, or become ensconced in situational dilemmas that wind up in unforeseen crises. Our ideal objective, as human services workers, is to establish primary prevention programs so effective that crisis interven- tion will seldom be needed. However, it appears that people will not be as quick to adopt preventive mea- sures for their psychological health as for their physi- cal health.

The Case for an Applied Viewpoint The materials and techniques we promote in this book come from two sources: first, the authors’ own experi- ences in teaching and counseling in crisis situations; second, interviews with people who are currently in the trenches, successfully performing counseling and crisis intervention. We have obtained input from many different individuals in the helping professions, whose daily and nightly work is dealing directly with human dilemmas, and related their views to the best of current theory and practice from the professional literature. Through many hours of dialogue, these experts have provided the most contemporary strate- gies and techniques in use in their particular fields. They have also reviewed the content on each crisis cat- egory and have provided much helpful commentary

and critique of the ecology and etiology, tactics and procedures, terminology, and developmental stages of the specific crises with which they work. Therefore, what you read in the case-handling strategies comes directly from the horse’s mouth.

Where controversies exist in regard to treatment modalities this text attempts to present as many per- spectives as possible. Dr. Gilliland has been dead for 13 years, so if you encounter problems with the tactics and techniques presented in the current edition, the fault is undoubtedly in Dr. James’s rendition of the current research and therapeutic modalities.

The authors have endeavored to incorporate, syn- thesize, and integrate the case-handling strategies of these resource people in a comprehensive, fluid, and dynamic way that will provide crisis workers with a basic set of tenets about effective crisis intervention. This book is not about long-term therapy or theory. Neither is it a volume dealing with crisis from only one theoretical perspective, such as a psychoanalytic approach or a behavioral system. The book incorpo- rates a wide diversity of therapeutic modalities and reflects our eclectic and integrated approach to crisis intervention.

Specific crises demand specific interventions that span the whole continuum of therapeutic strategies. The strategies present in this book shouldn’t be con- strued as the only ones available for a particular cri- sis. They are presented as “best bets” based on what current research and practice indicate to be appro- priate and applicable. Yet these strategies may not be appropriate for all practitioners with all clients in all situations.

Good crisis intervention, as well as good therapy of any other kind, is a serious professional activity that calls for creativity and the ability to adapt to changing conditions of the therapeutic moment. To that extent,

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crisis intervention at times is more art than science and is not always prescriptive. Therefore, we would caution you that there are no clear-cut prescriptions or simple cause-and-effect answers in this book.

The Case for an Experiential Viewpoint The fact that no single theory or strategy applies to ev- ery crisis situation is particularly problematic to those who are looking for simple, concrete answers to resolve the client problems they will face. If you are just begin- ning your career in the human services, we hope that while reading and trying out activities in this book you will suspend your judgment for a while and be open to the experience as you read about crisis work- ers attempting to implement theory into practice.

Moral Dilemmas. Another issue that permeates many of the topics covered in this book is the emotions they generate and the beliefs about what is morally “right” and what is morally “wrong” that pervades them. People have been willing to go to prison or die because of the strong beliefs they held about many of these topics. Where such moral issues and beliefs abound, we have attempted to deal with them in as even- handed a manner as possible. This book is not about the morality of the issues covered, but rather about what seems to work best for the people who are expe- riencing the dilemma. We ask you to read the book with that view in mind, and for at least a while, sus- pend your moral view of the situation or problem as you read about crisis workers attempting to grapple with these heart- and gut-wrenching problems.

Finally, because of a virtually unlimited supply of different crises situations, we have had to make tough decisions about what kinds of problems to illustrate in the most generic and comprehensive way possible so as to reach the broadest possible audience. We under- stand and empathize very deeply with readers who may have suffered terrible crises that are not men- tioned in this book and are puzzled, chagrined, and angry that we have not given space and time to the particular crisis that they have suffered through. For that we apologize. The space available means that we simply cannot include all situations. However, what we the authors would like you to do rather than rail at our callous treatment in ignoring your particular dilemma, is to imagine how the strategies and tech- niques you are reading about might apply to the par- ticular crisis you have experienced. Hopefully, what we say about those crises may help you come to under- stand the dynamics of your own a bit better.

Basic Relationship Skills. The listening and respond- ing skills described in Chapter 3 are critical to every- thing else the worker does in crisis intervention. Yet on cursory inspection these techniques and concepts may seem at best simplistic and at worst inane. They do not appear to fix anything because they are not “fixing” skills. What they do is give the crisis worker a firm ba- sis of operation to explore clearly the dilemma the cli- ent is facing. Basic listening and responding skills are the prerequisites for all other therapeutic modalities.

Our experience has shown us over and over that students and trainees who scoff at and dismiss these basic relationship skills are the ones who invariably have the most trouble meeting the experiential re- quirements of our courses and workshop training sessions. We feel very strongly about this particular point and thus ask you to read Chapter 3 with an open mind. Much the same can be said about Chap- ter 4, The Tools of the Trade. Students and veterans who operate out of a client-centered mode may find what we are proposing pretty close to heresy because a lot of these tools are directive and judgmental as to the action to be taken, particularly when client safety is concerned. Again we ask you to suspend judgment and give these tools a good tryout in this new venture.

Role Play. If this volume is used as a structured learn- ing experience, the case studies in each chapter are a valuable resource for experiential learning. So are the exercises your instructor will give you as well as the vid- eos. It is essential that you observe effective crisis inter- vention models at work and then follow up by actually practicing and enacting the procedures you have ob- served. Intensive and extensive role play is an excellent skill builder. A critical component of training is not just talking about problems but practicing the skills of handling them as well. Talking about a problem is fine, but attempting to handle a live situation enables the trainee to get involved in the business of calming, de- fusing, managing, controlling, and motivating clients. Role play is one of the best ways of practicing what is preached, and it prepares human services workers for developing creative ways to deal with the variety of contingencies they may face. Role play gives human services workers the chance to find out what works and doesn’t work for them in the safety of a training situa- tion and affords their fellow students and trainees an opportunity to give them valuable feedback.

A major problem in role playing is the perception of standing up in a class or workshop and risking making a complete fool of oneself. We want to assure

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you that in our classes and training sessions we don’t expect perfection. If our students and trainees were perfect at crisis intervention, they wouldn’t be taking instruction from us in the first place! Therefore, put your inhibitions on the shelf for a while and become engaged in the role plays as if the situations were real, live, and happening right now. Further, be willing and able to accept critical comments from your peers, su- pervisors, or instructors. Your ego may be bruised a bit in the process, but that’s far better than waiting until you are confronted with an out-of-control client before you think about what you are going to do. Over and over, our students report that this component of instruction was the most profitable to them and was also the most fun!

Give the exercises that go with each chapter your best effort, process them with fellow students or train- ees, and see what fits best with your own feelings, thoughts, and behaviors. Many times our students and trainees attempt to imitate us. Although it is gratifying to see students or trainees attempting to be “Dr. J.,” it is generally an exercise in futility for them. What they need to do is view us critically as we model the procedures and then incorporate their own style and personhood into the procedures. We would urge you to do the same.

Some of these chapters are REALLY long. We didn’t put all that “stuff” in there to beat you to death with verbiage. We did it because the field of crisis keeps expanding rapidly as does the knowledge base. Therefore you need to know “the stuff” to do your job effectively. If you just watch the PowerPoint presenta- tions, you might get enough knowledge to pass your instructor’s tests. However, you won’t know enough though to help your client or yourself when you get in a tight spot. So read, read, read.

Finally, if you are never, ever going to be a crisis in- terventionist, but a “consumer,” this book still can be very useful. Sad to say, but just through living, you are going to encounter a lot of crises in this book that are going to afflict you, your loved ones, your friends, your workplace and the ecosystem in which you live. To that end, this book can give you the basic knowledge to deal with the crisis or know when it’s time to get help.

Organization of the Book Part One, Basic Training Part 1 of the book introduces the basic concepts of crisis intervention as well as telephone and online cri- sis counseling. It comprises Chapters 1 through 6.

Chapter 1, Approaching Crisis Intervention. Chapter 1 contains the historical background, basic definitions, and the theoretical and conceptual information needed for understanding applied crisis intervention.

Chapter 2, Culturally Effective Helping in Crisis. Chapter 2 is concerned with how crisis and culture interact. Dealing effectively with people from diverse back- grounds who are undergoing a crisis or have survived a disaster mandates an understanding and sensitiv- ity to multicultural issues. What are called “social lo- cations” for both worker and client play a major role in crisis intervention work. A new derivation of those social locations, called SAFETY locations, has been formulated to specifically deal with a person in crisis.

Chapter 3, The Intervention and Assessment Models. Chap- ter 3 introduces the task model for crisis intervention as well as the triage assessment system for rapidly as- sessing the severity of the crisis in a multidimensional way in real time.

Chapter 4, The Tools of the Trade. Chapter 4 introduces the basic communication techniques and skills ap- plied to crisis intervention. It also details the strat- egies used to attack various kinds of problems that hinder individuals as they attempt to resolve the cri- sis and details how crisis workers operate on the di- rective–nondirective action continuum.

Chapter 5, Crisis Case Handling. Chapter 5 is an overview of how crises are handled. Long-term therapy is com- pared with crisis intervention. Different venues where crisis intervention operates are explored to give an overview of the general tactics and strategies that are used.

Chapter 6, Telephone and Online Crisis Counseling. The ma- jority of crisis intervention is still done on the tele- phone by trained volunteers. However, with the advent of the Internet and social media, more and more crisis intervention is being done online. Chapter 6 explores the issues and techniques that are involved in these two mediums of crisis communication.

Part 2, Handling Specific Crises: Going into the Trenches Part 2 (Chapters 7 through 13) addresses a variety of important types of crises. For each chapter in Part 2 the background and dynamics of the particular crisis type are detailed to provide a basic grasp of the driv- ing forces behind the dilemma. Although some the- ory is present to highlight the therapeutic modalities

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used, comprehensive theoretical systems are beyond the scope of this book. For sources of that infor- mation, turn to the reference section at the end of each chapter.

In Part 2 we provide scripts from real interven- tions, highlighted by explanations why the crisis workers did what they did. Throughout this section techniques and cases are used to support live tryout, experiencing, and processing of the cases and issues in each chapter.

Chapter 7, Posttraumatic Stress Disorder. Chapter 7, Post- traumatic Stress Disorder (PTSD), is the linchpin chapter of this section. Many of the following chap- ters will have problems that may be the precursors of PTSD, or alternatively, represent the manifestation of it. This chapter examines both adults and children who have suffered traumatic experiences and are in crisis because of them.

Chapter 8, Crisis of Lethality. Chapter 8 focuses on strat- egies that crisis workers need in working with people who are manifesting lethal behavior. Suicidal and homicidal ideation flows through many other prob- lems that assail people the human services worker is likely to confront and is a consideration for all pro- viders of crisis intervention services both in regard to the safety of those clients and keeping the interven- tionists safe.

Chapter 9, Sexual Assault. Chapter 9 addresses another societal crisis that practical every human services worker will eventually encounter—clients who have either experienced or been affected by sexual assault. Sexually assaulted clientele are a special population because of the negative moral and social connotations associated with the dehumanizing acts perpetrated on them. This chapter is in three parts. First, it details crisis intervention techniques in the immediate aftermath of sexual assault on adults. Second, the chapter examines the long-term traumatic wake adult survivors of sexual abuse experienced in childhood. Third, the chapter details intervention techniques with children who have suffered sexual abuse and the family systems they live in.

Chapter 10, Partner Violence. Chapter 10 deals with a cri- sis that many people in a domestic relationship face: being treated violently by their partners. This chapter provides strategies to help people who are suffering abuse in any kind of domestic relationship. The chapter also deals with emerging treatment techniques for the batterers themselves.

Chapter 11, Family Crisis Intervention. Chapter 11 is a new chapter that deals with the whole family as they seek to navigate the family system through a crisis. This chapter also introduces spiritual and religious components in the intervention process and the part they play in it.

Chapter 12, Personal loss: Bereavement and Grief. Chap- ter 12 presents a type of crisis that every person will sooner or later face: personal loss. Even though the phenomenon of loss has been with us as long as the human species has existed, many people in our contemporary culture are poorly prepared and ill- equipped to deal with it. This chapter examines a variety of loss models and looks at different types of losses. This chapter also provides models and strate- gies for coping with unresolved or complicated grief.

Chapter 13, Crises in Schools. Schools have become a fo- cal point for the violence perpetrated by gangs and disenfranchised and socially isolated children and adolescents. This chapter will examine crises as it im- pacts schools from preschool through higher educa- tion. It will examine what crisis workers need to do in assessing, screening, and working with the potentially violent individual student who is estranged from the social mainstream of the school. It will also deal with what the crisis worker needs to know in dealing with suicide, a problem that has become endemic in youth. This chapter will detail how and what goes into mak- ing up a crisis response team for a school building and system and how and what they respond to when a crisis occurs.

Part 3, On the Homefront: Crisis in the Human Services Workplace Part 3 (Chapters 14 through 16) concentrates on the problems of crisis workers themselves and their em- ploying institutions.

Chapter 14, Violent Behavior in Institutions. Chapter 14 tackles the little publicized, and badly neglected, type of crisis that workers in many institutions face daily: violent behavior within the walls of the institution. Regardless of the organizational settings where they are employed, workers will find in this chapter useful concepts and practical strategies that they and the in- stitution can put to immediate use with agitated and potentially assaultive clients.

Chapter 15, Legal and Ethical Issues on Crisis of Trauma. Legal and professional ethical standards for the practice of psychotherapy have been in existence for

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